Caudal Septal Deviation
The nasal septum divides the nasal cavity into right and left sides. When it is straight and in the midline, airflow through both sides of the nose is equal. When it deviates — curves or buckles to one side — it narrows the nasal passage on that side and causes obstruction. Septal deviation is extremely common and affects the great majority of adults to some degree. Most deviations are minor and cause no functional consequence. Significant deviation is one of the most common surgically correctable causes of chronic nasal obstruction.
Caudal septal deviation is a specific and clinically important subtype — deviation of the most anterior, lower portion of the septum. It carries particular functional and aesthetic consequences that distinguish it from deviation higher in the nose, and requires specific surgical management.
Read the full septoplasty information page →
Anatomy of the Caudal Septum
The nasal septum is composed of bone posteriorly (the perpendicular plate of the ethmoid and the vomer) and cartilage anteriorly (the quadrangular cartilage). The caudal septum is the free anterior edge of the quadrangular cartilage — the portion closest to the nostrils and nasal tip. It is supported inferiorly by the anterior nasal spine, a bony projection at the base of the nasal cavity, and connects superiorly to the dorsal septum and posteriorly to the vomer and perpendicular plate.
The caudal septum plays a critical structural role in the nose. It provides support to the nasal tip and columella, and its position directly determines the symmetry of the nostrils. Deviation of the caudal septum is visible — it can be seen by looking at the underside of the nose — and produces functional obstruction at the nasal valve, the anatomically narrowest part of the nasal airway.
How Caudal Septal Deviation Differs from Other Septal Deviation
Septal deviation can occur at any point along the septum’s length. High dorsal deviations affect the bony portion of the septum and are typically managed by straightening the bone during septoplasty or rhinoplasty. Mid-septal deviations involve the cartilaginous body of the septum and are addressed by cartilage scoring, resection of the deviated segment, or cartilage grafting.
Caudal deviation is technically more challenging than posterior deviation for several reasons. The caudal septum is close to the nasal tip — structural changes in this area affect tip support and the appearance of the columella and nostrils. Standard posterior-to-anterior septoplasty approaches may not adequately address the caudal end. And the caudal septum is under significant structural load — any reconstruction needs to maintain support for the overlying nasal tip and columella or the tip may drop.
For this reason, caudal septal deviation is often managed as part of rhinoplasty — using an open approach that allows direct visualisation and precise reconstruction of the caudal end — rather than as a simple septoplasty performed through the nostrils.
Clinical Presentation — What Patients Notice
Patients with significant caudal septal deviation typically present with one or more of the following:
- Nasal obstruction — typically worse on one side, often worse at night or during exercise
- Nostril asymmetry — one nostril appearing narrower than the other when viewed from below
- Crooked or off-centre nasal tip — the tip deflects toward the side of the deviation
- Columellar deviation — the columella (the strip of tissue between the nostrils) appears angled rather than vertical
- Snoring or disturbed sleep — nasal obstruction increases mouth breathing and palatal vibration during sleep
- Difficulty breathing through the nose during exercise
In some patients the deviation is primarily aesthetic — the nose looks crooked but breathing is not significantly impaired. In others, functional obstruction is the dominant concern. Most commonly, both aesthetic and functional elements are present to some degree, and their relative contribution is assessed at consultation.
Diagnosis
Caudal septal deviation is diagnosed by clinical examination. Anterior rhinoscopy — examining the inside of the nose with a speculum and good light — allows direct visualisation of the caudal septum and its position relative to the midline. Nasal endoscopy, which uses a narrow telescope passed into the nasal cavity, provides a more detailed assessment of the septum along its full length, the turbinates, and the nasal valves. In patients with significant deviation or coexisting sinus disease, a CT scan of the sinuses may be performed.
Physical examination also includes assessment of the external nose — the nasal tip position, columellar symmetry, and nostril shape — and palpation of the caudal septum to assess its position and the degree of tension or dislocation from the anterior nasal spine.
Surgical Management
Correction of caudal septal deviation is tailored to the specific anatomy. The surgical approach — and the technique used — depends on the severity and type of deviation, whether cosmetic rhinoplasty is also being performed, and the individual patient’s anatomy.
Recovery from caudal septal surgery is similar to standard septoplasty — most patients return to work within seven to ten days. Where an open rhinoplasty approach is used, an external splint is worn for the first week and swelling resolution follows the rhinoplasty timeline, with the final result at twelve to eighteen months.
Medicare and Private Health Insurance
Septoplasty for caudal septal deviation with documented functional obstruction is a Medicare-rebatable procedure. The relevant MBS item numbers (including item 45641) attract rebates from both Medicare and private health insurance. Where simultaneous cosmetic rhinoplasty is performed, the functional and cosmetic components are itemised separately. A detailed itemised fee estimate is provided at consultation.
Dr Roth’s Clinical Perspective
Caudal septal deviation is one of the more satisfying problems to correct because the functional improvement is usually substantial and the aesthetic benefit — a straighter, more symmetrical tip — is immediately visible. The challenge is in the reconstruction. Simply removing or trimming a deviated caudal septum without adequate replacement of the structural support leads to tip ptosis and loss of projection over time. I approach caudal deviation as a structural problem requiring structural solutions — whether that is repositioning with a swinging door technique, replacement with a straight graft, or stabilisation with columellar strut grafts — rather than a simple resection.
Many patients who present with what they describe as a crooked nose — where the whole nose appears off-centre — have a significant caudal component to their deviation. Addressing only the bony dorsum without correcting the caudal septum produces a result where the upper nose is straight but the tip and columella remain deviated. A thorough assessment at consultation is essential to identify all contributing factors.
— Dr Jason Roth, MBBS, FRACS (ORL-HNS), IBCFPRS
Septoplasty → | Rhinoplasty Surgery → | Nasal Valve Collapse → | Arrange a Consultation →
Specialist Otolaryngologist & Head and Neck Surgeon
Specialist registration — Otorhinolaryngology, Head & Neck Surgery
View full profile | Septoplasty →
