Septoplasty and Turbinate Surgery

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What is the clinical presentation of a patient with a deviated nasal septum and when should surgical correction be considered?

Nasal septal deviations can be congenital, developmental, or secondary to nasal trauma. Approximately 50% of the general population are thought to have some deviation in their nasal septum, and up to one third of individuals will seek medical care for nasal obstruction. Patients will often present with nasal congestion and can also present with nasal drainage, decreased sense of smell, and impaired sleep. If the deviation is severe, it can impinge on the turbinates, lateral nasal wall, and middle meatus and can predispose patients to recurrent and/or chronic rhinosinusitis. Medical therapy in the form of intranasal steroids is the first-line treatment. If this fails, surgical correction should be considered in appropriate patients with chronic symptoms that are significantly affecting their quality of life.

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What are the various approaches to the nasal septum when performing a septoplasty?

Typically, a septoplasty is performed through an endonasal approach. A unilateral incision is made just beyond the mucocutaneous junction, known as a Killian incision, or more anterior at the mucocutaneous junction, known as a hemitransfixion incision. The latter type of incision allows better access to the caudal septum compared with a Killian incision and allows for elevation of bilateral mucoperichondrial flaps if needed. A full transfixion incision is one that is made at the mucocutaneous junction on one side and is extended through to the contralateral mucocutaneous junction. Again, this type of incision allows for access to the caudal septum, columella, and medial crura. The hemi- and full transfixion incisions can cause disruption of the septo-columellar ligamentous tissue and can theoretically lead to loss of nasal tip support. Finally, complete access to the entire septum can be achieved via a degloving, or external rhinoplasty, approach if more advanced maneuvers are required for addressing abnormalities of the dorsal and/or caudal septum ( Fig. 28.1 ).

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What is an endoscopic septoplasty?

Most otolaryngologists perform a septoplasty using a headlight and direct vision for visualization of the surgical field. Many otolaryngologists are now using the endoscope for enhanced visualization. Outcomes are similar between approaches and choice of approach is best left to surgeon discretion in individual cases. Advantages of the endoscopic approach include magnification of the surgical field, improved access and visualization of the posterior nasal cavity, and the potential for more limited dissection in specific cases. Disadvantages include a potential inability to adequately address severe deviations of the anterior and caudal septum. Since the endoscope is often used through incisions that are traditionally used for headlight visualization, a more accurate term for this procedure may be endoscopic-assisted septoplasty.

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What are the steps for performing a typical septoplasty?

• 1.

  Decongest nasal cavities with topical oxymetazoline spray. Inject lidocaine mixed with epinephrine into the septum bilaterally in a subperichondrial plane.

• 2.

  Make an incision near the caudal septum. Elevate flap in the subperichondrial plane using broad, sweeping movements with the elevator. The elevation is carried posteriorly as required.

• 3.

  Disarticulate septal cartilage from the bony septum and resect portions of bony septum as required.

• 4.

  Resect deviated portions of septal cartilage as required, taking care to leave dorsal and caudal struts with a width of at least 1.5 centimeters for proper support of the nasal tip and dorsum.

• 5.

  Repair any tears in the mucosal flaps primarily with dissolvable suture, if possible.

• 6.

  If opposing tears exist, consider replacing excised cartilage into the mucoperichondrial pocket to decrease the risk of septal perforation, taking care not to cause further obstruction of the nasal cavity by doing so. Also consider documenting the precise amount of cartilage excised or remaining in the operative note, in case revision surgery is ever needed.

• 7.

  The mucosal incision is then closed with absorbable suture. At this point, the septum can be quilted with absorbable suture and/or splints can be placed.

5

What are the possible risks involved with septoplasty?

Risks include infection, bleeding, nasal dryness/crusting, persistent nasal congestion after surgery, septal hematoma/abscess, septal perforation, scarring, alteration of sense of smell/taste, numbness, CSF leak (rare), cosmetic deformity, complications of anesthesia, and need for further surgery.

6

What is the anatomy of the inferior turbinate?

The inferior concha is its own bone and attaches to the medial maxilla. The medial submucosal tissue is composed mostly of venous channels and erectile tissue, whereas the lateral submucosal tissue is mostly glandular. Hasner’s valve, which marks the opening of the nasolacrimal duct inferiorly, opens into the inferior meatus lateral to the inferior turbinate.

7

What are the topical medications typically used during septoplasty/turbinate surgery?

Topical oxymetazoline and topical epinephrine are medications that are commonly used during nasal and septal surgery. These medications work as alpha-1 receptor agonists, causing vasoconstriction and decongestion of the nasal mucosa, resulting in decreased systemic absorption of local anesthetics, improved visualization and working space, and hemostasis. Topical cocaine is less commonly used nowadays but is a very effective decongestant and anesthetic. These medications can be applied preoperatively and/or intraoperatively as needed. Care should be taken to only use these medications topically. Intravascular administration can cause immediate and life-threatening hypertension, tachycardia, and arrhythmias and could lead to myocardial infarction or stroke.

8

Which anesthetics are used during septoplasty/turbinate surgery? Can surgery be performed under local anesthesia?

Currently, most nasal surgery is performed under general anesthesia, although some surgeons prefer local anesthesia. During surgery, a local anesthetic mixed with dilute epinephrine is injected into the submucosal septum/turbinates. This results in hydrodissection of the injected plane, assisting with ease of surgical dissection and improved hemostasis as a result of vasoconstriction caused by the dilute epinephrine and helps with analgesia in the immediate postoperative period.

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