Introduction
Nasal septal deviation is a common finding in the ENT physical examination, with studies showing that it may affect half of the general population.Reference Tsang, Nguyen, Sivesind and Cervin1 While it may not lead to any clinical manifestations, nasal septal deviation represents the most common cause of nasal obstruction, with this deformity also being associated with various other symptoms.Reference Tsang, Nguyen, Sivesind and Cervin1, Reference Hsu and Suh2 As these symptomatic manifestations have been shown to impact patients’ quality of life negatively, septoplasty remains one of the most performed ENT surgeries in the world.Reference Tsang, Nguyen, Sivesind and Cervin1
Although extensively performed and associated with improvements in quality-of-life scores,Reference Alessandri-Bonetti, Costantino, Cottone, Carbonaro, Cardone and Amendola3–Reference Alanazy, AlQuniabut, Alenezi, Almutairi, Almutairi and Altheyab5 success after primary septoplasty remains variable, with rates ranging from 43–85 per cent.Reference Althobaiti, Fida, Almahmoudi, AlGhamdi and Alharbi6, Reference Youn, Shah, Wei, Kandathil and Most7 Maintenance of symptoms is one of the main causes of septoplasty dissatisfaction, with an elevated number of patients reporting nasal symptoms, particularly nasal obstruction, even after surgery.Reference Tsang, Nguyen, Sivesind and Cervin1 From an anatomical standpoint, nasal septum deviation might be only a part of several structural abnormalities, with other bony and cartilaginous structures, as well as soft tissues, also contributing to nasal obstruction.Reference Liu, Yan, Zhang and Wang8 As septoplasty addresses only the nasal septum, surgery may be insufficient to effectively treat nasal obstruction. Additionally, septoplasty may be associated with several complications that may also explain surgical failure, and, although rare, nasal deformities remain one of the possible complications after septoplasty.Reference Yeo and Jang9
Rhinoplasty is a surgical procedure that alters the internal and external nose structure, with cosmetic and/or functional goals.Reference Friedman, Cekic and Gunel10 As it deals with the external framework of the nose, rhinoplasty may be necessary to improve nasal breathing and nasal symptoms, as well as to correct potential cosmetic complications from septoplasty.Reference Mella, Oyer and Park11 While rhinoplasty is a strategy in both situations, information on the causes leading to rhinoplasty after septoplasty remains scarce.
Therefore, this study aims to determine what leads to rhinoplasty after septoplasty and the clinical characterisation of patients undergoing these interventions.
Material and methods
The present retrospective observational study was conducted at Unidade Local de Saúde de Santo António – Porto, Portugal. It included all patients submitted to rhinoplasty after septoplasty by the Otorhinolaryngology and Head and Neck Surgery department between January 2018 and July 2023. The present study was approved by the local ethical committee, and patients’ rights were protected in accordance with the ethical principles of the Declaration of Helsinki.
Demographic, clinical and surgical data were collected using patients’ digital hospital records, namely age and gender, symptoms reported by patients after septoplasty, findings of the physical examination after septoplasty and the rhinoplasty technique used. The time between septoplasty and rhinoplasty was also registered, as well as information regarding the need for additional surgical interventions. All rhinoplasties were performed by the same surgeon.
Statistical analysis was performed using the SPSS version 24 software (IBM Corp., Armonk, NY). A descriptive analysis of patients’ characteristics was performed considering frequencies (for categorical variables) and mean and standard deviation (SD) (for continuous variables). Normal distribution was assessed using the Shapiro–Wilks test and through analysis of the skewness and kurtosis. Normal distribution was assessed using the Shapiro–Wilks test and through analysis of the skewness and kurtosis. Differences among paired groups were evaluated with the use of a chi-squared test (for categorical variables) and an independent sample t-test or Mann–Whitney test (for continuous variables).
Results
Between January 2018 and July 2023, 219 patients underwent rhinoplasty at the Otorhinolaryngology and Head and Neck department of Unidade Local de Saúde de Santo António. Of those, 15 per cent (n = 33) of patients had a previous history of septoplasty, with this group having a mean age of 38.7 years and with 54 per cent (n = 18) being of the male gender (Table 1).
Study population
Table 1 Long description
The table summarizes the study sample by gender and age. There were 18 males, representing 54 percent of participants, and 15 females, representing 46 percent. Overall, the average age was 38.7 years. Age variability was moderate, with a standard deviation of 13.40 years. The table does not report age separately by gender, so differences in age between males and females cannot be assessed from these data.
Nasal trauma before septoplasty was the most common medical background finding (36%; n = 12), followed by allergic rhinitis (27%; n = 9) and obstructive sleep apnea (6%; n = 2).
Regarding the previous septoplasty, all patients (n = 33) had undergone surgical intervention using the Cottle technique.
Reported symptoms after septoplasty
All patients (n = 33) who had undergone septoplasty before rhinoplasty reported maintenance of nasal obstruction, with additional symptoms being reported by 15 per cent, or less, of patients (Table 2).
Symptoms after septoplasty
Table 2 Long description
The table lists symptoms reported after septoplasty and gives the percentage and number of patients with each symptom out of 33. Nasal obstruction was reported by all patients, 33 of 33. Rhinorrhoea, snoring, and nasal itching were each reported by 5 patients, representing 15 percent. Headache and dryness of the nasal or oral mucosa were each reported by 3 patients, representing 9 percent. Sneezing and epistaxis were each reported by 2 patients, representing 6 percent. Dysgeusia, chronic coughing, and hyposmia or anosmia were each reported by 1 patient, representing 3 percent. Percentages reflect this single sample size and do not indicate symptom severity or duration.
Physical examination findings after septoplasty
Upon physical examination after septoplasty, most patients presented with nasal deformities (54%; n = 18), with deviation of the nasal pyramid from the median line as the most common deformity (27%; n = 9), followed by maintenance of septal deviation (52%; n = 17) (Table 3).
Physical examination findings after septoplasty
Table 3 Long description
The table lists types of physical exam findings observed after septoplasty, reported as percentages with patient counts. The most frequent findings were nasal pyramid deformity at 54% (18 patients) and nasal septum deviation at 52% (17 patients). A nasal hump was reported in 27% (9), and nasal pyramid deviation was also 27% (9). Less common findings included nasal tip ptosis at 15% (5) and internal nasal valve insufficiency at 15% (5). External nasal valve insufficiency, septal perforation, and crooked nose were each 9% (3). Caudal septal deviation occurred in 6% (3), while Hoakes deformity and nasal bone irregularities were each 3% (1). Percentages may not sum to 100% because patients could have more than one finding.
Septorhinoplasty
In patients submitted to septorhinoplasty after primary septoplasty, a mean time of 77.16 months (6 years and 5 months) passed between surgical interventions, with a minimum time of 13 months (1 year and 1 month) and a maximum time of 392 months (32 years and 8 months).
All patients (n = 33) underwent revision septoplasty, with 9 per cent (n = 3) also undergoing nasal septal perforation repair.
Rhinoplasty was done using an open technique in 58 per cent (n = 19) of patients, with a closed technique being used in 42 per cent (n = 14) of cases. When approaching the nasal dorsum, Spare Roof technique AReference Ferreira, Monteiro, Reis, Almeida and Sousa12 and Spare Roof technique BReference Gonçalves Ferreira, Ishida, Ishida and Santos13 were performed in 42 per cent (n = 14) and 21 per cent (n = 7) of patients, respectively, with 76 per cent (n = 25) of patients undergoing lateral osteotomies. Nasal tip work was done using domal, interdomal and Gruber sutures in 100 per cent of patients. Grafts were performed in 73 per cent (n = 24) of cases, with columella strut as the most used graft technique (45%; n = 15) and the nasal septum as the commonest site of graft material collection (55%; n = 18) (Table 4).
Rhinoplasty surgical approaches
Table 4 Long description
The table summarizes how often different rhinoplasty techniques and graft choices were used, reported as percentages with case counts. Surgical access was open in 58% (19 cases) and closed in 42% (14 cases). For nasal dorsum work, spare roof technique variant A was used in 42% (14) and variant B in 21% (7). Osteotomies were most often lateral at 76% (25), while paramedian osteotomies were less common at 15% (5). Nasal tip management relied on sutures in 100% (33), with grafting also frequent at 73% (24); cephalic trim occurred in 58% (19) and septal advancement flap in 6% (2). Camouflage was used more often at the supratip at 30% (10) than at the dorsum at 6% (2). When cartilage was harvested for grafts, the nasal septum was the most common source at 55% (18), followed by the ear at 18% (6). Among graft types, columella strut grafts were most common at 45% (15), with lateral crural grafts at 15% (5), septal extension grafts at 12% (4), and cap and alar rim grafts each at 3% (1). Percentages may not sum to a single total because multiple techniques can be used in the same case and some categories list only selected options.
SRT = spare roof technique.
Symptoms and physical examination findings after septorhinoplasty
After rhinoplasty and revision septoplasty, 18 per cent (n = 6) of patients reported maintenance of nasal obstruction and 6 per cent (n = 2) complained of nasal bone irregularities. Upon physical examination, 6 per cent (n = 2) of patients presented nasal pyramid deviation and 3 per cent (n = 1) presented alar retraction. No statistically significant difference was found between surgical technique or nasal dorsum approach and the existence of symptoms after septorhinoplasty (Table 5).
Symptoms after septorhinoplasty
Table 5 Long description
The table compares whether patients reported symptoms after septorhinoplasty across two nasal dorsum approaches (open and closed) and two SRT techniques (SRT-A and SRT-B). For the open approach, 2 patients reported symptoms and 17 reported no symptoms. For the closed approach, 4 reported symptoms and 10 reported no symptoms. For SRT-A, 3 reported symptoms and 12 reported no symptoms, and for SRT-B, 3 reported symptoms and 16 reported no symptoms. In every group, the count of patients without symptoms is higher than the count with symptoms. Reported p-values indicate no statistically significant difference between open versus closed approaches and between SRT-A versus SRT-B.
SRT = spare roof technique.
Of all patients submitted to septorhinoplasty, 9 per cent (n = 3) underwent revision rhinoplasty, with one patient undergoing three revision surgeries. There was no statistically significant difference between the sex, type of septorhinoplasty approach or dorsal approach and the need of further revision surgeries (Table 6).
Need of revision after septorhinoplasty
Table 6 Long description
The table reports how many patients did or did not need a revision after septorhinoplasty, grouped by sex, by open versus closed technique, and by two nasal dorsum approaches labeled SRT-A and SRT-B. Revisions were rare across all groups: males had 1 revision and 17 without, while females had 2 revisions and 13 without. For technique, open cases had 2 revisions and 17 without, and closed cases had 1 revision and 13 without. For dorsum approach, SRT-A had 1 revision and 18 without, and SRT-B had 2 revisions and 12 without. The reported p-values for sex, technique, and dorsum approach comparisons are all above common thresholds for statistical significance, so the table does not indicate clear differences between groups. Because the revision counts are very small, the comparisons may have limited power to detect modest differences.
SRT = spare roof technique.
Discussion
Septoplasty remains the commonest ENT surgery performed in adults, with surgery rates being as high as 12.2 interventions per 10 000 inhabitants, in Germany.Reference Ferreira, Monteiro, Reis, Almeida and Sousa12 Nasal obstruction continues to be the main indication for septoplasty, and while long-term objective and subjective measures appear to improve significantly after surgery, doubts remain regarding its efficacy.Reference Tsang, Nguyen, Sivesind and Cervin1, Reference MMHT, Rovers, Tillema and van Neerbeek14, Reference Fearington, Awadallah, Hamilton, Olson and Dey15 As additional nasal structures other than the septum may contribute to the development of nasal symptoms, mainly nasal obstruction, in some patients, septoplasty done alone may be insufficient to address the symptom, and rhinoplasty may later be warranted to effectively improve patients’ symptoms and quality of life.Reference Friedman, Cekic and Gunel10
To this end, this study aimed to identify patients submitted to rhinoplasty after primary septoplasty and the type of symptoms and physical examination findings that led to the need for a second surgical intervention.
In this study, all patients undergoing rhinoplasty after primary septoplasty reported maintenance of nasal obstruction, with more than half of these patients showing septal deviation. These findings are in accordance with literature, where septoplasty failure has been mostly attributed to inadequate correction of septal deviation, particularly by insufficient separation and resection of the bony–cartilaginous junction and by inadequate correction of caudal septal deviation, sites associated with particular challenges during surgery.Reference Althobaiti, Fida, Almahmoudi, AlGhamdi and Alharbi6 Work on the bony–cartilaginous junction and the perpendicular plate of the ethmoid is related to the risk of disturbing the keystone area, damaging the olfactory area, or cerebrospinal fluid fistula.Reference Derin, Sahan, Deveer, Erdogan, Tetiker and Koseoglu16 These risks might lead to avoidance of work in this area, allowing posterior bony deviations to remain, with consequent narrowing of the nasal cavity and persistence of nasal obstruction.Reference Derin, Sahan, Deveer, Erdogan, Tetiker and Koseoglu16 Caudal septal deviation, found in 6 per cent of patients in this study, is also a surgical challenge, with this deformity often being addressed poorly for fear of nasal tip drop.Reference Baser, Surana, Singh and Patidar17 However, as caudal septal deviations are associated with a great functional impact, ineffective management of caudal deviations may lead to severe nasal obstruction.Reference Baser, Surana, Singh and Patidar17, Reference Lee, Jo, Kwon, Park, Kim and Cho18
Missed nasal valve dysfunctions present another major cause for septoplasty failure, with 15 per cent and 9 per cent of patients in this study presenting with internal and external valve insufficiency, respectively. Nasal valve anomalies, whether narrowing or collapse, are associated with significant nasal obstruction, with studies showing that patients who undergo nasal valve procedures in addition to septoplasty have a significantly lower chance of needing revision septoplasty and that nasal valve repair significantly improves nasal blockage.Reference Althobaiti, Fida, Almahmoudi, AlGhamdi and Alharbi6 These findings emphasise the importance of thoroughly assessing all nasal structures associated with nasal obstruction in patients reporting this symptom, enabling a more comprehensive treatment plan that addresses all causes of nasal obstruction simultaneously, potentially reducing dissatisfaction rates associated with septoplasty.
Another physical examination finding of importance was that most patients who had already been submitted to septoplasty presented nasal pyramid deformities, particularly the presence of a nasal hump or deviation of the nasal pyramid from the midline. These deformities can be corrected through different rhinoplasty techniques that may not only alter the overall look of the nose and, therefore, have a cosmetic impact, but also positively impact nasal breathing, leading to functional improvement.Reference Friedman, Cekic and Gunel10 This, once again, enhances the importance of proper evaluation of all nasal structures before primary septoplasty, allowing for both functional and cosmetic goals to be addressed at one surgical time, thus reducing admission periods, workplace absence, and operation room costs.
In the present study, 15 per cent of patients with nasal deformities presented with nasal tip ptosis, and 9 per cent (n = 3) of patients presented with septal perforation. Both findings are well known complications of septoplasty that may warrant additional surgeries, namely rhinoplasty, in order to be addressed and corrected.Reference Ketcham and Han19.
Regarding the surgical techniques used during rhinoplasty, most patients underwent surgery through an open approach, despite the closed approach being the technique mostly used by the surgeon who performed the surgeries in this study. While several advantages and disadvantages of open and closed rhinoplasty have been described, surgeon preference remains important when choosing an approach. The fact that, in patients previously submitted to septoplasty, the surgeon shifted his preference from a closed to an open approach may indicate a more complex surgical intervention, requiring improved and direct visualisation of anatomic structures and an even more precise identification and correction of deformities.Reference Cafferty and Becker20, Reference Rohrich and Afrooz21
After rhinoplasty and septoplasty revision, most patients reported improvement in nasal obstruction. This is another indicator that nasal obstruction is sometimes associated with structures other than the nasal septum and that surgically addressing those structures using rhinoplasty techniques is necessary for symptom improvement.
Despite these findings, this study presents some limitations, particularly being a retrospective study that relies on written data collection. Additionally, no subjective measures were used when assessing the impact of nasal symptoms, whether before primary septoplasty, after primary septoplasty or after rhinoplasty and revision septoplasty.
Nonetheless, this study allows for a better understanding of the patients seeking rhinoplasty after primary septoplasty, with nasal obstruction as the main motivator for the new surgical intervention, more so than cosmetic reasons, and maintenance of septal deviation as one of the main physical findings.
• Nasal septal deviation remains a common finding in ENT practice, with septoplasty being one of the most performed surgeries by ENT
• A total of 43–85 per cent of patients maintain nasal obstruction after septoplasty
• Structures other than the nasal septum contribute to nasal obstruction, and rhinoplasty is sometimes necessary to correct this symptom
• Previous studies have shown that inadequate nasal septal deviation correction is the most common reason behind septoplasty failure
• The present study also points to missed nasal pyramid deformities as one of the commonest findings among patients maintaining nasal obstruction after septoplasty, stressing the importance of correctly assessing these patients pre-operatively
• It also shows that most patients who maintain nasal obstruction after septoplasty improve after rhinoplasty
Conclusion
Septoplasty remains one of the most commonly performed ENT surgeries. As nasal obstruction is often associated with several structures other than the nasal septum, septoplasty may sometimes be insufficient to improve nasal obstruction, with rhinoplasty being sometimes necessary to correct the anatomic deformities underlying this symptom.
