Septoplasty

septoplasty

1. Septoplasty Presenter : Dr. Taba Nitin ENT PGT Silchar Medical College and Hospital. Moderator : Dr. Shams Uddin Prof. and HOD Dept. of ENT and Head and neck surgery. SMCH

2. Introduction The term septoplasty takes its meaning from the Greek term that means “to reshape or mold the septum.” Surgical techniques have subsequently been improved, especially with the advent of endoscopy. Techniques used today are geared toward septal resection, but more emphasis has been placed on preservation, realignment, or a combination of the two. Most standard procedures today recognize mucosal preservation as a primary goal and make use of a submucosal approach to the cartilaginous and bony abnormalities. It is done when the septal L-strut is involved as SMR is ineffective in this cases.

3. Historical Perspective of septoplasty and its trend. The earliest written treatise describing the correction of a deviated septum dates back to the Egyptian Edwin Smith Surgical Papyrus (c. 3000 B.C.), which prescribed closed reduction with Splinting. Quelmaltz : proposed daily digital pressure to correct a deviated septum in the 18th century. In 1875 Adams proposed closed reduction and splinting for treatment of a deviated septum. While the physiological role of the nasal septum remained poorly understood during the 19th century, surgeons emphasized on excising obstructing segments of the septum in an atempt to relieve nasal obstruction.

4. Krieg (1890s), performed septectomies , removing entire segments of septal cartilage and bone along with its mucosa. These patients enjoyed a short-lived improvement in nasal obstruction, only to suffer nasal whistling, crustng , epistaxis , worsening nasal obstruction from turbulent airflow, and saddle nose. And later Krieg concluded that mucosa preservation and removal of only deviated septal cartilage could decrease complications. Bosworth sawed off deviated septal spurs, sacrificing the ipsilateral mucosa while maintaining the contralateral mucosa. Asch (1899) proposed a full cruciate incision through the cartilaginous septum to “destroy the resiliency” of the cartilage while preserving mucosa.

5. In 1882 Ingals , who some call the father of septoplasty , described the targeted resection of a deviated septum with the preservation of bilateral mucosa. Up to this point, there was little emphasis on the septum’s role in providing structural support for the external nose. In fact, experts at the time considered the septal mucosa to be the only physiologically relevant structure within the nose. Patients with overly aggressive septal cartilage resection eventually developed nasal tip ptosis , columellar retraction, and saddle nose deformity.

6. Era of Contemporary Septoplasty Techniques : Submucous resection : At the turn of the 20th century, Freer and Killian ushered in the era of contemporary septoplasty . They proposed submucous resection of the deviated septum while maintaining a dorsal and caudal strut of the cartilage of suffcient size to support the nose . In 1929 Metzenbaum described Swinging Door technique for Caudal Septal Deviation. Cottle 1947 advocated for a more conservative “maxilla- premaxilla ” septoplasty approach. King and Ashley introduced extracorporeal septoplasty in 1952. Endoscopic septoplasty was introduced by Giles and colleagues in 1994 .

7. The nasal septum The nasal septum has both functional and aesthetic significance. The septum is the main support structure of the external nose. It divides the nose into two cavities, regulates airflow through the nose, and supports the mucosal lining of the nasal cavities.

8. Parts of nasal septum 1. Columellar Septum : It is covered on either side by skin. It contains medial crura of lower lateral cartilages, joined together with fibrous tissue. 2. Membranous Septum: It lies between the columella and the caudal border of septal cartilage and consists of only double layer of skin. There is no bony or cartilaginous support in membranous septum. 3. Septum Proper: It is covered with mucous membrane and consists of osteocartilaginous framework. Perpendicular plate of ethmoid , the vomer and a large quadrilateral septal cartilage, which is wedged between vomer and ethmoid plate. Other bones, which make very small contributions, include crest of nasal bones, nasal spine of frontal bone, rostrum of sphenoid, crests of palatine and maxilla and the anterior nasal spine of maxilla.

9. A projection of the septal cartilage called the sphenoidal process or septal tail extends posteriorly between the vomer and perpendicular plate of the ethmoid . The septal tail can serve as an additional source of cartilage to harvest especially during revision rhinoplasty . The inferior attachment sits within the nasal crest of the maxilla and is bound by looser connective tissue creating a pseudoarthrosis . This joint allows mobility of the septal cartilage base during flexion thereby reducing the risk of fracture or dislocation with trauma.

10. Mucosa : pseudostratified columnar epithelium  along inferior two-thirds olfactory epithelium  along superior one third.

11. Embryology of nasal septum Development of the nasal airway begins during the fourth week of gestation. The nasal septum develops as a downgrowth from the merged medial nasal processes and the nasofrontal process and thus defines the right and left nasal cavities. During the ninth week : The nasal septum and the palatine processes begin to fuse anteriorly . Fusion is completed posteriorly by the twelfth week. During the late embryonic period, the epithelium invaginates on each side of the nasal septum, thereby forming diverticula known as the vomeronasal organs. A vomeronasal cartilage develops ventral to each diverticulum . Shortly before birth, the vomeronasal organs begin to regress and usually disappear completely; the vomeronasal cartilages are usually the only adult remnants.. The perpendicular plates of the ethmoid and the nasal bones do not completely ossify until puberty.

12. Blood supply of nasal septum Both the external and internal carotid arteries contribute to the vascular supply of the nasal septum. External carotid  internal maxillary artery. 1 . Sphenopalatine artery ( supply posteroinferior septum through posterior septal artery) ** The posterior septal artery is the basis of the nasoseptal mucosal flap which is the workhorse for endoscopic skull base reconstruction. 2. Greater palatine arteries enters the nasal cavity through the incisive canal. supply the anteroinferior portion of the septum. 3. Superior labial artery : (branch of the facial artery.) supply the caudal septum and columella . Internal carotid  the ophthalmic artery Anterior ethmoid artery ( anterosuperior portion) Posterior ethmoid artery ( posterosuperior portion)

13. The venous system Posteriorly : Sphenopalatine vessels  pterygoid plexus Anteriorly : facial veins Superiorly: The ethmoidal veins communicate with  superior ophthalmic system. There maybe direct intracranial connections through the foramen caecum into the superior sagittal sinus.

14. Nerve supply of nasal septum

15. Indications of septoplasty : Deviated nasal septum causing nasal obstruction and recurrent headaches. Deviated nasal septum causing obstruction to ventilation of paranasal sinuses and middle ear resulting in recurrent infections. Recurrent epistaxis from septal spur As a part of septorhinoplasty As an approach to surgeries of sphenoidal sinus, vidian nerve and pituitary gland.

16. DEVIATED NASAL SEPTUM Deviated nasal septum (DNS) is quite a common condition, which usually presents with nasal obstruction. There is no age and sex bar but usually males are affected more than females. Deviated nasal septum is more common in Caucasians. Etiological Factors Accidental trauma : A lateral blow displaces the septal cartilage from the vomerine groove and maxillary crest. A crushing frontal blow results in buckling , fractures and telescoping of its fragments. Childhood injuries are often forgotten . Natal trauma : Trauma inflicted to the fetus at difficult delivery (forceps) Antenatal : Abnormal intrauterine postures can compress nose and upper jaw . Developmental : Buckling of the nasal septum can result from unequal growth between the palate and the skull base.If septum starts growing at a more rapid rate than face, it becomes buckled. Mouth breathers : Buckling of nasal septum in children can result from highly arched palate, which occurs in mouth breathers such as in adenoid hypertrophy . Mass in nose : Tumors and polyps of nose

17. Types of DNS Anterior dislocation (caudal septal deviation ) C-shaped deformity or reverse C-shaped deformity S-shaped deformity Spurs Thickening

18. Type I : Mild deviation in vertical plane Type II : Moderate anterior vertical deviation of cartilaginous septum in full length. Type III : Posterior vertical deviation at level of OM and middle turbinate Type IV : ‘ S’-shaped, posterior to one side and anterior to other Type V : Horizontal septal crest touching or not touching the lateral nasal wall Type VI : Prominent maxillary crest contralateral to the deviation with a septal crest on the deviated side Type VII : Combination of previously described septal deformity types

19. Some special tests to consider before septoplasty 1. Acoustic rhinometry : The sound waves are delivered to nasal cavity and the reflected sound waves are measured ( rhinogram ), which include calculation of minimal cross-sectional area of nose and nasal airway resistance . The first and second dips in rhinogram are caused due to nasal valve and anterior tips of turbinates (inferior and middle) respectively . 2. Rhinomanometry or rhinometry : This computerized electronic technique measures transnasal pressure and resultant nasal airflow . Initially , water columns and mechanical devices were used in rhinomanometry . More than 3 cm H2O/L/s combined bilateral resistance of adult nose at rest indicates nasal obstruction.

20. Investigations X ray CT scan Can help us in planning the surgery well.

21. SEPTOPLASTY STEPS

22. The surgical field The surgical field must be optimized. Hemostasis is obtained by: 1) working with the anesthetist to reduce cardiac output. *** Fentanyl and versed acts as a stabilizer for cardiac and smooth muscle; these combined agents counter the potential increase in heart rate or blood pressure that is sometimes seen. 2) positioning the patient with the head raised about 30 degrees to reduce dependent vasocongestion , 3) Placement of neuropatties containing 1 : 1000 epinephrin . The (right-handed) surgeon is placed on the patient’s right.

23. 1% lidocaine with 1 : 100,000 epinephrine is used with a maximum suggested dose of 4 to 7 mg/kg, depending on the epinephrine content. We rarely use more than 10 mL , which is well within the safety limits for adults. The local injection is performed with either a 27- or 30-gauge needle. Due to hydrodissection correct dissection plane can be identified. The injection is started at the caudal end of the septum, and secondary injections are performed more posteriorly , until the mucosa is well blanched, or until maximum volume based on patient weight is met. Forceful injection is avoided to prevent retrograde vascular communication. The contralateral membrane should also be injected, and so should the area of the nasal floor around the maxillary crest. After the injection is performed, waiting at least 10 minutes ensures maximum vasoconstriction. Local A naesthesia infiltration

24. The Incision and approach Insert the nasal speculum into the nose and gently retract the slightly opened speculum revealing the caudal septal edge. The No. 15 blade is then used to incise mucosa down to and through the perichondrium on the concave side. 1. The hemitransfixion or transfixion incision: It is made at the caudal border of the septum. Allows access to the deviated caudal septum and any posterior deflections. The incision is created within the squamous epithelium of the vestibule and hence has less of a tendency to tear under stress. The length of the incision depends on the access required. If access is required to the whole of caudal arm of the L-strut then a full hemitransfixion is used. However, if access is not required for the most posterior parts of the septum, then a partial hemitransfixion would suffice. If access is required to the floor of the nasal cavity then an extended hemitransfixion incision is used. In certain conditions, both mucosal flaps are raised (e.g. S-shaped septal deformity)

25. Open Rhinoplasty approach : Some may still approach the septum through an open rhinoplasty approach using marginal and transcolumellar incisions. In the open approach to the septum, after a transcolumellar skin incision is made, the medial crura are separated, and the caudal septum is then identified. Tip support is significantly weakened with this open dissection technique, therefore we reserve this approach for those undergoing an open approach to septal perforation repair or in complex cases.

26. Plane identification and mucoperichondrial flap elevation Identification of the proper plane. This can be achieved by scoring the area to find the desired plane. The Cottle elevator, with its two dissecting faces—one shaped like a sharpened spade, the other more flat and dull is used to raise the envelope under direct vision. The sharper, spadelike end is used first to begin the dissection in the submucoperichondrial plane.

27. After the dissection is started, the flat and dull end efficiently elevates the envelope in an atraumatic fashion. Elevate the envelope with a wide front to ensure the best visibility and to decrease the risk of mucosal tearing. Longer specula are now used as the dissection proceeds posteriorly .

28. When the bony osseocartilaginous junction is reached, this junction is disarticulated to gain access to the opposite side of the bony septum. Carefully raise the mucosal flap from the opposite side of the bony septum. Disarticulation of the quadrilateral cartilage from the maxillary crest. Septum moved to midline. Often a sliver of bone or cartilage needs to be removed. The 1 cm of bony-cartilaginous junction at the L-strut is left undisturbed if possible but often this area requires special attention.

29. Managing the spur Raising the flap over a septal spur can be challenging as the perichondrial fibres of the cartilaginous septum and the periosteal fibres of the maxillary crest are interwoven. The mucoperichondrial flap is raised over the quadrilateral cartilage and the bony septum; this constitutes the anterior tunnel over the spur. Then another subperiosteal tunnel is raised posterior to the septal spur which constitutes the posterior tunnel. Connecting the two tunnels directly helps to avoid mucosal tears. The dissection may be eased with the use of the sharper spade end of the Cottle elevator

30. The risk of membrane fenestration is greatest in the area of a spur. To mobilize the bony deviation or spur, Becker septal scissors are used to make cuts in the bony septum above and below the deviated septal segment or spur. To prevent cribriform plate injury, the superior bony septum is never manipulated without first performing a superior septal incision or cut. Even then, any posterior septal removal is done within one rotational plane.

31. Removal of the freed segment with a nonbiting forceps completes the resection using wide-mouthed Watson-Williams forceps

32. SEPTOPLASTY TECHNIQUES The deviated septum can be addressed by : 1) Cutting techniques 2) Grafting techniques 3) Suturing techniques 4) Relocating techniques. The techniques can be used alone or in combination.

33. CUTTING TECHNIQUES Scoring of the septal cartilage on the concave side allows the septum to become straight. The septum will be kept in position by the scar tissue in grooves created by scoring on the concave side In S-shaped septal deformities, the scoring needs to be done on the concave segments on both sides; hence the need for raising bilateral mucoperichondrial flaps. In the swinging door technique, an appropriate amount of caudal L-strut is excised to allow the septum to return to the midline. The septum then needs to be secured to the midline again; this can be achieved by suturing the septum back to the anterior nasal spine or its periosteum . To apply sutures to the anterior nasal spine, a hole is made in the bone using a strong hypodermic needle or using a drill with a Fissure burr. The septum is then secured in place with 4 x 0 PDS sutures.

34. GRAFTING TECHNIQUES This technique involves harvesting a suitable piece of perpendicular plate of ethmoid which is then thinned down using a large diamond burr (e.g. 5 mm diamond burr). The graft is then perforated using a Fissure burr and it is splinted against the concave side of the septum. Both septal cartilage and septal bone can be used. The perpendicular plate of ethmoid is stronger and thinner compared to the septal cartilage and so is used more frequently. Care must be taken to position the bony strut a few millimetres from the septal edge so that it is not felt by the patient and it does not cause obstruction for dorsal reconstruction (e.g. spreader grafts). A fine absorbable or non-absorbable suture is used to secure the graft to the septum (e.g. 5 × 0 PDSR). The deviation of the dorsal L-strut can be corrected by spreader grafts too. The concave part of the dorsal septum is scored and returned to midline; it is then splinted by spreader grafts and secured in place by sutures (e.g. 5 × 0 PDSR).

35. SUTURING TECHNIQUES A mattress suture can be used to control the septal curvature. In this technique, the septum is first scored (preferably underscored) just enough to make it pliable so it can be shaped and kept in shape by fine sutures. The entrance and exit sutures are placed on the convex side and the knot is incrementally tightened until the desired position and shape is achieved. A fine non-absorbable suture (e.g. 5 × 0 ProleneR ) is used for this purpose and bilateral mucoperichondrial flaps are raised so that the suture is covered by the septal mucosa. Bow-Tie Mattress Suture Universal horizontal mattress suture

36. Some other suturing techniques A, When reapproximating septal segments, a simple interrupted or figure-of-eight suture does not provide support for the segments and can lead to overlapping. B, A Wright suture stabilizes the fractured segments to one mucoperichondrial flap and to each other to maintain the proper alignment. To perform this maneuver, a figure-of-eight suture is made that includes the contralateral mucoperichondrial flap in both the sutures through the superior and inferior segments. Quilting mattress sutures of the septal flaps prevent hematomas and hemorrhage.

37. RELOCATING TECHNIQUES These techniques are used when the septum is dislocated off the midline and it only requires reinsertion onto the maxillary crest. A deviated septum off to the side of the maxillary crest must be separated from the bony perpendicular plate. The inferior cartilaginous portion must be trimmed and secured in its midline position Suture the septum either onto the periosteum of the anterior nasal spine or to the actual bone by drilling a hole onto it. Fine absorbable or non-absorbable sutures can be used for this purpose. Often a deviated caudal septum can be improved by door-stop technique where the septal cartilage is dissected free along the maxillary crest and is relocated over the nasal spine which acts as a door stop and secures the caudal septum in a straighter position.

38. Reskeletonizing the septum Postoperatively, septal flaps without interposed cartilage adhere to one another without supporting structure; these weakened flaps are susceptible to injury and potential perforation. Crushed cartilage placed between the mucoperichondrial flaps prevents motion of the membrane with inspiration or expiration, helps prevent septal perforation, and allows easier reentry if another procedure is required. After reskeletonization , the entire septal flap from anterior to posterior is mattressed with a continuous 5-0 plain stitch; a curved needle should be used for this purpose

39. Tongue-in-groove maneuver by Kridel and colleagues for caudal septal deviations. Bilateral mucoperichondrium elevated. After the septum along the floor and the crest are straightened, as described above, and after creation of the swinging door, the length of the septum is evaluated. If the septum is long, a conservative trim is warranted. Otherwise, the caudal margin can be repositioned to the midline nasal spine, secured, and sandwiched within a pocket created between the medial crural footplates. A columellar-septal mattress suture of 4-0 chromic gut is passed transcutaneously and holds the caudal septal margin and medial crura in place.

40. Preoperative image of a caudal septal deviation Postoperative view after septorhinoplasty using swinging door and tongue-in-groove techniques.

41. SPECIAL SEPTOPLASTY CONSIDERATIONS 1. Endoscopic septoplasty : Improve visualization It also allows minimal access dissection to reach isolated deviated parts of the septum particularly of more cephalic septal deformities. . Endoscopic septoplasty can be used concomitantly along with sinus surgery. It is also an effective teaching tool . 2. Extracorporeal septoplasty : In cases of a severely fractured and deformed septum. The septum (both cartilaginous and the bony segment) is excised in one piece as intact as possible . The septum is then measured and a template is made to represent the new septum .

42. 3. Paediatric septoplasty : There remains controversy about the optimal age and Extent of septal surgery in the paediatric population . Studies have demonstrated that septal surgery performed in children as young as 6 years old provides long-term satisfactory outcomes . The most important aspect of surgery is to resect the cartilage conservatively and to avoid disrupting the endochondral ossification plates if possible . Excision should be kept to minimum and any excised segment should be reinserted after remodelling .

43. POSTOPERATIVE CARE A light nasal pack is placed to prevent large clot accumulation. Tight packs are avoided as there is tendency to adhere to mucosa, cause pain, and create bleeding when removed. A single- or double-folded nonstick cotton pad impregnated with gentamicin cream is inserted before extubation and is removed the day after surgery. The use of cream, rather than petroleum-based ointment, may decrease the initiation of petroleum cysts during this early healing phase. After the nasal packs are removed, a thrice-daily regimen of saline flushing of the nose is initiated. Twenty-four hours after the procedure, when incisions are closed and sealed, the patient is instructed to start the instillation of antibiotic ointment into each vestibule. Gentle suctioning on postoperative days 5 through 7 and continued local care for at least 2 to 3 weeks allows for adequate healing. Gentle nose blowing is permitted after the third week, and strenuous exercise is discouraged for a total of 5 weeks.

44. COMPLICATIONS OF SEPTOPLASTY Most common : Persistence in the subjective complaint of nasal obstruction. septal hematoma septal perforations Nasal shape changes (e.g., tip ptosis , dorsal nasal saddling) synechiae Excessive bleeding CSF rhinorrhea Wound infection Septal abscess Toxic shock syndrome Sensory changes : anosmia or dental anesthesia

45. It is interesting to note that the goal of septal surgery is the same as it was 100 years ago.. but now the process has changed, the nasal surgeon strives to maximize the symptomatic improvement of nasal obstructive complaints and minimize the risks involved in such a pursuit

46. THANK YOU FOR YOUR ATTENTION

47. References Scott brown 8 th edition Cummings Otolaryngology 6 th edition