Chapter 185 - Septoplasty, Turbinate surgery Flashcards
Strut - what it is, why its important
1.cm dorsocaudal
Avoid loss of tip support, saddle nose
What to do with excised cartilage
May replace into mucoperichondrial pocket to decrease septal perf risk
Blood supply to IT
br of posterior lateral nasal artery
Tip support maj/min
Major: septum, lower lateral cart, upper lat (attachments between these)
Minor: interdomal lig, dorsal septum, membranous septum, sesamoid, skin, SQ tissue of tip, maxillary spine
Nose in cleft lip/palate
I/L LLC displaced I/P/L
Nasal tip, caudal septum, columella toward non-cleft side
Bony septum toward cleft side
Common complications of untreated septal hematoma
Septal perf, Saddle nose
What to do if afrin is injected into vessels
phentolamine (a blocker)
Oxymetazoline will cause HTN, vasoconstriction, tachycardia
Sx of TSS
high fever, vomiting, hypotension, diarrhea, rash, multiorgan failure
Due to TSST-1 toxin
How many people have a deviated septum?
50%
most asymptomatic
Killian vs Hemitransfixion vs Transfixion
Killian - past mucocutaneous junction, less risk of tip support loss?
Hemi- at mucocutaneous junction, better access to caudal septum, allows bilateral flap elevation
Transfixion - bilateral hemi, allows access to caudal, columella, medial crura
Steps to septoplasty
- afrin spray, inject epi:lido bilateral in subperichondrial space
- incision near caudal septum, subperichondrial flap
- disarticulate septal cart, remove bony septum if necessary
- resect septal cart (leave strut)
- repair tears in flaps
- consider replacing excised septum into mucoperichond pocket
- close mucosal incision, quilt septum, splints
Postop care and instructions after septoplasty
May have congestion, pain, bloody drainage mild intermitt, fatigue. Also may have nausea, dry mouth, difficulty sleeping
ABX, analgesics, antiemetics
Moisten nasal cavities with saline, keep head elevated
Take a week off work/school
Light activity first week
Full activity 1-2 weeks
F/u in 1-2 weeks
Complete mucosal healing within 3-4 weeks
Risks of septoturbinoplasty
infection, bleed, dry/crust, persist congestion, hematoma/abscess, perf, scar, alter smell/taste, numb, CSF leak, cosmesis
Anatomy of IT
medial submucosal tissue - vein, erectile
lateral- glandular
Hasner’s valve (flap at NLD orifice) opens into inf meatus
Max dose of lidocaine, bupivacaine, cocaine
Lido: 5 (without epi) 7 (with epi) mg/kg (some say 4/7.5)
Bupiv: 3mg/kg
Cocaine: 2-3 mg/kg or 200mg
Amides vs Esters
Amide- metaolized in liver. Lidocaine, Bupivacaine. Almost never have allergic rxn (if so, likely to preservative)
Ester- met in liver and plasma, may have allergic rxn, ut still likely due to preservative. Cocaine.
Sx of local anesthetic toxicity
- Sense of doom, HA, anxiety, palp, respiratory distress, HTN, restless, disorient, rambling speech, seizures, vomiting, tachy, sweat
- THEN: LOC, apnea, bradycardia, hypotension, CV collapse
prilocaine, banzocaine toxicities, how to treat the major one
Benzo 200mg, Prilo 7mg/kg
Methemoglobinemia - hypoxia, SOB, cyanosis, AMS, HA
arrythmia, seizure, coma, death
Pulse ox inaccurate
Tx- supp O2, slow IV influsion of 1-2 mg/kg 1% methylene blue
Improving hemostasis in nasal surgery
Stop anti-coagulant meds 1-2 weeks before and after surgery
HOB elevated 30 deg during surg
Decongestants
Minimize mucosal trauma
When congestion due to turbinate hypertrophy is better during the day
upright
exposure to steam
exercise
When to do surgery on turbintes
Persistent sx affecting QOL
Despite steroids, a-histamine, saline, decong
Treatment of ozena
(Empty Nose Syndrome)
Saline, topical ointments, augment inferolateral nasal wall
When to consider middle turbinate surgery
Avoid if unnecessary because it helps with humidification, airflow, proper sinus drainage, olfaction
May reduce if polypoid degeneration or concha bullosa
Internal nasal valve
Septum, head of inf turb, upper lateral cartilage
External nasal valve
columella, lateral crus of LLC, nasal ala
Congestion with nasal valve collapse: worse or better with exercise?
Worse
Better with breathe right strips or cottle maneuver
Treatment of nasal valve collapse
Intranasal stent, Breathe Right
Spreader graft, flaring sutures, butterfly graft, batten graft, lateral crural strut graft, alar rim graft, bone anchored suture
Cartilage from septum, ear or rib
Septal hematoma/abscess presentation
Acute congestion, pain, swelling, fever
Fluctuance of septum occluding nose
Septal hematoma/abscess treatment
Immediate I&D (local or general)
nasal splints 1 wk (prevent recurrence)
Presentation of septal perforation
whistling sound, dryness, crust, bleeding, pain, congestion, drain, ASx
DDx septal perforation
surgery trauma drug use vasculitis infxn granulomatous disease malignancy
Treatment of septal perf
Cons: saline, ointment
Surg: silastic septal button or repair
If 5mm or less, primary repair with interpositional graft
If 0.5-2cm, open approach, local mucosal flaps
If >2cm, tough to repair
Contraindications to septal perf repair
active cocaine abuse
active infection, inflammatory, malignant disease
Causes of saddle nose
nasal trauma
aggressive surgery during hump reduction
inadequate dorsal strut in septoplasty
Treatment of saddle nose deformity
Open
Augment area with conchal or rib cartilage (onlay technique)
How old a child should be prior to septoplasty
16 (by then, nose development usually complete)
Can do turbinoplasty when younger, but be conservative
When you may need to go from endonasal septoplasty to open
Deviation from midline in dorsal septum, septal angle, caudal septum, nasal spine
How to correct deviation of dorsal septum, septal angle
shave, extended spreader grafts
How to correct deviation of posterior septal angle
shave, reposition cartilage on nasal spine
How to correct deviation of caudal septum
septal batten graft, reposition, tongue-in-groove technique, caudal septal extension graft
Pros and cons to nasal splints after nasal surgery
Pros: eliminate dead space between flaps, prevent hematoma, enhance mucosal healing, prevent synechiae, stabilize remaining septal cartilage
Remove 1 wk after
Cons: discomfort, infection, studies don’t show major differences between splint and non-splint, so may not be necessary
How nasal surgery impacts sleep disordered breathing
Improved CPAP compliance, subjective sleep sx, QOL
More likely to help if breathe right strips or topical decongestants help decrease snoring or improve sleep quality
