Perception of Caudal Septal Dislocation and
Practices of Otolaryngologists in Saudi Arabia
Ibrahim AlQuniabut1*, Abdulaziz Abuabat2, Ibrahim AlAwadh3, Abdulrahman Alfarhan2 and Abdullah Altuaysi4
1Department of Surgery, Qassim University, Saudi Arabia
2College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Saudi Arabia
3Department of Surgery, King Abdulaziz University Hospital, Saudi Arabia
4Otolaryngology Head and Neck Surgery Department, King Saud Hospital, Saudi Arabia
Submission:April 04, 2021; Published: May 06, 2021
*Corresponding author:Ibrahim AlQuniabut, Assistant Professor of Otorhinolaryngology Head and Neck Surgery, Department of Surgery, Unaizah College of Medicine and Medical Sciences, Qassim University, Kingdom of Saudi Arabia
How to cite this article: Ibrahim A, Abdulaziz A, Ibrahim A, Abdulrahman A, Abdullah A. Perception of Caudal Septal Dislocation and Practices of
Otolaryngologists in Saudi Arabia. Glob J Oto, 2021; 24 (3): 556136. DOI: 10.19080/GJO.2021.24.556136
Introduction: The nasal septum is the internal part of the nose, which holds a vital role in maintaining the functional and structural integrity. Considering its anterior location, the caudal septum is subjected to trauma, which makes it vulnerable to dislocation. This study aims to study the current practices and perception of otolaryngologists in Saudi Arabia in dealing with such cases.
Methodology: A survey study targeted otolaryngologists in Saudi Arabia.
Results: A total of 77 surgeons answered the survey. Septal repositioning was the most com-mon technique used by the participants. Asymmetrical nostrils and nasal obstruction were the two most common patient complaints. 67% felt comfortable dealing with such cases and 32% were uncomfortable and refer cases to facial plastic specialists. Significant correlations were found between the area of specialization and the desired surgical outcome, with a p-value of 0.001. Facial plastic specialists target functional and aesthetic outcomes, while non-facial plastic focus on functional outcomes. In addition, a significant difference was found in terms of comfort level and competency between non-facial plastic and facial-plastic otolaryngologists, with a p-value of 0.004 favoring the latter.
Conclusion: Discrepancies were found in terms of practices, perception, and comfort level in dealing with caudal septal dislocation among otolaryngologists in Saudi Arabia, suggesting that various surgical techniques are used in correcting caudal dislocation and that there is a diversity of cases presented in residency programs.
The nasal septum forms the foundation for the nasal pyramid, providing central support to the osseocartilaginous framework of the nose. The caudal septum is the inferior-anterior segment of the cartilaginous structure. The caudal septum extends beyond the anterior nasal spine and thus it can be subjected to trauma that can ultimately lead to deviation or dislocation . The stability and functionality of the caudal septum is critical for maintaining the patency of the nasal nostrils. Caudally, the cartilaginous septum has a great impact on the shape of the dorsum of the nose and the nasal tip.
Nasal obstruction is a highly prevalent complaint in Saudi Arabia, and one that negatively affects patients’ quality of life .
A deviation in the caudal septum can compromise the ex-ternal
nasal valve, resulting in direct airway obstruction and impairment of the nasal airflow . Cosmetically, caudal septal irregularities can drastically affect lobular and columellar relationships, dorsal shape and projection, and tip position and symmetry .
Caudal septal deviation constitutes 8% of patients with nasal septal deviation [4,5]. Many causes of caudal septal deviations have been addressed in the literature and can be classified as either traumatic or iatrogenic. Most commonly, this deformity is the result of the effects of trauma [6,7]. The challenges of correcting caudal septal deviations are undeniable [8,9]. This attributable to the unique property of the nasal intrinsic cartilage memory . The literature shows significant differences of opinion regarding the appropriate technique used. [10,11] However, there is consensus regarding the main methods of addressing caudal nasal septum dislocation,  which be classified as cartilage reshaping
or reconstruction. A wide variety of techniques for both methods
have been introduced in the literature.
This study aims to report the practices and perceptions
of otolaryngology surgeons in Saudi Arabia in dealing with
caudal septal dislocation. To our knowledge, this is the first
study to provide fundamental information concerning Saudi
otolaryngologists’ and facial plastic surgeons’ approach to the
caudal nasal septum. This study also focuses on awareness of
surgical techniques and reviews the existing knowledge and
current practice of otolaryngology specialists regarding the
caudal nasal septum.
This was a cross-sectional survey-based study targeting
otolaryngology surgeons in Saudi Arabia. A self-developed
questionnaire was distributed electronically, and participants
were encouraged to take part. All otolaryngology consultants
and board-certified physicians practicing in Saudi Arabia were
included and targeted for the study. It contained several sections
including demographic data, region of practice, and sections about
types of surgical techniques used for caudal septal dislocation.
A pilot study was conducted among 10 participants prior to
the distribution to identify any issues or concerns with the
interpretation of the questionnaire. Study was conducted upon
approval in December 2020 up to January of 2021.
Table 1 shows the profile of participants. A total of 77
participated in the study, 55 (71%) of whom were males and 22
(28%) were females. The age group 30 to 35 composed most of
the participating physicians 34 (44%), while physicians in the
age groups 51 to 55 and 55 and above had the least number of
participants, with 5 (6.5%) each. The majority (40; 51%) had from
6 to 10 years of experience. Most of the participants are based in
the central region (51; 66%). A total of 56 (72%) participants
reported working in a governmental hospital, 2 (2%) in a private
center, and 19 (24%) reported working in both.
Table 2 reports participants’ answers to what the common
techniques are that are used in their own practice. A total of
54 (70%) participants said that they commonly use the septal
repositioning technique. The second most common technique
was the suturing technique (48; 62%), followed by the tonguein-
groove (29; 37%), and the wedging, scoring, or morselization
technique (23; 29%). Regarding the number of caudal septal
dislocation patients seen by our participants in their practice
per month, the majority (63; 81%) reported seeing less than 5
cases, 10 (13%) saw between 5 to 10 cases per month, three (3%)
reported seeing between 11 to 15 cases, and 1 (1%) reported
seeing more than 15 cases per month.
Table 3 shows the association between years of experience
as an otolaryngological surgeon and the level of comfort in
dealing with caudal septal dislocation cases, utilizing a chi-square
test with a p-value of .001. Surgeons who had 5 years or less
experience (5; 45%) felt uncomfortable. Most surgeons (12; 30%)
who had between 6 to 10 years’ experience felt semi-comfortable.
A large number (16; 61%) of surgeons with more than 11 years’
experience were semi-comfortable.
Table 4 shows the comfort level in association with the area of
specialization (p=0.004). Most non-facial plastic otolaryngologists
said they felt semi-comfortable in dealing with those cases,
whereas most facial plastic specializing otolaryngologists felt very
comfortable with them. Table 5 shows the association between
the area of specialization and the desired surgical outcomes
post-surgery for caudal septal dislocation. Practicing as a general
otolaryngologist (32; 88%) was associated with considering both functional and aesthetic outcomes in dealing with those
patients with a (p=0.001) and working as a subspecialized
non-facial plastic otolaryngologist (18; 48%) was associated
with considering functional outcomes to a greater extent (p-
=0.001). Regarding subspecialty, working as a specialized facial
plastic surgeon (4; 100%) was associated with considering both
To our knowledge, this is the first study in the literature to
discuss and report the current practices and perceptions of
otolaryngologists in Saudi Arabia in dealing with caudal septal
dislocation. Caudal septal dislocation is challenging to repair, with
many proposed techniques aiming to achieve the most desirable
aesthetic and functional outcomes . Failure to address caudal
septal dislocation appropriately can result in many devastating
functional and cosmetic consequences, resulting in possible
need for revisional surgery. Septal repositioning and suturing
techniques were the two most popular surgical techniques among
our participants. These results contrast with the findings of a
study that evaluated the practices of otolaryngologists in North
America, where the two most popular techniques for caudal
correction were swinging door and extracorporeal septoplasty,
69% and 46%, respectively .
Table 3 shows the relationship between years of experience
as an otolaryngologist and comfort level in dealing with caudal
septal dislocation. In our study, surgeons with 11 or more years’
experience prefer to be more conservative with caudal septal
dislocation, as they tend to be semi-comfortable in dealing with
such cases and unlikely to refer them to a facial-plastic specialist.
Interestingly, we found in our study that surgeons with 6–10
years’ experience showed extreme and contradicting preferences
of either being uncomfortable with them and tending to refer
them to specialized facial plastic or comfortable in dealing with
caudal dislocation cases. However, for future research it is worth
investigating whether this lack of comfort in dealing with caudal
septal dislocation among junior surgeons is due to a lack of
training and exposure to such cases during residency training or
a sub specialization effect. Data from such studies can be useful
in determining weaknesses in residency training and correcting
them for future generations of surgeons.
In Table 4, we can see a significant difference in comfort
level about area of specialization. Otolaryngologists specializing
in facial-plastic were overall more confident and comfortable
dealing with caudal septal dislocation patients, while the selfreported
comfort level of otolaryngologists not specializing in
facial-plastics varied, with the majority feeling semi-comfortable.
This raises the important question of whether these differences
reflect an actual lack of exposure and training in dealing with
caudal septal dislocation patients, and whether more emphasis is
needed to be put in place during residency training to train future
otolaryngologists to feel more confident and experienced with
As shown in Table 5, we again see a difference between facialplastic
otolaryngologists and non-facial plastic otolaryngologists
in terms of desired post-correction outcome in caudal septal dislocation. All the facial-plastic otolaryngologists surveyed target
functional and aesthetic improvement with equal importance.
However, answers from surgeons from different areas of
practice (i.e., general otolaryngologists and other specialties of
otolaryngology) varied from targeting solely functional outcomes
or favoring both functional and aesthetic outcomes. All in all,
these findings show that although post-correction aesthetic goals
are important, most surgeons prioritize achieving functional
improvement of their patients above all else.
Our study discussed the current practices and perceptions
of otolaryngologists in dealing with caudal septal dislocation in
Saudi Arabia, an ambiguous area of practice in otolaryngology with
many proposed techniques, the most popular of which among our
participants was the septal repositioning and suturing technique.
Significant associations were found among self-reported comfort
level, area of specialization, and years of experience as an
otolaryngologist. These findings can promote further research
in this area to investigate whether residency pro-grams in the
Kingdom of Saudi Arabia have sufficient training and exposure for
their trainees in dealing with caudal septal dislocation cases.