Septal surgery: septoplasty and submucous resection
- Procedure
A deviated nasal septum is straightened by lifting its lining and repositioning or removing the obstructing cartilage and bone.
See it in 3D: Nasal septum · Vomer · Ethmoid bone · Inferior nasal conchae · Cribriform plate
What it is
The nasal septum has a cartilaginous part (quadrangular cartilage) and a bony part (perpendicular plate of the ethmoid and vomer), covered by mucoperichondrium and mucoperiosteum. Classic submucous resection (Killian's operation) removes most of the cartilage and bone between the mucosal flaps and leaves only an L-shaped framework along the dorsum and caudal border. Septoplasty is conservative: it frees, repositions and removes only what is needed, which is why it is preferred today and can be done more cautiously in adolescents. Both are done inside the nose, sometimes with an endoscope.
Indications and contraindications
- Septal deviation with symptomatic nasal obstruction that does not improve with medical treatment.
- Access for other operations: endoscopic sinus surgery, pituitary, artery ligation in epistaxis, dacryocystorhinostomy.
- Recurrent epistaxis from a spur, or headache from spur contact with the turbinate (a debated indication).
- Source of cartilage grafts for rhinoplasty or the middle ear.
- Contraindications: growing children for wide resection, acute nasal infection, uncorrected bleeding disorder, active intranasal cocaine use.
- A major external deformity is corrected with septorhinoplasty, not septoplasty alone.
How it is done
- Before: anterior rhinoscopy and nasal endoscopy before and after decongestion; rhinitis, polyps or a collapsing nasal valve are ruled out.
- General or local anaesthesia; the mucosa is infiltrated with local anaesthetic containing a vasoconstrictor.
- Septoplasty: hemitransfixion incision at the caudal border; submucous resection: Killian incision a few millimetres further back.
- The mucoperichondrial and mucoperiosteal flap is raised on one side, taking care not to tear it.
- The cartilage is freed from the bone and nasal floor and the deviated parts are removed (spur, maxillary crest, vomer).
- Septoplasty: the cartilage is repositioned in the midline and the L-strut kept; submucous resection: almost all is removed, leaving the L.
- The flaps are brought together with sutures or sheets (splints) and sometimes packing; these are removed in the following days.
Submucous resection compared with septoplasty
| Feature | Submucous resection (Killian) | Septoplasty (Cottle) |
|---|---|---|
| Philosophy | Radical: removes most of the cartilage and bone | Conservative: frees, repositions and removes only what is needed |
| Incision | A few millimetres behind the caudal border of the cartilage | At the caudal border (hemitransfixion) |
| Caudal deviation and caudal dislocation | Does not correct it | Corrects it |
| Flaps | Raised on both sides | Can be raised on one side only |
| Age | Not before 17 years | Can be done in children and adolescents if obstruction is severe |
| Complications | More perforation, saddle nose and flapping septum | Fewer complications; revision is easier |
Complications
- Septal haematoma: if not drained, the cartilage becomes necrotic and infected (septal abscess).
- Septal perforation, especially if both flaps tear at the same place.
- Saddle nose from loss of dorsal support; columellar retraction from loss of caudal support.
- Persistent obstruction or a septum that «flaps» for lack of cartilage.
- Bleeding, adhesions between septum and turbinate, numbness of the upper incisor teeth.
- Rare: cerebrospinal fluid leak from cribriform plate injury and toxic shock syndrome with packing.
Next step / Initial management
- Before referral: examine the nose before and after a topical decongestant and treat associated rhinitis with intranasal corticosteroid (fluticasone) for several weeks.
- After surgery: saline irrigation, no forceful nose-blowing, avoid straining and non-steroidal anti-inflammatory drugs that increase bleeding if the surgeon advises so.
- Refer urgently, the same day, if there is septal pain and swelling blocking both sides with fever (septal haematoma or abscess) or bleeding that does not stop.
- Refer urgently if there is high fever, diffuse redness and low blood pressure in a patient with packing (toxic shock) or clear watery discharge from one side.
- Refer on a routine basis to ENT fixed one-sided nasal obstruction that does not improve with medical treatment.
Test yourself
Think of the answer, then tap the question to see it.
Why is classic submucous resection of the septum not done before 17 years of age?
Because septal cartilage is a growth centre for the nose and maxilla; removing it can stunt facial growth and deform the nose.
What advantage does septoplasty have over submucous resection for a caudal border deviation?
Septoplasty, with a hemitransfixion incision at the caudal border, can free and reposition the caudal cartilage; submucous resection does not correct that deviation.
Three days after septoplasty, a patient has blockage of both sides, pain and a soft red swelling on the septum. What do you suspect and what do you do?
Septal haematoma: urgent drainage by ENT and packing or splints to prevent abscess, cartilage necrosis and saddle nose.
Which structure must be kept to avoid a saddle nose after septal surgery?
The L-shaped cartilage strut: a dorsal and a caudal strip of the quadrangular cartilage.
Connections
See it in 3D5
The structures of Durgical's 3D anatomy where it is found.
Educational content; it does not replace a medical assessment and is not a clinical instruction. For a real case, follow current guidelines and specialist advice.
Sources: Septoplasty (StatPearls) (StatPearls Publishing, NCBI Bookshelf, 2022); Septal Perforation (StatPearls) (StatPearls Publishing, NCBI Bookshelf, 2023); Septoplasty (MedlinePlus, U.S. National Library of Medicine, 2025).
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Representative model, for educational purposes only.