The caudal septum

What repeats

Five findings that hold across the literature.

It is a small share of septal surgery and the part that goes wrong

Caudal septal deviation accounts for around five percent of septal deviations that require surgery. The caudal septum supports the nasal tip, deviation there narrows the airway and makes the nostrils uneven, and over-resection compromises support and leads to tip collapse or a saddle nose. Surgeons describe correction of the caudal septum as the most difficult part of a septoplasty and a common cause of revision septoplasty.

Rests on: Javed et al., caudal septoplasty review · Seo et al., traction suture · and saddle nose.

Cutting it out is not the operation

Submucosal resection, the standard move in the rest of the septum, is only usable when the deviation does not involve the L-strut. Endonasal approaches are adequate for mid and posterior deviations, and the external approach is used where the L-strut is involved. Practice has moved toward tissue-preserving methods that keep structural integrity, matched to the type and severity of deviation.

Rests on: Javed et al. · Abrol and Lu, nuances of septal deviation repair · Latif et al., surgical techniques.

Suture techniques straighten about nine in ten

In 67 patients treated with a septal cartilage traction suture, endoscopy showed complete correction in 91.0% at three months, with acoustic rhinometry rising from 0.3 and 4.3 to 0.7 and 7.7, and no septal haematoma, no perforation and no loss of tip support at six months. A separate traction-suture series of 35 patients achieved a straight septum in 31, 91.1%, with NOSE falling from 85.1 to 22.4 and no complications. A prospective series of 95 cases reported significant improvement on NOSE and on the Rhinoplasty Outcome Evaluation, with complications in seven patients, 7.3%, all minor.

Rests on: Seo et al. · Aksakal and Akti, traction suture · Sabino et al., traction-suturing.

A batten graft splints the straightened edge

Bony batten grafting in 141 patients produced a straight septum in 128, 90.8%, with NOSE falling from 70.5 to 28.7, four septal haematomas, two cases of hyposmia, one of chondritis and four revisions. Caudal septal division with strip excision and a bony batten in 27 patients gave a straight septum in 23, 85.1%. A cartilage batten in 26 patients took NOSE from 75.38 to 13.85 at one month and held at 14.04 at six months. A printed polycaprolactone mesh batten in 20 patients gave a straight septum in 19, 95.0%, with NOSE from 68.2 to 15.0 and no complications to 364 days.

Rests on: Kim et al., bony batten · Aksakal, division and batten · Chi et al., cartilage batten · Moon et al., printed mesh batten.

The bone the septum sits on matters as much as the cartilage

Deviation of the anterior nasal spine is a common cause of caudal septal deviation. Relocating the spine in 378 patients straightened the septum completely in 312, 82.5%, left mild remnant deviation in 66, 17.5%, and produced significant improvement in airflow in 351, 92.9%. No patient breathed worse afterwards and none asked for revision surgery.

Rests on: Ng et al., anterior nasal spine relocation.

By technique

The named operations, and what each has been measured to do.

Swinging door, tongue in groove, cutting and suture

Thirty-six patients were divided into three groups of 12. NOSE fell from 72.5 to 23.33 with the swinging door, from 73.75 to 19.17 with tongue in groove, and from 72 to 22 with cutting and suture plus a unilateral bony batten. At six months 30 patients, 83%, had a straight septum and six, 17%, had residual deviation. Four had synechiae managed without surgery. The authors rate tongue in groove the most effective of the three.

Rests on: Ghosh and Choudhary, comparative study.

Traction sutures

The caudal L-strut is pulled to the midline and held there with sutures placed through a modified Killian incision, without an external scar. The three series above report straightening in about nine of ten with minor complications only.

Rests on: Seo et al. · Aksakal and Akti · Sabino et al..

Battens of bone, cartilage or printed mesh

A stiff strip is fixed alongside the straightened caudal septum to resist the cartilage springing back. Bone taken from the septum itself, cartilage from the same source and printed polycaprolactone mesh have each been reported. Bone grafts in 81 patients, 66 with adequate follow-up, gave a midline septum in 55, 83%, resolution of obstruction in 86%, and both at longest follow-up in 49, 74%. Nine patients, 14%, reported obstruction afterwards and three needed revision.

Rests on: Lee and Baker, septal bone grafts · Kim et al. · Moon et al..

A caudal septal extension graft

A graft is fixed to the caudal septum and extends past it, which sets tip projection and rotation as well as straightening. In 40 patients, 20 with the graft and 20 without, minimal cross-sectional area rose from 0.45 to 0.67 cm2 in the graft group and from 0.44 to 0.60 cm2 in the control group, with no significant difference between the two afterwards. The nasolabial angle in the graft group moved from 78.15 to 90.70 degrees.

Rests on: Karadavut et al., caudal septal extension graft · Rohrich et al., extension versus columellar grafts · and rib cartilage grafts.

Grafts that interlock or reshape the whole L-strut

An interlocked spreader graft placed on the convex side acted as a spring against the cartilage warping back, and all 15 patients had improved airway and appearance. Where the caudal and the high dorsal septum are both deviated, an L-shaped cut and suture on the L-strut in 30 patients took NOSE from 47.2 to 13.6 and minimal cross-sectional area from 0.43 to 0.74 cm2, with no saddle nose.

Rests on: Giacomini et al., interlocked graft · Lee et al., L-septoplasty · and the middle vault.

What to ask about caudal septal surgery

Questions the evidence supports asking.

Will any cartilage be removed from the front edge

Over-resection here is the route to tip collapse and saddle nose, and the modern techniques are built around keeping the L-strut and moving it rather than cutting it away. Ask what will be taken out and what will be left.

Rests on: Javed et al. · Latif et al. · and saddle nose.

What holds it in the midline afterwards

Sutures, a batten, a repositioned nasal spine, or a combination. Ask which, and what the surgeon does when the cartilage springs back.

Rests on: Seo et al. · Kim et al. · Ng et al..

Will the shape of my tip and nostrils change

Tongue in groove and a caudal septal extension graft both fix the tip to the septum, which changes projection and rotation. In the extension-graft series the nasolabial angle moved by more than 12 degrees. Ask to see photographs at one year in the base view, where nostril shape shows.

Rests on: Karadavut et al. · Rohrich et al. · Ghosh and Choudhary.

Am I having this endonasally or through an open approach

Endonasal approaches carry most of the suture and batten series. The external approach is the one used where the L-strut is significantly involved.

Rests on: Abrol and Lu · and open versus closed rhinoplasty.

How is the result measured

Endoscopy and a symptom questionnaire in most series. A computed tomography method measuring the distance from the septum midline to the palatal plane found a median deviation of 3.01 mm before surgery and 1.6 mm afterwards, a reduction of 1.26 mm.

Rests on: Wiederkehr et al., computed tomography evaluation.

The terms, defined

The words used about this part of the nose.

• Caudal septum: the front edge of the septum, between the nostrils, supporting the tip. [40042569]
• L-strut: the L-shaped band of dorsal and caudal septum left behind to hold the nose up. [40042569]
• Anterior nasal spine: the small bony projection of the maxilla the caudal septum sits on. [31820063]
• Swinging door: freeing the deviated caudal cartilage and swinging it back to the midline. [39376267]
• Tongue in groove: setting the medial crura of the tip cartilages against the caudal septum and suturing them there. [39376267]
• Batten graft: a stiff strip fixed alongside the caudal septum to hold it straight. [28520827]
• Traction suture: a suture that pulls the caudal L-strut to the midline and holds it. [32040201]
• Caudal septal extension graft: a graft fixed to and extending past the caudal septum, setting tip projection and rotation. [32332531]
• Columellar strut: the alternative tip support, placed between the medial crura rather than fixed to the septum. [32332531]
• Minimal cross-sectional area: the narrowest area measured inside the nose by acoustic rhinometry. [27184923]
• Nasolabial angle: the angle between the columella and the upper lip, which changes when the tip is rotated. [27184923]
• Saddle nose: collapse of the dorsum after the septal support under it is lost. [40042569]

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology publishes a clinical practice guideline on nasal form and function after rhinoplasty, with a plain language summary written for patients. It sets what a surgeon should assess before operating and what belongs in the record afterwards, tip support included.

Rests on: the clinical practice guideline · the plain language summary.

The surgeons' own textbook chapters

Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, carries a Septal Surgery section with three chapters on the front of the septum and the twisted nose. They are written for surgeons and go further into technique than a patient page should.

• Treatment of the Caudal Septum
• Algorithm for treatment of anterior septal deviations
• Extracorporeal septorhinoplasty for the twisted nose

The reference summaries

Two StatPearls chapters on the National Library of Medicine's Bookshelf carry the anatomy, the indications and the complication lists in full text at no charge.

• Septoplasty.
• Rhinoplasty, which covers tip support and the L-strut.

The societies

• ENT Health, the patient site of the American Academy of Otolaryngology, on the deviated septum.
• American Society of Plastic Surgeons, patient information.
• American Academy of Facial Plastic and Reconstructive Surgery, patient information.
• The Rhinoplasty Society, the surgeons' body, with its member directory. See associations.

The trials in progress

Two registered trials cover this part of the septum.

• Cartilaginous Batten Graft Septoplasty in Caudal Septal Deviation, completed, 20 participants.
• Evaluation of Metzenbaum Technique in Correction of Caudal End Nasal Septal Deviation, status unknown, 20 participants.

What is not settled

• The techniques have been compared head to head once, in 36 patients split into three groups of
  12. [39376267]
• Follow-up in most series is three to six months. The single-series claim about long-term behaviour rests on a batten study reporting to 364 days. [32040201] [37876017]
• Straightness is graded by endoscopy in most series rather than measured. The computed tomography method exists and has been applied to 20 patients. [35749812]
• Reported straightening runs from 82.5% to 95.0% across techniques, and case selection differs between them. [31820063] [37876017]
• The review authors state directly that more research on surgical outcomes is needed to improve the evidence base. [40042569]
• No single technique addresses all deviation patterns, and the current recommendation is a graduated approach rather than one operation. [41981762]