All Things Septoplasty

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Dr. Anil Shah, facial plastic surgeon in downtown Chicago, IL, discusses the importance of the septum in septoplasty and rhinoplasty.

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All Things Septoplasty

  1. 1. All Things Septum Anil R. Shah MD
  2. 2. Epidemiology <ul><li>33% of people complain of nasal obstruction </li></ul><ul><li>26% of those have deviated septum as the cause </li></ul>Vainio-Mattila J: Correlations of nasal symptoms and signs in random sampling study. Acta Otolaryngol Suppl 1974; 318: 1-48
  3. 3. Septum <ul><li>Essential for every otolaryngologist </li></ul><ul><li>Appreciate role of septum in functional surgery </li></ul><ul><li>Understand the importance of septum and aesthetics </li></ul><ul><li>Nuances of technique and anatomy </li></ul>
  4. 4. Anatomy <ul><li>Cartilaginous angles </li></ul><ul><ul><li>Anterior septal, middle septal, posterior septal angles </li></ul></ul><ul><ul><li>Foundation for the nose </li></ul></ul><ul><ul><li>Preserve 1.5 cm </li></ul></ul>
  5. 5. Vasculature and Nervous Supply <ul><li>Arteries </li></ul><ul><li>Nerves </li></ul><ul><li>What nerve at risk with nasal spine excision and what is the manifestation? </li></ul>Answer: Nasopalatine Nerve, Anesthesia Of anterior portion of hard palate and Incisors
  6. 6. Bony articulations <ul><li>What are the all the bones and bony interactions of the “septum”? </li></ul>
  7. 7. Bony articulations <ul><li>Bony articulations </li></ul><ul><ul><li>Quadrangular cartilage, vomer, perpendicular plaste of ethmoid, premaxilla, palatine bones </li></ul></ul><ul><ul><li>Superorly with frontal, nasal and sphenoid bones </li></ul></ul>
  8. 8. What is that?
  9. 9. Vomeronasal organ <ul><li>Vomeronasal organ for olfaction (primordial) </li></ul><ul><li>Aka Jacoben’s organ </li></ul><ul><li>Located on anterior septum </li></ul><ul><li>Found with endoscopy 76% of the time </li></ul><ul><li>Don’t biopsy but recognize as normal anatomic structure </li></ul>
  10. 10. Autonomic supply of nasal cavity <ul><li>What is the autonomic supply of the septum and where do the nerves synapse? </li></ul><ul><li>parasympathetic supply is derived from the greater superficial petrosal (GSP) branch of cranial nerve VII. The GSP joins the deep petrosal nerve (sympathetic supply), which comes from the carotid plexus to form the vidian nerve in the vidian canal. The vidian nerve travels through the pterygopalatine ganglion (with only the parasympathetic nerves forming synapses here) to the lacrimal gland and glands of the nose and palate via the maxillary division of the trigeminal nerve. </li></ul>
  11. 11. Perichondrium <ul><li>Lined by thin, strong inner perichondrial layer and an outer mucosal layer </li></ul><ul><li>Perichondrium into flap results in biomechanically stronger flap with greater vascular supply and less likely to perforate </li></ul>
  12. 12. Physics 101 (revisited) <ul><li>Flow (pressure/resistance)- laminar flow is linear, turbulent flow follows random paths </li></ul><ul><li>Poiseuille’s law (major determinant of resistance to airflow is the radius, airflow increases to the fourth power as radius increases) </li></ul><ul><li>Venturi effect (as airflow through nose increases, suction is created) </li></ul>
  13. 13. <ul><li>The valves of the nose and internal nasal valve are dynamic. On inspiration the nostril and the internal nasal valve narrow and on expiration the widen. T/F </li></ul>
  14. 14. Ventilation <ul><li>Inspiration generates a negative pressure, nostrils enlarge (dilators of the nose) and internal valve narrows as upper lateral cartilages approximate septum </li></ul><ul><li>Expiration, the internal nasal valve opens and the nostrils narrow </li></ul>Cole P. Nasal and oral airlfow resistors: Site, function, and assessment. Arch Otolaryngol Head Neck Surg 118:790-793, 1992
  15. 15. Nasal cycle <ul><li>Normal phenomenon of cyclic alteration of constriction and dilatation of each side of the nasal airway </li></ul><ul><li>Typically 4-6 hours to complete </li></ul>
  16. 16. Preoperative assessment <ul><li>History </li></ul><ul><ul><li>Allergies </li></ul></ul><ul><ul><li>Nasal obstruction (unilateral/bilateral, constant/intermittent, seasonal) </li></ul></ul><ul><ul><li>Bilateral symptoms that change in severity (mucosal disease) </li></ul></ul><ul><ul><li>Constant obstruction (fixed structural abnormality) </li></ul></ul><ul><ul><li>Presence of epistaxis or rhinorrhea </li></ul></ul><ul><ul><li>Prior nasal surgery </li></ul></ul><ul><ul><li>Medication history (especially vasoconstrictive sprays, OC’s) </li></ul></ul><ul><ul><li>Trauma </li></ul></ul><ul><ul><li>Symptoms (crusting, dry mouth, frequent sore throats, sinus problems) </li></ul></ul>
  17. 17. Physical exam <ul><li>External appearance of nose </li></ul><ul><li>Mouth breather </li></ul><ul><li>Adenoid facies (maxillary hypoplasia) </li></ul><ul><li>Location of deviation </li></ul><ul><li>Tip support </li></ul><ul><li>Nasal valve </li></ul><ul><li>Remove all crusts (? Underlying perforation, exophytic lesion, etc) </li></ul><ul><li>Any abnormal crusts, ulcerations, or polypoid changes should delay elective surgery for possible underlying systemic condition </li></ul><ul><li>Examine with vasoconstrictor </li></ul><ul><li>Headlight, speculum, endoscope </li></ul>
  18. 19. Anosmia/hyposmia <ul><li>University of Pennsylvania Smell Identification Test (UPSIT) </li></ul><ul><ul><li>Help identify malingering and gross degree of impairment </li></ul></ul><ul><ul><li>34% of patients scored lower postoperatively after septal surgery </li></ul></ul><ul><ul><li>66% improved or were unchanged </li></ul></ul>
  19. 20. Rhinomanometry <ul><li>Anterior rhinomanometry </li></ul><ul><li>Posterior rhinomanometry </li></ul><ul><li>Pernasal rhinomanometry </li></ul><ul><ul><li>Objective information regarding respiratory function </li></ul></ul><ul><ul><li>Quantifies nasal air flow and pressure </li></ul></ul><ul><ul><li>Nasal resistance (pressure/flow) </li></ul></ul>
  20. 21. Acoustic rhinomanometry <ul><li>Measures the cross-sectional area of the nasal cavity as a function of distance from the nostril </li></ul><ul><li>Sound generator, wave tube, microphone, and a computer </li></ul>
  21. 22. Optimizing acoustic rhinomanometry <ul><li>Must form an acoustic seal with wave tube without distorting the nasal tip </li></ul><ul><li>Results represent cross sectional area as a function of distance (cm) from end of nosepiece </li></ul><ul><li>Does not detail shape of the airway, cannot provide information on nasal airway resistance </li></ul>
  22. 23. Goals of surgery <ul><li>Exposure of the pathologic portion of septum </li></ul><ul><li>Removal or reconstruction of the defective portions </li></ul><ul><li>Preserve nasal mucosa and lining </li></ul><ul><li>Prevent external deformity of patient </li></ul>
  23. 25. <ul><li>Do not fear deviations of the dorsum or L-strut (limits practice) </li></ul>
  24. 26. Classification of Septal Deviations <ul><li>Mild deviations </li></ul><ul><li>Moderate deviations </li></ul><ul><li>Severe deviations </li></ul>
  25. 27. Local anesthetics <ul><li>Injection of local anesthetic </li></ul><ul><ul><li>Hydrodissection of mucoperichondrium from cartilage </li></ul></ul><ul><ul><li>Cocaine </li></ul></ul><ul><ul><ul><li>What percentage is absorbed from cotton swabs? </li></ul></ul></ul><ul><ul><ul><li>(30%) </li></ul></ul></ul><ul><ul><ul><li>What is the half life of cocaine? </li></ul></ul></ul><ul><ul><ul><li>(30-90 minutes) </li></ul></ul></ul><ul><ul><ul><li>What is the maximum dose of cocaine? </li></ul></ul></ul><ul><ul><ul><li>(2-3mg/kg) </li></ul></ul></ul>
  26. 28. Uh… Oh!! <ul><li>You inject lidocaine with epinephrine and the patient becomes tachycardic, hypotensive, and syncope… </li></ul><ul><li>Vasovagal?, Allergic Reaction to PABA?, Intravascular Injection of Epinephrine? </li></ul><ul><li>Vasovagal-Bradycardic, Cool skin, Hypotensive, Impending sense of doom </li></ul><ul><li>Allergic Reaction-Tachycardic, Hypotensive, Flushed and warm skin </li></ul><ul><li>Intravascular Epinephrine-Tachycardic (from epinephrine), Hypotensive from impaired ventricular filling of heart, Peripheral Vasodilation (depending on the dose) can occur </li></ul><ul><li>2 I’s are amides, esters have PABA </li></ul>
  27. 29. Incisions <ul><li>Kilian incision </li></ul><ul><ul><li>Preserves projection the best </li></ul></ul><ul><ul><li>Should not be too far posterior (difficult to close) </li></ul></ul><ul><li>Hemitransfixion incision </li></ul><ul><li>Full transfixion incision </li></ul><ul><li>High and Low transfixion incision </li></ul><ul><li>Open rhinoplasty incision </li></ul>
  28. 30. Technique <ul><li>Classic Submucosal Technique </li></ul><ul><li>Scoring </li></ul><ul><li>Morselization </li></ul><ul><li>Sutures </li></ul><ul><li>Swinging door </li></ul><ul><li>Removal and replacement </li></ul>
  29. 31. Classic Book Teaching
  30. 32. Keystone areas <ul><li>Preserve along bony cartilaginous junction </li></ul><ul><li>Preserve along nasal floor </li></ul>
  31. 33. Submucous resection limitations <ul><li>Caudal end deformities are not addressed </li></ul><ul><li>Poor access to nasal spine </li></ul><ul><li>Dorsal deformities not addressed </li></ul>
  32. 34. Reconstitution <ul><li>Morselized cartilage replaced between flaps </li></ul><ul><li>Less risk of septal perforation </li></ul><ul><li>Future source of cartilage for rhinoplasty and easier dissection </li></ul>
  33. 35. Scoring the cartilage <ul><li>Which side do you score the cartilage on, concave or convex? </li></ul>
  34. 36. Deviated caudal septum
  35. 38. Caudal margin & Inferior margin to the left of the maxillary spine
  36. 39. Eliminate all posterior bony attachments to mobilize the anterior septum
  37. 40. Shift caudal margin & inferior margin to opposite side of the Maxillary spine
  38. 41. CONSIDER RELAXING INCISIONS ON CAUDAL MARGIN
  39. 42. 1 . Anterior septum separated from Vomer and Ethmoid
  40. 43. Maxillary Spine 1 . Anterior septum separated from Vomer and Ethmoid
  41. 44. Maxillary Spine 1 . 2 . Anterior septum separated from Vomer and Ethmoid
  42. 45. Maxillary Spine 1 . 2 . 3 . Anterior septum separated from Vomer and Ethmoid
  43. 46. Maxillary Spine 1 . 2 . 3 . Anterior septum separated from Vomer and Ethmoid Anterior septum to midline
  44. 47. Deviated Dorsal Septum <ul><li>Crooked perpendicular plate </li></ul><ul><li>Does patient need spreader or onlay graft </li></ul><ul><li>Score Dorsally on convex side and place either a bone or cartilage </li></ul><ul><li>Resect septum and reconstruct L-Strut </li></ul>
  45. 53. Correct Dorsal septal deviation with suture suspension to nasal bone
  46. 59. Warping Theory Fry H. Nasal skeletal trauma and the interlocked stresses of the nasal septal cartilage.Br J Plast Surg. 1967 Apr;20(2):146-58. Gibson, T. Davis W.B. The distortion of autologous cartilage grafts: Its cause and prevention. Br J. Plast. Surg. 10; 257, 1958
  47. 61. Poor tip support <ul><li>Poor tip support after a “standard septoplasty”, what do you do? </li></ul><ul><li>Tongue-in groove imbrication between medial crus and septum </li></ul><ul><li>Placement of columellar strut </li></ul><ul><li>Consider opening nose </li></ul>
  48. 62. Septal spur <ul><li>Inferiorly based tunnel </li></ul><ul><li>Preserve mucosal flap on nonspur side if possible </li></ul>
  49. 63. Disarticulation of Bony and cartilaginous septum <ul><li>Diagnose </li></ul><ul><ul><li>Prominent saddling of nose </li></ul></ul><ul><ul><li>Loss of stability </li></ul></ul><ul><li>Treatment at low point </li></ul><ul><ul><li>Stabilize with suture through nasal spine </li></ul></ul><ul><ul><li>16 gauge needle to drill hole </li></ul></ul><ul><li>Secure at high point </li></ul><ul><ul><li>Secure Cartilage to bony septum (overlap cartilage, figure 8 cartilage, spreader/bony cartilage complex) </li></ul></ul><ul><ul><li>Drill holes through nasal bones and secure cartilage with suture </li></ul></ul><ul><ul><li>K-wire fixation (show video) </li></ul></ul>
  50. 64. Prior surgery <ul><li>Look for flap on flap division </li></ul><ul><li>Hydrodissection assistance </li></ul><ul><li>Do No Harm! </li></ul>
  51. 65. Postoperative care <ul><li>Nasal splints? </li></ul><ul><li>Packing? </li></ul><ul><li>Antibiotics? </li></ul><ul><li>Nasal exercises for external deviations </li></ul>
  52. 66. Complications <ul><li>Excessive intraoperative bleeding </li></ul><ul><li>Infection </li></ul><ul><li>Recurrence of septal deformity </li></ul><ul><li>Persistent nasal obstruction </li></ul><ul><li>Septal hematoma </li></ul><ul><li>Septal perforation </li></ul>
  53. 67. Septal Perforation <ul><li>History </li></ul><ul><li>Crusting, bleeding, whistling if perforation is small </li></ul><ul><li>Rhinorrhea and disruption of lamellar flow if perforation is large </li></ul><ul><li>Pain signifies chondritis </li></ul><ul><li>More anterior the perforation the more likely the patient will become occult </li></ul>
  54. 68. Septal Perforation <ul><li>Must rule out a chronic inflammatory disease process, cocaine abuse, granulomatous process in face of granulation tissue on perforation </li></ul>
  55. 69. Physical Exam <ul><li>Crusting on mucosa due to dry nonlaminar flow, not necessarily at site of perforation </li></ul><ul><li>Bleeding at edge of perforation </li></ul><ul><li>Picture with endoscope and ruler to assess size of perforation </li></ul>
  56. 70. What tests do I order? <ul><li>Nasal cultures for fungal and bacterial infections </li></ul><ul><li>Skin testing for TB, fungi and anergy </li></ul><ul><li>VDRL, FTA-Abs, C-ANCA </li></ul><ul><li>Biopsy to rule out autoimmune process </li></ul>
  57. 71. Principle <ul><li>Perforation is unlikely to heal on its own </li></ul><ul><li>More likely to contract and create a larger opening </li></ul>
  58. 72. Medical Therapy <ul><li>Petroleum based ointments </li></ul><ul><li>Antiseptic wash per Fairbanks (1 teaspoon salt in warm water delivered by Water-Pik device +/- glycerin to moisturize + boric acid or vinegar) </li></ul><ul><li>Medical button </li></ul>
  59. 73. Surgical therapy <ul><li>Skin graft or buccal graft (leaves nose dry, continual crusting) </li></ul><ul><li>Close primarily by advancement of local tissues </li></ul><ul><li>More difficult if posterior, vertical, nasal dorsum </li></ul><ul><li>Graft selection (temporalis fasica vs alloderm) </li></ul>
  60. 74. Surgical therapy <ul><li>Endonasal repair </li></ul><ul><ul><li>Small perforations </li></ul></ul><ul><li>External approach </li></ul><ul><ul><li>Most perforations less than 2cm </li></ul></ul><ul><li>Tissue expander </li></ul><ul><li>Free flap </li></ul>
  61. 78. www.shahmd.com

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