2. INDICATIONS
1. Deviated nasal septum (DNS) causing symptoms
of nasal obstruction and recurrent headaches.
2. DNS causing obstruction to ventilation of
paranasal sinuses and middle ear, resulting in
recurrent sinusitis and otitis media.
3. Recurrent epistaxis from septal spur.
4. As a part of septorhinoplasty for cosmetic
correction
5. As a preliminary step in hypophysectomy (trans-
septal
trans-sphenoidal approach) or vidian neurectomy
(transseptal approach)
3. 1. Patients below 17 years of age. In such
cases, a conservative surgery (septoplasty)
should be done.
2. Acute respiratory infection.
3. Bleeding diathesis.
4. Untreated diabetes or hypertension.
4. Local anaesthesia is preferred.
General anaesthesia is used in children and
apprehensive adults.
6. 1. The incision
The incision is made
on one side of the
septum about 5mm
from the anterior
edge of the septum.
Its carried through
the mucosa and
perichondrium.
The incision should be
made on the side of
maximum deviation
7. 2. The Dissection
A plane of cleavage
is found between
the cartilage and
perichondrium and
this is opened by
dissection
8. 3.
The cartilage is
incised in the same
line as the original
incision and a cut is
taken through the
cartilage to open
another plane on
the other side again
between the
cartilage and
perichondrium
9. 4.
The cartilage is removed by punch forcep
or by a ballenger swivel knife as far as the
dissection has proceeded and then further
separation of flaps is continued back onto
the perpendicular plate of ethmoid and
vomer
10. There is no set amount of cartilage or
bone to remove, as much is removed as is
necessary to straighten the septum.
A strip of cartilage should be left
anteriorly ,in front of incision ,about 5mm
wide and another similar strip along the
dorsum of nose. these are to maintain
shape of the nose and preent collpase of
the nasal tip or retraction the collumella
11. 5.
Stitching. One or two catgut or silk stitches
are applied in the initial mucoperichondrial
incision.
12. 8. Packing.
Ribbon gauze, smeared with an antibiotic
ointment or liquid paraffin, is packed in each
nasal cavity to prevent collection of blood
between the flaps.
Nasal dressing is applied.
13. Septoplasty is a conservative approach to
septal surgery;
As much of the septal framework as possible
is retained.
Mucoperichondrial/periosteal flap is
generally raised only on one side. This
operation has almost replaced the SMR
operation
14. 1. Deviated septum causing nasal obstruction on one or both
sides.
2. As a part of septorhinoplasty for cosmetic reasons.
3. Recurrent epistaxis usually from the spur.
4. Sinusitis due to septal deviation.
5. Septal deviation making contact with lateral nasal wall
and causing headaches.
6. For approach to middle meatus or frontal recess in
endoscopic sinus surgery when deviated septum obstructs
the view and access to these areas.
7. Access to endoscopic dacryocystorhinostomy operation in
some cases.
8. As an approach to pituitary fossa (trans-septal trans-
sphenoidal approach).
9. Septal deviation causing sleep apnoea or hypopnoea
syndrome.
18. 1. Infiltrate the septum with 1% lignocaine with adrenaline, 1:100,000.
2. In cases of deviated septum, make a slightly curvilinear incision, 2–3
mm above the caudal end of septal cartilage on the concave side
(Killian’s incision). In case of caudal dislocation, a transfixion or
hemitransfixion (Freer’s) incision is made. The latter is
septocolumellar incision between caudal end of septal cartilage and
columella.
3. Raise mucoperichondrial/mucoperiosteal flap on one side only.
4. Separate septal cartilage from the vomer and ethmoid plate and
raise mucoperiosteal flap on the opposite side of septum.
5. Remove maxillary crest to realign the septal cartilage.
19. 6. Correct the bony septum by removing the deformed
parts. Deformed septal cartilage is corrected by
various
methods, such as:
(a) Scoring on the concave side.
(b) Cross-hatching or morselizing.
(c) Shaving.
(d) Wedge excision.
Further manipulations like realignment of nasal spine,
separation of septal cartilage from upper lateral
cartilages, implantation of cartilage strip in the
columella or the dorsum of nose may be required.
7. Trans-septal sutures are placed to coapt
mucoperichondrial flaps.
8. Nasal pack.
20. POSTOPERATIVE CARE
1. Patient is placed in semi-sitting position to prevent
oozing of blood. Outer nasal dressing is changed if
soaked in blood.
2. A soft diet should be taken in the first two
postoperative days to minimize active mastication
which causes bleeding.
3. Pain, if any, should be controlled with analgesics.
4. Antibiotic cover is given for 5–6 days.
5. Nasal packs are gently removed after 48 h -72hand
thereafter, decongestant nasal drops started..
6. Patient should avoid trauma to the nose for several
days.
21. 1. Bleeding. It may require repacking, if severe.
2. Septal haematoma. Evacuate the haematoma
and give intranasal packing on both sides of
septum for equal pressure.
3.Septal abscess. This can follow infection of
septal haematoma.
4. Perforation. When tears occur on opposing side
of mucous membrane.
5. Depression of bridge. Usually occurs in supratip
area due to too much removal of cartilage along
the dorsal border.
6. Retraction of columella. Often seen when
caudal strip of
cartilage is not preserved
22. 7.Persistence of deviation. It usually occurs due to
inadequate surgery and may require revision
operation.
8. Flapping of nasal septum. Rarely seen, when too
much of septal framework has been removed.
Septum, which now consists of two
mucoperichondrial flaps, moves to the right or left
with respiration.
9. Toxic shock syndrome. It is rare after septal
surgery. It can follow staphylococcal (sometimes
streptococcal) infection and is characterized by
nausea, vomiting, purulent secretions, hypotension
and rash. It should be diagnosed early. It is treated by
removal of packing, hydrating the patient,
maintaining blood pressure and administering proper
antibiotic
