Septoplasty, Tropical environment,
Deviated nasal septum
Septoplasty is a common surgical procedure
performed by otorhinolaryngologist [1-4].
The nasal septum is a rare rectilinear area; it is
often the seat of morphological abnormalities that
cause functional disorders [5-7].
Major anatomic variants leading to osteo-meatal
obstruction are deviated nasal septum, concha
bullosa, paradoxical middle turbinate and infra
orbital (Haller cell) .
Septal deviation can be cartilage and/or bone;
causes a narrowing of the nasal area in the convex part
with a decrease in respiratory field (linear thickening);
the overall impact on the human organism can then
occur secondary to this condition [3,7,8].
Some people are born with a bent septum, overs
acquire a bend as a result of trauma [6,9].
Osteal obstruction may lead to fluid accumulation
and stagnation, creating a moist, hypoxemic
environment ideal for growth of the pathogens [5,6].
A disorder of the nasal architecture can join; there
is a tip of the nose without support.
Diagnosis is often delayed, in the tropical area
most patients are seen before by other health
professionals not specialized in the field of ENT
diseases. This state of doing favors a non-adequate
care based on poorly adapted treatments for these patients with deformity of the nasal septum:
iterative treatments to the nasal mucosa (nasal drops
vasoconstrictor, inhalation of often toxic substances
traditional); such a situation can only complicate an
eventual surgery of the nasal septum.
Aim of study
To report our experience in the appropriate
management of nasal septal deviation in the tropics.
Patients and Methods
A retrospective study was carried out in patients
with symptomatic deviated nasal septum who
underwent septoplasty in the ENT Unit of the
reference health center in the town of Bamako,
District IV, from March 2010 to August 2014. 33
patients between the ages of 22-51 years of both the
sexes with symptomatic deviated nasal septum i.e.
type 2 and 3 regarding the Cottle’s classification [2,10]
have been included in the study.
Our exclusion criteria were patients suffering
from medical problem (e.g. uncontrolled diabetes
and hypertension, heart problems, coagulopathies).
Informed written consent was taken from
every patient. A detailed examination of the nose,
throat and ears was performed. Laboratory tests
were carried out on patients before surgery, and
systemic diseases were not present in any case. X-ray
examination of associated paranasal sinuses and
nasopharynx was also done (Figure 1).
Figure 1: X-ray of sinuses
The various nasal symptoms are evaluated.
Our surgical procedure:
All patients were operated under local anesthesia:
- Topical anesthesia of the nasal mucosa by 5%
xylocaine with naphazoline
- Infiltration anesthesia with 2% xylocaine
- Premedication was conducted one hour before
the operation by: neurosedative [Hydroxyzine
(atarax®)], analgesic (paracetamol) and hemostatic
- Treatment with hemostatic was introduced
three days before and after the operation
- A Killian incision was used in all patients
- All incisions were sutured using 4-0 Vicryl® rapid
- The nasal packing impregnated with antibiotic
ointment (Aureomycin®) was removed after 72
- After surgery, antibiotics were recommended
to all patients for 10 days, and oral analgesic, nasal
saline lavage and anti-inflammatory treatment was
used as needed.
Between 2010 and 2014, a total of 33 patients,
aged 22-51 years (means 36 years), 30 (90.90%)
male and 3 (9.10%) female, underwent septoplasty
for deviated nasal septum.
The observed probable causes were: not
established 27 cases (81.81%) and traumatic 6 cases
Depending on the portion of the deviated nasal
septum: cartilagenous portion 30 cases (90.90%)
and bony portion 3 cases (9.10%).
The essential symptoms were: nasal obstruction,
facial pain, vasomotor rhinorrhea
Short and long-term postoperative were simple.
Minor hemorrhage was observed in all cases 30
patients (90.90%) have only benefited a nasal
packing and 3 patients (9.10%) had a septal suturing
and a nasal packing. All patients were able to join
home 8 hours’ time after the operation. The total
disappearance of the preoperative symptoms were
observed in 90% of cases and increased moderate in
10% of cases.
Septoplasty is one of the most widely used surgical
methods for correction of septal deviation [8,10-13].
In Sub-Saharan Africa the studies related to the
correction of the nasal deviation are very rare. Many
obstructive nasal disorders are caused by the septal
deviation. Management for the traumas of the nose
in distant areas far from the hospital structures
specialized promotes huge problems and most
patients remain with their deviation from the nose without early correction after a trauma.
Our study will no doubt allow emphasis on
this neglected rhinological pathology and which
negatively influence the quality of life of patients.
This study confirmed the role of the septoplasty
in rhinologic surgery within our unit despite the
inadequacy of the medical equipment; this is a
surgery that does not generally require expensive
means that can represent an obstacle to its realization
in such a unit like ours.
The majority of our patients is male with an
average age of 36 years, confirmed numerous works
dealing with the septoplasty [2,9,11,14-17].
The main indications of the deviation of nasal
septum surgery are dominated mainly by traumatic,
congenital malformative etiologies [1,3,6,8,13,18]. The low
rate related to trauma in our study only 6 cases could
be explained by the ridge that most patients have
not been able to assert or set aside a history of nasal
Contraindications to the septoplasty apart from
those inherent in any intervention, concern mainly
under age 18 years, for some authors at this age, the
development of the facial skeleton is incomplete and
it has a risk for reproduction of the deviation [1,3,6,12,14].
However other authors operate under-18 years
without damage [19,20]. Deviations of the nasal septum
may to concern two portions of the septum (cartilage
and bone) or one of the two [3,6]. Deviation at the level
of the cartilaginous portion was especially found
our patients 90.90% as is the case in some reported
The symptoms caused by septal deviations are
entirely the result of their effects on nasal function.
The dominent symptom being nasal obstruction, but
this is rarely severe enough to cause anosmia [6,14].
The effects of septal deviation are not negligible:
nasal obstruction, mucosal changes, neurological
The main symptoms observed in our patients
(nasal obstruction, facial pain, catarrh) are usually
those found in the literature [1,2,6,14].
Our patients presented primarily symptoms of
deviation of nasal septum of type 2 and 3 according
to the classification of Cottle [2,10]. Cottle classified
septal deviation in to 3 types i.e
1) Simple deviation: only mild deviation with no
obstruction and it is the most common type
2) Obstruction: here the deviated septum touches the lateral wall, but on decongestion with
vasoconstrictors the turbinate shrinks and the
obstruction is relieved.
3) Impaction: massive angulation of the septum
with a spur.
Surgical techniques for deviated nasal septum
are diverse they relate mainly to used anesthesia,
the incision of the nasal septum, the packing of the
nose, the suture of the cartilage, the postoperative
Submucosal resection of nasal septum is ideally
performed under local anaesthesia [3,8,18].
All our patients were operated under local
anaesthesia, mode of anesthesia that we considered
suitable to our technical conditions bearable on
the cost plan and reassuring for our patients whose
most don’t have too much confidence in general
anesthesia. A non-negligible number of operators
There are several types of incision of the nasal
mucosa for the septoplasty: Killian, Passow, Halle
and Freer Incisions [7,10,11,14,21,22]. We opted for the
Killian’s incision  (Figure 2).
Figure 2: Killian's incision
Killian's incision is preferred for sub mucosal
resection operations, it’s the commonly used
incision [2,3,8,11,18]. It is an oblique incision given
about 5 mm above the caudal border of the septal
The peculiarities of the septoplasty are variously
cited according to the authors: difficult detachment
caused by a cartilage deflected in various directions,
complicated crests, pre-existing perforations,
anterior galvanocauterization, adhesions of septal
cartilage (risk of perforation) [1-3].
Opinions are divided on a nasal packing
tamponade or a suture of the nasal septum during a
Anterior nasal packing is done routinely in many
nasal surgeries, particularly in septoplasty [3,8,12,13,17,18].
History of nasal packing after nasal surgery
falls back to 1847 in the time of Gustay Killian
of Germany  and Otto Tiger Freer of USA , yet
systematic sub mucosal resection (SMR) and nasal
packing was started in 1882 by Ephraim in Chicago
and Peterson in Germany. Different types of nasal
packing have been used like ribbon gauge soaked
in bismuth iodoform paraffin paste, liquid paraffin,
antibiotic ointments and others. Numerous other
agents like polyvinyl acetate sponge (merocel),
Nasopore (bioresorbable dressing), various balloon
tamponade devices are also available .
Nasal packing after septoplasty has been used
to approximate septal mucopericondrial flaps
mechanically, to prevent bleeding and septal
haematoma, to support the septum, to stabilize the
repositioned cartilage and bone fragments, and to
prevent synechiae between the septum and lateral
nasal wall [3,8,12,17,18].
But few studies suggested that nasal packing is
not necessary after nasal septoplasty as it causes
discomfort when it is being removed [12,16,17].
Thus some authors opt for the suturing the
septum after septoplasty has the advantage of
eliminating discomfort for the patients, has minimal
complications and the hospital stay is less than with
the nasal packing [1,12,16,17].
Whereas the conditions of the tropical
environment with its adverse impact on the nasal
mucosa, we especially preferred anterior nasal
packing. Thus all of our patients have benefited of a
the nasal packing without suture and three patients
had in addition to packing a suture of the nasal
septum to better approach the flaps after a difficult
This approach allowed a perfect mastery of
bleeding associated with the chirurgical procedure
and all of our patients have joined the home after 8
hours of observation. We have removed the packing in our patients on the 3rd day of the intervention
with virtually no observed bleeding contrary to the
approach taken in the majority of studies that have
mentioned a nasal packing maintained for 48 hours.
We deemed it necessary to remove the packing
after 72 hours given our experiences accumulated in
a tropical environment in support of the bleeding of
the nose and we don’t observed major damage to
the nasal mucosa.
The septoplasty complications may occur:
synechiae, perforation, and deviation from the
Mucosa, often very serious epistaxis, rarely an
intracranial complication, thrombophlebitis
of lower extremities causing a pulmonary
A well suitable surgical technique allows to make
it bearable and beneficial for the patient and reduce
the risk of complications [2,3,16,23-25].
We have observed minor intraoperative bleeding
in the majority of cases and our postoperative suites
were simple without major complications.
The implementation of appropriate therapy
(general and especially local to prevent the
adhesions and crusty rhinitis favored by our tropical
climate dry and hot) in postoperative period as rated
in the works referring to the septoplasty [1-3], allowed
a better healing of the nasal mucosa and a beneficial
impact of intervention for our patients ; evidenced
by our results.
Despite its rarity in our unit, the septoplasty is
a procedure that must occupy a significant place in
rhinologic surgery in our country. The lack of ENT
specialist causes the difficulties in the diagnosis of
its obstructive diseases of the nose and sinuses.
Our results confirm that this intervention is well
feasible despite the poor technical platform we have
and the profits that are not negligible for the comfort
of patients with deviated nasal septum.
- Avakoudjo F, Adjibabi W, Lawson Afouda S, Hounkpatin SHR, Vodouhe J and Hounkpe YYC (2012)Place de la septoplastie dans l’obstruction nasale chez le sujet noir africain. Médecined'Afrique Noire5907: 359-363.
- Basith Y, Balasubramanian T (2012) Role of anatomical obstruction in the pathogenesis of chronic sinusitis. A case series study based on radiological assessment.
- Antoniv VF and Titova (2001) LA Correction of intranasal structures in nasal septum deformity.VestnOtorinolaringol 6:45-47.
- Pannu KK, Chadha S and Kaur IP (2009) Evaluation of benefits of nasal septal surgery on nasal symptoms and general health. Indian J Otolaryngol Head Neck Surg61:59-65.
- Mohamed AAG, Sacko HB (1995)Profil bactériologique des sinusites maxillaires purulentes observées dans le service ORL de l’Hôpital Gabriel Touré de Bamako(Mali). Mali Médical10: 9-11.
- Balasubramanian T, Deviated nasal septum, drtbalu’s otolaryngology online
- Zimont DI (1933)Diseaeses of the upper aero-digestive tract (in Russian).
- Protasevich GS, Gavura IA and Kovalik AP (2001)Ultracaine anesthesia in submucous resection of the nasal septum. VestnOtorinolaringol 4:41-43.
- Basavaraj NW, Rashinkar SM, Watwe MV, Anees F and Kakkeri A (2011)A Comparative Study of Septoplasty with or Without Nasal Packing. Indian J Otolaryngol Head Neck Surg (July-September 63:247-248.
- Cottle MH and Loring RM (1948) Surgery of the nasal septum. New operative procedure and indications. Ann. Otol. Rhinol. Laryngol 57: 703-713.
- Killian G (1904) Die submucoseFenesterresektion der Nasenscheidewand/Archives fur Laryngologie und Rhinologie (in German) 16: 362-387.
- Cukurova I, Cetinkaya E A, Mercan GC, Demirhan E andGumussoy M (2012) Retrospective analysis of 697 septoplasty surgery cases: packing versus trans-septal suturing method. Actaotorhinolaryngologicaitalica 32:111-114.
- Rajashri S, Balasaheb P and Anjana M (2013) Indian. Comparison of Septoplasty With and Without Nasal Packing and Review of Literature. J Otolaryngol Head Neck Surg 65: 406-408.
- Bernardo MT,Alves S, Lima NB, Diamantino H and Condé A (2013)Septoplasty with or without postoperative nasal packing? Prospective study.Braz J Otorhinolaryngol 79:471-474.
- Arunachalam PS, Kitcher E, Gray J and Wilson JA (2001) Nasal septal surgery: evaluation of symptomatic and general health outcomes. ClinOtolaryngol Allied Sci 26:367-370.
- Konstantinidis I, TriaridisS, Triaridis A, Karagiannidis K andKontzoglou G (2005) Long term results following nasal septal surgery. Focus on patients' satisfaction. AurisNasus Larynx32:369-374.
- Eşki E, Güvenç IA, Hızal E and Yılmaz I (2014) Effects of nasal pack use on surgical success in septoplasty. Kulak BurunBogazIhtisDerg24: 206-210.
- Morokhoev VI (1990)Various aspects of endonasal corrective surgery. VestnOtorinolaringol 4:47-51.
- Piltcher O (2013)Septoplasty in children: problem or solution?Braz J Otorhinolaryngol 79:408.
- Lawrence R (2012) Pediatric septoplasy: a review of the literature. Int J PediatrOtorhinolaryngol 76:1078-1081.
- Freer OT (1902) Thecorrection of deflection of the nasal septum with a minimum traumatization. JAMA 38: 636-642.
- Halle M (1915) Die intranasalenOperationenbeieitrigenErkrankungen der Nebenhollen der Nase. Arch. Laryngol.Rhinol (in German) 29: 73-112.
- Uppal S, Mistry H, Nadig S, Back G and Coatesworth A (2005) Evaluation of patient benefit from nasal septal surgery for nasal obstruction.AurisNasus Larynx 32:129-137.
- Pinto Bezerra TF, Stewart MG, Fornazieri MA, Pilan RRM, Pinna FR, Padua FGM andVoegels RL (2012) Quality of life assessment septoplasty in patients with nasal obstruction. Braz J Otorhinolaryngol 78:57-62.
- Moxness MHS and Nordgard S (2014)An observational cohort study of the effects of septoplasty with or without inferior turbinate reduction in patients with obstructive sleep apnea. BMC Ear, Nose and Throat Disorders14: 11.