SEPTOPLASTY, SUBMUCOUS RESECTION, DEVIATED NASAL SEPTUM,ANTRAL PUNTURE,TILLEY LITCHWICH TROCAR AND CANNULA, COTTLES LINE,

1. Dr.Ashly Alexander
ENT PG Resident
GMC, Bhopal

4.  Etiology:-
 Trauma
 Developmental error
 Racial factors
 Hereditary factors

5.  Anterior dislocation
 ‘C’ shaped deformity
 ‘S’ shaped deformity
 Septal spur
 Thickening of septum

6.  Nasal obstruction
 Sinusitis
 Epistaxis
 Hyposmia or anosmia
 Ext. deformity
 ME infections
 Mucosal changes
 Neurological changes
 Paradoxical nasal obstruction

7.  Treatment :-
minor degree of septal deviation with no symptoms
does not require any t/t . It is only when deviated
septum produce mechanical nasal obstruction or
symptomatic require operation.
 Operation for septal correction :-
 Submucous resection of septum ( SMR )
 Septoplasty

8.  COTTLE’S LINE
the septum can be devided in
to ant and post segment by a
vertical line drawn between
nasal process of frontal and
nasal spine of maxillary bone
called cottle’s line.
Deviations anterior to this
line are corrected by
septoplasty and post to this
line are corrected by SMR.

9.  SMR:- It is generally done in adult under local aneasthesia.it
consists of elevating the mucoperichondrial and mucoperiosteal flaps on
either side of septal framework by a single incision made on one side of
septum , removing deflected part of bony and cartilaginous septum and
repositioning the flaps.
 Septoplasty ;- it is a conservative approach to septal
surgery.in this operation much of the septal framework is retained,
only the most deviated parts are removed. Rest of the septal
framework is corrected and repositioned by plastic means.
Mucoperichondrial , mucoperiosteal flap is generally raised only on one
side of septum retaining the attachment and blood supply on the other
side.
 septal surgery is usually done after the age of 17 yrs so as not to
intrefere with growth of nasal skeleton.

10.  Nasal obstruction
 Crusting
 Rhinorrhoea
 Post nasal discharge
 Recurrent sinusitis
 Epistaxis
 Headache
 Sleep apnoea and snoring

11.  Patients below 17 years of
age.
 Acute episodes of
respiratory infection.
 Bleeding diathesis.
 Untreated diabetes or
hypertension.

12.  Operation is done under combination of :
◦ Intravenous analgesia: Sedation / tranquilization /
comfort.
◦ Topical anesthesia :
 Spray decongestant 10-15 min prior to induction
(diminish bleeding).
 Neuro-surgical cottonoids soaked in 4% Xylocaine with
adrenaline are positioned in each nasal cavity
(tamponade, anesthesia, and vasoconstriction).
◦ Local infiltration: 2% xylocaine with adrenaline.
 Principle of hydraulic dissection is used
Position : Reclined position with head end
elevated.

13. Killians Incision
 5 mm above caudal border of the
septal cartilage.
 It is a curvilinear, convex
forwards incision (Left side /
concave side).
 Cuts only through mucosa and
perichondrium.

14. 2. Elevation of mucoperichondrial
and mucoperiosteal flaps:
 Mucoperichondrial flap is elevated on the concave
side of cartilaginous septum  continued
posteriorly to elevate mucoperiosteum on same
side.
 An incision is made on cartilage through its entire
thickness a few mm posterior to mucosal incision
and a muco perichondrial flap is elevated on
opposite side

15.  Working between two flaps a small incision is
made on the edge of septal cartilage 2-3 mm
below the roof of nose using turbinectomy
scissor.
 The blade of Ballinger swivel knife is now
inserted into this nick and knife is moved back
wards, downwards and forwards. The septal
cartilage is removed as a whole piece using the
luc’s forcep.
 A dorsal and caudal strut of cartilage is
retained.

17.  A separate break through over bone is
required (as in different plane).
 Crest is then removed with gouge and hammer.
 Now nasal speculum is removed.

18. 5. Stitching
 If flap is torned  tear is reinforced by
inserting an autologous cartilage / bone graft in
between flaps  suturing

19.  Patient placed in semi-sitting position to
prevent oozing of blood. Change outer nasal
dressing if soaked.
 Soft diet to avoid active mastication.
 Pain if present should be controlled with
analgesics.
 Antibiotic cover for 5-6 days.

20.  Nasal pack should be removed after 24 hours and
thereafter, decongestant nasal drops and steam
inhalations are given daily for 5-6 days.
 Silk stitch, if any is removed on 5th and 6th day.
 Patient should avoid trauma to nose for several
days.

21. ImmediateImmediate DelayedDelayed
Hemorrhage (PrimaryHemorrhage (Primary)) Reactionary / secondary h’gReactionary / secondary h’g
CSF rhinorrhoeaCSF rhinorrhoea Septal hematomaSeptal hematoma
Trauma to surrounding tissueTrauma to surrounding tissue Septal abscessSeptal abscess
Septal perforation 6.91%Septal perforation 6.91%
Flapping nasal septumFlapping nasal septum
SupratipSupratip
Depression/SaddlingDepression/Saddling
Widening , Bulbosity of tipWidening , Bulbosity of tip
Retraction of columellaRetraction of columella
Synechiae and adhesionsSynechiae and adhesions
Toxic Shock SyndromeToxic Shock Syndrome

22. Most deviated septa may be appropriately
reconstructed rather than resected and septal
functions preserved without embarrassing the
septal support.

23. Freer’s Incision
A unilateral (hemitransfixation)
incision at lower border of septal
cartilage is adequate for septoplasty
conveniently made on left side.
Advantages:
 Site is relatively avascular plane.
 Mucosal edges are tough and thick
here  so less chances of tears.
 Easy to repair even if tear occurs.
 Easy access to whole of septum, its
caudal border, region of anterior nasal
spine and premaxillary crest.
 Easily extendible if rhinoplasty is
planned (full Transfixation).

24. 1. Incision – Freer’s type.
2. Elevation of mucoperichondrial
and mucoperiosteal flaps –
 Submucoperichondrial plane is located
and developed.
 If fracture adhesions, cartilage
overlaps or scarring interferes than
bypass these vexing areas.

25.  Anterior Tunnel:
Working up and
backwards above
chondro – vomerine
suture line.

26. ◦ Inferior tunnel
Incise periosteum over anterior
nasal spine and elevating
backwards over the crest of
premaxillae, vomer working
below Chondro-vomero suture
line unite anterior and
inferior tunnels.
◦ Posterior Tunnel
Exposing bony septum by
sharp dissection small
incision at bony cartilagenous
junction to elevate
mucoperiosteum of opposite
side.

27. Cartilage:
 Separate lower border of septal
cartilage from osseous base.
 This lower border of cartilage is
encased in perichondrium which
can be elevated around its lower
border and few millimeters over
the convex side of septum.
 Disarticulation of bony and
cartilaginous septum.

28.  After cartilage has been freed an attempt is made to
reposition it in midline to rest on osseous base but
due to excess height it may not be possible. So a
small strip can be removed (3-4 mm wide).

29.  A series of transeptal transperichondrial through and
through suture are positioned to coapt the flaps,
thereby closing all dead space.
 Hemostasis promoted and hematoma avoided.
 Figure of eight suture used sometimes to immobilize the
lower border of septum to anterior nasal spine
 Finally septo-columellar incision is closed.

30.  Can be done in children.
 Flapping of the septum does not occur.
 Perforation does not occur usually (0.86%).
 Revision surgery if needed is easy.

31.  It is a procedure done both for diagnosis and
treatment of sinusitis, where a canula is
inserted into the maxillary sinus via an opening
made in the inferior meatus

32. Therapeutic:
 Antral Lavage:
(a) In cases of chronic maxillary sinusitis, not
responding to conservative medication.
(b) For instillation of medicaments and irrigation in
cases of atrophic rhinitis.
 Diagnostic:
1. Proof puncture: Radiological appearances of
sinusitis is confirmed by a puncture.
2. The washing can be sent for pus, smear culture,
antibiotic sensitivity and cytological examination.

33.  1. Not done in children below 3 years of age due
to proximity of the orbital floor and teeth in
small maxillary sinus
2. Acute sinusitis.
3. Traumatic conditions damaging orbital floor
and maxilla.
 4. Hypertension, diabetes mellitus

34.  It is usually done under local anaesthesia but
can be done under general anaesthesia.
The 3 main nerves blocked by local anaesthesia
are:
1. Superior alveolar nerve near the inferior
meatus
2. Anterior ethmoidal nerve near the roof of
the nose
3. Posteriorly the sphenopalatine ganglion

35.  Puncture sides:
The Tilley Lichtwitz trocar and cannula is
passed under the attachment of the inferior
turbinate pointing to the homolateral ear.
 Procedure:
An Higginsons syringe with sterile or normal
water at 37 Degree Celsius is attached to
cannula and the maxillary sinus is flushed.
 Three successive flushed of clear saline water
are required.

41. 1.Bleeding: This occur from local blood vessels
2. Orbital damage: Perforation of the orbital
floor causing proptosis and pain
3. Cheek swelling: Breaching of soft tissue of
the cheek and anterior wall
4. Air embolism due to injury to veins.
5. Infection of maxillary sinus
6. Vasovagal Shock
7. Anaesthesia Complications

42. THANK YOU