27 Septoplasty & Turbinate Surgery Flashcards
What is the clinical presentation of a patient with a deviated nasal septum and when should surgical correction be considered?
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. About 50% of the general population are thought to have some deviation in their nasal septum, and most of these are asymptomatic. Symptomatic patients will often present with nasal congestion, and can also present with nasal drainage, decreased sense of smell, difficulty sleeping, dryness, and pain. 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 sinusitis. Surgical correction should be considered in appropriate patients with chronic symptoms related to a deviated nasal septum that are significantly affecting their quality of life.
What are the various approaches to the nasal septum when performing a septoplasty?
What are the various approaches to the nasal septum when performing a septoplasty?
Typically, a septoplasty is performed through an endonasal approach. Unilateral incisions are made just pass 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 to 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 (Figure 27-1).
What is an endoscopic septoplasty?
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. Advantages of this approach include magnification of the surgical field, improved ergonomics, improved access and visualization for the posterior nasal cavity, and the potential for more limited dissection in certain 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.
What are the steps for performing a typical septoplasty?
What are the steps for performing a typical septoplasty?
- Decongest nasal cavities with topical oxymetazoline spray. Inject lidocaine mixed with epinephrine into the septum bilaterally in a subperichondrial plane.
- Make 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 (Figure 27-2).
- Disarticulate septal cartilage from the bony septum, and resect bony septum as required.
- Resect septal cartilage as required, taking care to leave dorsal and caudal struts with a width of at least 1 to 1.5 cm for proper support of the nasal tip and dorsum.
- Repair any tears in the mucosal flaps primarily if possible with dissolvable suture.
- Consider replacing the previously 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.
- 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.
What is a typical postoperative course after septoplasty/turbinate surgery?
What is a typical postoperative course after septoplasty/turbinate surgery?
Most patients are discharged home after surgery. Some patients are kept overnight for observation if there is concern for complications or significant sleep apnea. Recovery can take anywhere from several days to several weeks. During this time, patients will usually have nasal congestion, moderate nasal and midfacial pain, mild intermittent bloody nasal drainage, and generalized fatigue. Patients may also have nausea, difficulty sleeping, and dry mouth. Antibiotics, analgesics, and antiemetics are typically prescribed. Patients are instructed to moisten the nasal cavities with saline frequently and to keep the head elevated. Patients should plan on taking at least a week off of work or school before returning. Light activities are permitted during the first week after surgery, and full activities can gradually be resumed after 1 to 2 weeks. Patients are seen for follow-up 1 to 2 weeks after surgery. Complete healing of the mucosa usually occurs at 3 to 4 weeks after surgery.
What are the possible risks involved with septoplasty/turbinate surgery?
What are the possible risks involved with septoplasty/turbinate surgery?
Risks of surgery should be discussed with patients preoperatively as part of the informed consent process. These include infection, excessive bleeding, nasal dryness/crusting, persistent nasal congestion, septal hematoma/abscess, septal perforation, scarring, alteration of sense of smell/taste, numbness, CSF leak, cosmetic deformity, complications of anesthesia, and need for further surgery.
What is the anatomy of the inferior turbinate?
What is the anatomy of the inferior turbinate?
The inferior concha is its own bone, which attaches to the medial maxilla. The medial submucosal tissue is made mostly of venous channels and erectile tissue, whereas the lateral submucosal tissue is mostly glandular. Hasner’s valve, a flap of tissue at the nasolacrimal duct orifice, opens into the inferior meatus.
What are the topical medications typically used during septoplasty/turbinate surgery?
What are the topical medications typically used during septoplasty/turbinate surgery?
Oxymetazoline and phenylephrine are medications that are commonly applied topically to the nasal cavities as decongestants. Topical epinephrine can also be used if desired. These medications work as α-1 receptor agonists, causing vasoconstriction and decongestion of the nasal mucosa, resulting in decreased systemic absorption of local anesthetics, improved visualization, working space, and hemostasis. Topical cocaine is less commonly used nowadays, but is also a very effective decongestant and anesthetic. These can be applied preoperatively and/or intraoperatively as needed. Care should be taken to only use these medications topically, and not accidentally inject them intravascularly. This can cause immediate and life-threatening hypertension, tachycardia, and arrythmias, and could lead to myocardial infarction or stroke.
What anesthetics are used during septoplasty/turbinate surgery? Can surgery be performed under local anesthesia?
What anesthetics are used during septoplasty/turbinate surgery? Can surgery be performed under local anesthesia?
In the past, nasal surgery was commonly performed under local anesthesia with light sedation. Currently, most nasal surgery is performed under general anesthesia for improved patient comfort. 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, improved hemostasis as a result of vasoconstriction caused by the dilute epinephrine, and helps with pain control in the immediate postoperative period.
Local anesthetics are divided into amides and esters. Amides are metabolized in the liver, and esters are metabolized in both the liver and plasma. Lidocaine and bupivicaine (amides) are the most common local anesthetics used during nasal surgery. The maximum dose of lidocaine is 4 mg/kg (with epi 7.5 mg/kg), and the maximum dose of bupivicaine is 3 mg/kg. The maximum dose of cocaine (ester) is 2 to 3 mg/kg or 200 mg. Signs of adverse reactions to local anesthetics should be recognized and treated promptly if needed. Signs of epiniphrine toxicity include restlessness, anxiety, a sense of impending doom, headache, palpitations, repiratory distress, hypertension, and tachycardia. Allergic reactions are extremely rare and are usually attributed to the preservatives in the anesthetic. True allergic reactions are almost always caused by the ester anesthetics. Signs can range from a simple rash to anaphylaxis. Finally, local anesthetics administered in toxic doses can result in a progression from CNS and cardiovascular excitation to depression. First, the patient may show anxiety, disorientation, rambling speech, seizures, tachycardia, hypertension, vomiting, and sweating. This is followed by loss of consciousness, apnea, bradycardia, hypotension, and cardiovascular collapse. Treatment should consist of supportive care, including supplemental O2, airway support, IV fluids, and appropriate supportive medications, which may include antiseizure medications or benzodiazepines.
What is a unique adverse reaction to toxic doses of prilocaine and benzocaine?
What is a unique adverse reaction to toxic doses of prilocaine and benzocaine?
The max dose of benzocaine is 200 mg, and the max dose of prilocaine is 7 mg/kg. Above these doses, methemoglobinemia can occur, resulting in hypoxia, shortness of breath, cyanosis, mental status changes, and headaches. Severe cases can result in arrhythmias, seizures, coma, and death. Pulse oximetry is inaccurate in assessing oxygenation with this condition. Treatment includes supplemental O2 and a slow IV infusion of 1 to 2 mg/kg of 1% methylene blue.
What are some techniques that help with hemostasis during and after septoplasty/turbinate surgery?
What are some techniques that help with hemostasis during and after septoplasty/turbinate surgery?
Hemostasis is important during nasal surgery to ensure proper visualization, which allows for a more thorough and complete procedure. It is also important after surgery to decrease the risk for hemorrhage, and to improve the patient’s comfort and postoperative experience. Hemostasis starts preoperatively by reviewing the patient’s medications, and stopping anticoagulants, NSAIDs, vitamins, and herbal supplements 1 to 2 weeks prior to surgery. Restarting these meds postoperatively should be delayed for 1 to 2 weeks if possible, but may need to be restarted sooner, depending on the patient’s comorbidities. Mucosal inflammation is treated preoperatively with topical nasal steroids, antihistamines, oral steroids, and antibiotics as indicated. On the day of surgery, topical decongestants are applied just prior to surgery and/or during surgery. Local anesthetics mixed with dilute epinephrine are injected into the septum and turbinates, resulting in further vasoconstriction. The patient is then positioned with the head elevated 30 degrees, decreasing venous congestion. Careful surgical technique with minimization of mucosal trauma is a must. Finally, dissolvable or nondissolvable nasal packing can be placed in the nasal cavities at the end of the procedure, but these have not been shown to significantly reduce rates of hemorrhage.
What is the clinical presentation of a patient with turbinate hypertrophy and when should surgery be considered?
What is the clinical presentation of a patient with turbinate hypertrophy and when should surgery be considered?
Patients with turbinate hypertrophy usually present with chronic complaints of nasal congestion, and can also have symptoms of nasal drainage, facial pressure, ear fullness, and sleeping difficulty. The congestion is often described as bilateral, alternating from side to side, worse during sleep in a supine position, and improved in the upright position, with exposure to steam (e.g., in the shower), with exercise, and with use of decongestants. A history of allergies is common. Surgery should be considered when symptoms related to turbinate hypertrophy are significantly affecting quality of life despite medical treatments, including nasal steroids, antihistamines, nasal saline, and decongestants.
How is turbinate surgery performed?
How is turbinate surgery performed?
Once the appropriate candidate is identified, surgery can be performed under local or general anesthesia. The surgery is often performed in conjunction with a septoplasty and is usually directed toward the inferior turbinates. The goal of surgery is to reduce the size of the turbinate, thereby improving the nasal airway, without sacrificing function. There are a wide variety of techniques for turbinate reduction, and this is best accomplished by a submucous resection of soft tissue and/or bone, thereby preserving the overlying functional mucosa as much as possible. Some of the various techniques that have been described include (full/partial) turbinate resection, laser cautery, electrocautery (monopolar or bipolar), cryotherapy, coblation, radiofrequency ablation, submucosal resection, and lateral outfracture.
What is empty nose syndrome?
What is empty nose syndrome?
Also called ozena or chronic atrophic rhinitis, empty nose syndrome is an uncommon condition in which the patient experiences chronic symptoms of nasal congestion despite a widely patent nasal airway. Additional symptoms can include dryness, crusting, bleeding, drainage, and pain. Typically, patients have a history of prior nasal surgery. On exam, the turbinates have been resected, and there may be a septal perforation. It is thought that the severe distortion of intranasal anatomy results in decreased sensation of normal airflow, thereby resulting in a subjective sensation of congestion. Treatment options are limited, and include nasal saline, topical ointments, and antibiotics when indicated. Surgical augmentation of the inferolateral nasal wall has been reported with some success. The best strategy is avoidance of this complication with careful preoperative planning and proper surgical technique.
When is middle turbinate surgery indicated?
When is middle turbinate surgery indicated?
The middle turbinate is an important intranasal structure that facilitates humidification, normal airflow, proper sinus drainage, and olfaction. Unlike the inferior turbinates, middle turbinates do not commonly develop mucosal or submucosal hypertrophy, and do not fluctuate as much in size with changes in blood flow. As a result, middle turbinate surgery is less common. In some cases, the middle turbinate can have a concha bullosa, which is an air-filled cell of thin bone, causing it to be much larger than normal. This can contribute to symptoms of nasal obstruction, deviation of the septum, and impair mucociliary drainage of the sinuses. In cases of severe nasal polyps, the middle turbinate can develop polypoid degeneration. In these cases, reduction of the middle turbinate can be considered.
What is the nasal valve?
What is the nasal valve?
The nasal valve refers to the narrowest area in the anterior nasal cavity through which air flows. Abnormalities of the nasal valve result in symptoms of nasal obstruction. The valve has both internal and external components. The internal nasal valve refers to the area of the nasal cavity bounded by the septum, head of the inferior turbinate, and upper lateral cartilage. The external nasal valve refers to the area bounded by the columella, lateral crus of the lower lateral cartilage, and nasal ala. The area between the internal and external valves is referred to as the intervalve area.
How is the nasal valve evaluated?
How is the nasal valve evaluated?
When evaluating a patient with symptoms of nasal congestion, the external nose and nasal valve should be examined along with the intranasal anatomy. The nasal dorsum, nasal sidewalls, nasal tip, nasal alae, and columella are examined from an anterior view, profile view, and base view at rest and during inspiration. The Cottle maneuver is performed by displacing the cheek laterally. The modified Cottle maneuver is performed by supporting the lateral nasal wall intranasally with a cotton tip applicator or ear curette during inspiration. In patients with abnormalities of the nasal valve, these maneuvers will result in marked improvement in nasal breathing. Abnormalties of the nasal valve are important to detect preoperatively, as they can cause persistent symptoms of nasal obstruction after septoplasty/turbinate surgery.
What is nasal valve collapse?
What is nasal valve collapse?
Nasal valve collapse refers to nasal obstruction caused by an abnormality of the nasal valve. This can be congenital or acquired from prior surgery, trauma, or facial paralysis. Symptoms of congestion are usually constant, improved with use of Breathe Right nasal strips or lateral displacement of the cheeks, and worse with exercise. “Collapse” can be either static or dynamic depending on the patient’s anatomy.
How is nasal valve collapse treated?
How is nasal valve collapse treated?
Nonsurgical treatment options include use of Breathe Right nasal strips or disposable intranasal stent devices. There are a wide variety of surgical treatment options depending on what is found on physical exam. These include placement of spreader grafts, flaring sutures, butterfly graft, batten grafts, lateral crural strut grafts, alar rim grafts, and bone anchored suture techniques to name a few. Surgery can be performed via a closed or open approach. Cartilage grafts are harvested from the septum, ear, or rib.
What is the clincal presentation and treatment for a septal hematoma/abscess?
What is the clincal presentation and treatment for a septal hematoma/abscess?
This condition can occur as a result of recent nasal surgery or nasal trauma. Symptoms include acute onset of severe nasal congestion, pain, swelling, and possibly fever. Exam shows occlusion of one or both nasal cavities by fluctuance of the septum. Treatment is immediate incision and drainage of the fluid collection under local or general anesthesia and placement of nasal splints for 1 week to prevent recurrence. Delay in treatment could result in necrosis of septal cartilage, septal perforation, and saddle nose deformity.
What is the clinical presentation and treatment of a septal perforation?
What is the clinical presentation and treatment of a septal perforation?
Septal perforations can cause symptoms including a whistling sound with respiration, dryness, crusting, bleeding, pain, congestion, and drainage, or may be asymptomatic. The differential includes prior surgery, trauma, drug use (nasal sprays, recreational), vasculitis, atypical infection, granulomatous disease, or malignancy. On exam, the size and location of the perforation should be noted. Nonsurgical treatment options include nasal saline and topical ointment. Surgical treatment options include placement of a silastic septal button or surgical repair. Perforations 5 mm or less can be repaired primarily with placement of an interpositional graft via an endonasal approach. For perforations 5 mm to 2 cm, an open approach should be considered, and local mucosal flaps will be needed. Perforations greater than 2 cm are more difficult to successfully repair. Surgery is contraindicated in patients actively abusing cocaine, or with active infectious, inflammatory or malignant disease.
What is the clinical presentation and treatment of saddle nose deformity?
What is the clinical presentation and treatment of saddle nose deformity?
Patients with saddle nose deformity present with a depression or concavity involving the dorsum of the middle third of those. This is typically caused by prior nasal trauma or overly aggressive nasal surgery during dorsal hump reduction, or from overresection of the dorsal septal strut during septoplasty. Surgical correction is performed using an open approach for exposure of the nasal dorsum. The deficient area is then augmented with either conchal (ear) or rib cartilage using an onlay graft technique.
What is toxic shock syndrome?
What is toxic shock syndrome?
Toxic shock syndrome is a rare complication of S. aureus infection. The TSST-1 toxin produced by the bacteria causes high fever, rash, hypotension, vomiting, diarrhea, and multiorgan failure. This has rarely been associated with nasal packing. As a result, patients with nasal packing or splints are typically covered with antistaphylococcal antibiotics. Treatment includes removal of the nasal packing, IV antibiotics, and supportive/resuscitative care.
What considerations are involved in revision nasal surgery?
What considerations are involved in revision nasal surgery?
About 5% to 10% of patients have persistent or recurrent symptoms of nasal congestion after nasal surgery. A careful history and exam should be performed, and a CT scan should be considered to evaluate for sinus disease. The prior operative notes should be reviewed if possible, and the full differential for nasal congestion should be considered in the assessment. If revision surgery is considered, surgical options include revision septoplasty for persistent deviation, revision turbinate reduction for recurrent hypertrophy, and nasal valve surgery. An open approach may be needed for modification of the remaining septal struts, placement of cartilage grafts, or nasal valve surgery.
