SEPTOPLASTY & SMR

Presented by 2nd year residents, Ajou University Hospital, April 1996


Clinical Indicators for surgical procedures:
from
The American Academy of Otolaryngology-Head and Neck Surgery


Clinical Indicators for Nasal Septal Surgery

Strategy

Indicators (one of the following):

Nasal airway obstruction secondary to septal deformity
Persistent or recurrent epistaxis
Evidence of sinusitis secondary to septal obstruction
Symptomatic septal perforation
Headaches secondary to intranasal deformity (rhinogenic headache)
Lab tests (as indicated)
Other tests (as indicated)
Evaluation of airway patency
Type of anesthesia (as indicated)
Location of service (as indicated)

Process

Criteria for discharge

Recovery from anesthesia
No active bleeding
Removal of packing
Absence of signs of toxic shock

Outcome

Results

Absence of signs of toxic shock
Patency of nasal airway

Follow-up

Treatment of nasal crusting


1. HISTORY OF SEPTAL SURGERY

Freer (1902) : Submucosal resection of total septal cartilage
Killian (1904) : Modified `Freer method'
preservation of dorsal and caudal portion of septal cartilage
Mezenbaum (1929) : Septoplasty by `Swinging door' technique
Peer (1937) : Concept of removal of caudal septum and replacement after its alteration
Cottle (1958) : `Maxilla-Premaxilla' approach

2. ANATOMY

* Nasal septum
* Cartilage
Septal cartilage, anteriorly
* Bone
Perpendicular plate of ethmoid bone, posteriorly
Vomer, inferiorly
Maxillary crest - perpendicular projection from maxilla and palatine
anterior: cartilage, posterior: vomer
Palatine bone

* Orientation
Relate to the head in upright position
Cephalic
Caudal
Dorsal
Ventral

* Articulation
* Cartilage and bone : Fibrous attachment between perichondrium and periosteum
* Bone : End-to-end relationship

* Blood supply

* Innervation

* Function of nasal septum
* Separate the nasal column
* Dorsal support of nose
* Protective shock-absorbing mechanism frontal foss

* Divided 2 parts of septum
Vertical line between nasal bone tip and maxilla bone (nasal spine)
+- Anterior segment : more conservative
+- Posterior segment : easily and effectively treated


Septal deformity classified by Cottle
Simple deviation
Spur formation
Subluxation
Tension septums

Caudal border fracture
Septal crushes
Saddling with loss of the septal height

* Spur : Sharp angulation which may occur at the junction of vomer below,
with the septal cartilage and/or ethmoid bone above
- usually result of vertical compression forces
- increase the difficulty of flap elevation in this area
* Deviation : `C' or `S' shaped deviation
- usually involve both cartilage and bone or with external nose
* Dislocation : lower border of septal cartilage
* Associated abnormality
A. Lateral nasal wall : compensatory hypertrophy of the turbinate and ethmoidal
bullae in concave side
B. Maxilla : flattening of cheek, elevation of affected nasal floor, distortion of palate
with orthodontic abnormalies slightly smaller maxillary sinus on affected side
C. External nasal pyramid : cartilagenous deviation
the C deviation and S deviation


3. ETIOLOGY OF SEPTAL DEFORMITY

* Intrinsic factor (less common)

* Direct trauma - long term result
* Birth moulding theory
A. Abnormal intrauterine posture may result in compression forces acting on nose
and upper jaws
B. Displacement of septum due to torsion forces during parturition

* Extrinsic factor (more common)

* Abnormally large or laterallized premaxillary spine
* Abnormality of maxillary crest-vomer relationship
* Vomer fracture
* Deformity of perpendicular plate of ethmoid bone
* Previous nasal bone fracture
* Upper lateral cartilage abnormality
* Abnormality of lateral nasal fracture
* narrow and high nose


4. INDICATION

* Septal surgery for primary septal pathology
A. Alteration of nasal physiology
Assessment by rhinomanometry
Hx and P/E : most important
B. Closure of septal perforation
C. Bleeding
D. Sinus drainage
* Septal surgery as part of rhinoplasty
* Source of grafting material
* To obtain surgical access : hypophysectomy, Vidian neurectomy


5. PRINCIPLE OF SEPTAL SURGERY

* The septum is divided into anterior and posterior segment by a vertical line between
nasal processes of frontal and maxillary bone
* Anterior deviation : conservative SEPTOPLASTY technique
Posterior deviation : classic Killian SMR operation

6. PROCEDURES

* Anesthesia
* Cotton pledgets satured in anesthetic solution
- High in the superior meatus : anterior ethmoidal nerve
- Posterior end of middle turbinate : sphenopalatine ganglion
- Floor of anterior nares : nerves issuing from the incisive canal
* Injection of Xylocaine
* No more than 5 ml of 1~2% Xylocaine with 1 : 80,000 epinephrine
- the membranous septum
- the lower end of upper lateral cartilage
- the front of inferior turbinate
- the region of incisive canal in each side
- along the base of vomer
- Opposite side to septum for speculum
* Midportion of septum is not recommended because of existing arterial and venous connection of cranium

* Incision
* Killian's incision
Junction of vestibular membrane with mucous membrane of septum
* Hajek's incision, Freer or hemitransfixion incision
- Extreme anterior margin of septal cartilage
- To remove anterior portion of deflected cartilage
* Side : concave side
usually left side due to right handed surgeon

* Elevation of mucoperichondrium and periosteum
( Developement of anterior and inferior tunnel at one side )
* Begin with sharp or semisharp elevator and completed with dull elevator at one side
(Opposite side perichondrium attach to septal cartilage intact)

* Elevator is directed parallel with the ridge of nose
- The direction of the least resistance
* Elevation should be made with whole shank of instrument on downward and backward direction to the crest of vomer
* Incision through the periosteum along the crest of maxilla and vomer
* Elevator is reintroduced and continued to nasal floor
* ELEVATION MUST BE DONE WITH AVASCULAR PLANE (Subperichondrial and subperiosteal)

* Separation of the septal cartilage from the bone
* Separation starts at dorsal part
* Boomerang shaped piece of cartilage excision
* Opposite site subperiosteal elevation
- Extension of superior tunnel and development of opposite side inferior tunnel

* Displacement of septal cartilage laterally
`Swinging door' technique
- Subperiosteal plane is elevated from the contralateral surface of the perpendicular plate of the ethmoid
- Septal cartilage : swing freely
Opposite mucoperichondrial flap is still attached
Posterior and posteroinferior parts of the bony septum : inspection *

* Removal of maxillary crest and vomer
* By V(U)-shaped gouge and mallet
* Until the ridge is removed in its entirety
* Vomer - separated from mucoperichondrium
* Gouge directed parallel to anteroposterior direction of crest of vomer

* Removal of deviated portions of perpendicular plate of the ethmoid
By Foster-Ballenger bone forcep
Heavy dressing forcep
Jansen-Middleton bone forcep
Bone scissors

* Straightening of septal cratilages by
* Full-thickness incision on the concave side of septum with preserving opposite side
perichondrium for blood supply
* Wedge excision of convex side
* Morselization : crush to some extent
* Checkerboard method of gridding
Crossing cut through the cartilage to, but not into, the opposite perichondrium
Cartilage island
Retain the nourishment of the still-intact contralateral perichondrium
* Excision of fracture line - Silver excision
Obvious old fracture line : responsible for the deviation

* Membrane approximation suture
From one side to other
Back and forth
Closing transfixion suture
Caudal portion of septal cartilage suture with periosteum of nasal spine

* Dressing
* Purpose
Coaptation of the membrane
Prevention of formation of a blood clot in mucoperichondrial pouch
* Removed in 4~6 days

7. COMPLICATIONS


* Hematoma
Cause : failure to close intramembraneous dead space
Signs : swelling and pain
Drainage through the previously made incision
Needle aspiration
Appropriate packing and antibiotics coverage

* Infection
Septal abscess : from trauma, complication of infectious disease
pyogenic bacteria invade hematoma and convert into abscess

* Hemorrhage
Usually from mucosal tears
Repair with suture

* Nasal obstruction
Usually related to scar formation (synechiae) or turbinate hypertrophy
Synechiolysis or laterallization of turbinate
Turbinectomy

* Septal perforation
Bilateral mucosal tear opposite one another
Cause - * Postop infection
* excessive packing
* hematoma
* too tight suture

* Nasal deformities
Excessive removal of septal cartilage
Postop nasal deformities : 1~2 months after surgery
at the junction of upper and lower cartilage,
along the dorsum or by retraction of columella
Lessened by replacing small pieces of cartilage
Saddle nose, broadening of the nose, twisted nose

8. SEPTAL SURGERY IN CHILD
Avoid until age of 16, if possible
More conservative
Reduction of septal dislocation in newborn


9. VARIOUS TECHNIQUE

* Inferior tunnels
Making inferior tunnel with greatly curved tunnel elevator
Close contact with nasal bony floor
Semicircular movement
Repeated in other side

* Vomerine spur
Repeated osteotomy from above spur,
down to spur
In major spur, if dissection is difficult fracturing the intervening part after osteotomy : make easy for dissection

* Deviation of PP of ethmoid bone
Remove with cutting or fracturing
Replace with hemograft cartilage or laminar transposition
Supplement posterior fracturing with Cottle elevator

* Premaxillary deviation

* Large wing of the premaxilla without other deviation
- Subluxatioon or dislocation of inferior margin of septal cartilage
- Sagittal chiselling of the most prominent part
- Reposition to the median line

* Deflected premaxilla and anterior end of the vomer
- Remove pronounced premaxillary wing
- Leaving deflected premaxilla
- Preserve premaxilla and place the posterior corner of the cartilage
- Anterior part trimmed to fit the height

* Deviation of septal cartilage

* Nasal dorsum straight in sagittal plane
Support : good
- Fitting
- Close to the maxilla

* Nasal dorsum sinking in sagittal plane
Support : poor, `lift up'
- Freeing inferior part of septal cartilage
- Lifting the free cartilage
- Trim inferior margin
- Place figure of 8 suture somewhat more posteriorly in the cartilage

* Straightening curved cartilage
* Scarification
* Transection

* Residual deviation of the inferior edge
- Suture with periosteum by figure of 8 for fixation
- Use non-absorbable material
- Drill and wire
- Suture with vomer for further fixation

* Caudal deviation
- If caudal edge is less than 3 mm from the middle line : freeing, scarification and fixation
- Suture with nasal spine
- If greater than
: transection from the concave side or wedge excision from the convex side

* Fracture caudally, the remainder plane
- Reinsertion of the fragmented pieces in postroinferior part
- Caudal part
: Take a piece of straight cartilage and graft through and through suture

* Residual deviation of central parts
- Circular excision of three quarters of deviating area
- Sagittal smoothing of the peak
- Re-insertion in other side
- At least 1 cm below the dorsum must not be touched

* Laminar transposition
- At least 5 mm from edge must be preserved
- Cut with curved osteotome
- Make drill hole
- Trimming
- Replace and figure of 8 suture

* Suture

* Figure of 8 suture
* transfixion suture

* Tubes for respiration

* Packing

3~4 days after resection or very small plastic repairs to prevent synechiae
6 days after major resection


9. REFERENCES

1. Cummings et al, Otolaryngology-Head and Neck surgery, 2nd Ed. Vol 1, P 786~80, Mosby, St.Louis, 1993
2. Finn Jeppesen, Septo and Rhinoplasty, P41~66
3. Hollinshed, Anatomy for surgeon, 3rd Ed, vol 1 P230~248