Diagnostic nasal endoscopy is a critical aspect of the evaluation of the revision rhinoplasty patient who reports nasal obstruction (Fig. 9). Pownell et al have described diagnostic nasal endoscopy in the plastic surgical literature.14 They trace the historical development of nasal endoscopy, explain its rationale, review anatomic and diagnostic issues including the differential diagnosis of nasal obstruction, and describe the selection of equipment and correct application of technique, emphasizing the potential for advanced diagnostic potential.

Levine15 reported that 39% of patients with a complaint of nasal obstruction had findings on endoscopic examination that were not identified with traditional rhinoscopy. Many of Levine’s patients had seen other physicians for this problem and had not received appropriate treatment. Becker et al described that, in patients seeking cosmetic nasal surgery who also had nasal obstruction, nasal endoscopy (Fig. 9) allowed the diagnosis of additional pathology not seen on anterior rhinoscopy, including obstructing adenoids, enlarged middle turbinates with concha bullosa, choanal stenosis, nasal polyps, and chronic sinusitis.16 In this series, additional surgical therapy was undertaken in 28 of 96 rhinoplasty patients due to findings on endoscopic exam. Thirteen patients had endoscopic sinus surgery. Nine patients had a concha bullosa requiring partial middle turbinectomy. Three patients—all revision surgeries—had persisting posterior septal deviation requiring endoscopic septoplasty. Two patients underwent adenoidectomy. One patient required repair of choanal stenosis.

As alluded to above, if septal deviation persists posteriorly after a septoplasty, persisting nasal obstruction may require revision septoplasty. Because the mucosal flaps are often densely adherent after a septoplasty, revision septoplasty involving a traditional approach may present technical difficulty, including significant risk of septal perforation.

Endoscopic septoplasty is a relatively recent and important technique that has direct application in this situation. The endoscopic approach may be a useful adjunct in these difficult revision cases in which a complete elevation of the mucoperichondrial flap presents difficulties, such as persistent posterior septal obstruction after prior septoplasty or prior septal injury (such as hematoma or abscess) with loss of cartilaginous septum. In these cases, typical surgical dissection planes are obliterated and complete elevation of the mucoperichondrial or mucoperiosteal flaps may be difficult. The ability to address a persisting deviation, elevating the mucosal flap directly over the offending deviation using endoscopic techniques, greatly facilitates treatment. Indeed, Becker and Kallman report that in a series of 90 primary septorhinoplasties, one patient underwent endoscopic septoplasty. In 23 revision functional septorhinoplasties, 4 patients benefited from endoscopic septoplasty approaches.¹⁷

Most rhinologic (i.e., sinus) surgeons are familiar with the benefits of diagnostic endoscopy and endoscopic surgical techniques in the context of sinus and nasal dysfunction. However, these advantages may not be as widely recognized in the rhinoplasty community. Diagnostic nasal endoscopy, and endoscopic techniques including endoscopic septoplasty, are important tools in the revision rhinoplasty surgeon’s armamentarium.

Endoscopic septoplasty is a well-described technique for correction of septal deformities.^18–23 First described in 1991,¹⁸ its use has been reported for the treatment of isolated septal spurs^18–21and in the treatment of more broad-based septal deformities.²² Advantages of the endoscopic technique include potentially improved visualization of posterior septal deformities, the opportunity for limited minimally invasive procedures, and potential improved access in certain revision cases.

Endoscopic septoplasty offers distinctive advantages in selected difficult cases of revision septoplasty. ^17,21 Whereas septoplasty does not commonly require endoscopic approaches, the endoscopic approach may be a useful adjunct in difficult revision cases in which complete elevation of a mucoperichondrial flap presents difficulties. Examples include a persistent posterior septal obstruction after prior septoplasty or after septal injury (such as hematoma or abscess) with loss of cartilaginous septum. In these cases, typical surgical dissection planes are obliterated, and complete elevation of a mucoperichondrial or mucoperiosteal flap may be difficult. The ability to directly address a persisting deviation, elevating the mucosal flap directly over the offending deviation using endoscopic techniques, greatly facilitates treatment.

The technique of endoscopic septoplasty has been well-described.^17–23 For a broadly based Figure 9 septal deviation, a standard Killian or hemitransfixion incision may be made. For an isolated posterior deformity, the incision may be positioned in the immediate vicinity of the deformity. Mucoperichondrial and mucoperiosteal flap elevation is facilitated by a suction elevator. For a broadbased deviation, the septal cartilage may be incised and the contralateral mucoperichondrial and mucoperiosteal flaps are elevated, taking great care to preserve a generous L-strut of at least 15 mm for continued nasal support. If an isolated posterior deformity is addressed, the cartilage or bone is incised several millimeters posterior to the mucosal incision, and the contralateral mucosal flap is elevated. Deviated portions of septal cartilage and bone are corrected or removed. Straightened or morselized cartilage may be replaced, and the septal flaps may be closed with a quilting suture, although in more limited cases suturing may not be necessary.