Head & Neck Surgery - Otolaryngology
4th Edition

Septoplasty alleviates nasal obstruction by means of surgical resection of impinging anterior cartilaginous or posterior osseous septal deviation. The clinical indications are tabulated in Table 23.3.

Septoplasty involves the surgical correction of a deviation of the septum. The surgeon resects only the deviated portion of the septum, allowing maximal preservation of this important structural component of the nose. Whereas the submucosal resection of the septum involves removal of the septum except for a 1-cm wide dorsal and caudal strut that remains for the nasal support, we prefer the concept and term septoplasty, because each procedure should be individualized and limited to conservative resection of abnormal cartilage only.

Septoplasty can be performed with either a local or a general anesthetic. The latter is preferred for operations on patients who are apprehensive about surgery, or when a long procedure such as endoscopic sinus surgery, is combined with septoplasty. The infiltration in the subperichondrial plane is the key step in the operative procedure. This is performed with a hemostatic solution, such as lidocaine 1% with 1:100,000 epinephrine. The infiltration can be done from either anterior to posterior, or posterior to anterior, although the authors prefer the former. Multiple injections may be needed over the spur, but the first injection is the key in elevating the flaps, because the injection must be in the right plane with high pressure to elevate the perichondrium. This is usually accomplished with injection at dorsal anterior injection point. Waiting 10 minutes after injection maximizes the effect of vasoconstriction.

Placement of incision depends on the specific area of the septum that needs to be addressed. Freer’s hemitransfixation is preferred if the caudal quadrangular cartilage is dislocated. This incision passes through the membranous septum, between the medial crura of the lower lateral cartilages and the caudal quadrangular cartilage. The Killian incision (vertical incision about 1 to 2 cm from columella) is preferred if the obstruction is in the posterior cartilaginous septum or the bony septum (Fig. 23.1). The third type of incision, is an endoscopic septoplasty incision, in which the incision is made just parallel to the spur that needs to be removed.

The side of incision depends on multiple factors. Usually the right-handed surgeon prefers a left-sided incision. Sometimes, the surgeon may prefer to use the incision on the convex side of the septal deviation. Therefore, even a right-handed surgeon may need to make a right hemitransfixation incision if the caudal septum is convex towards the right. After the incision is made, a mucoperichondrial-mucoperiosteal flap is raised on the side of the incision (Fig. 23.2). The confluence of the septal cartilage, the perpendicular plate of the ethmoid, and the vomer is a difficult area to raise without perforating the mucosa. It requires meticulous dissection with a Freer or Dunning elevator. The mucoperichondrium-mucoperiosteum on the
contralateral side is also raised. Access to the contralateral side is either via an incision through the septum or around the caudal septum, depending on the exposure required. Deviated portions of the septum are identified and removed. If the cartilage is normal and only a ventral cartilage, maxilla or vomer deformity is the problem, complete flap elevation of the contralateral side is not always essential. A knife is used to incise the cartilage above the ventral deformity. Septal spurs that are due to overgrowth of the maxillary crest can be removed with a Freer chisel. Resection of vomer deformity can be accomplished with an osteotome. Care is taken not to rock the perpendicular plate of ethmoid bone. Rocking can cause fracture at the cribriform plate and can cause cerebrospinal rhinorrhea. Care also is taken to avoid tearing the septal flaps, because bilateral tears can cause septal perforation. Occasionally, torn mucosa and perichondrium can inadvertently be removed with bone and cartilage. Loss of mucosa will obviously delay healing and increase the risk of septal perforation.

When deviation involves the dorsal strut of the septum or the caudal end of the septum, the initial approach is to release the septum by excision of a small strip of ventral cartilage, which may allow the septum to return to a midline position. An overhanging septal cartilage may also be shortened by minimal resection (2 to 4 mm) of the caudal septum. With severe deformity, extended cartilage removal may require cartilage grafting to avoid loss of nasal tip and dorsal support. While conserving as much cartilage as possible, the surgeon needs to be wary of leaving deformed cartilage in place, which can cause renewed obstruction. Deformed cartilage can be crushed or scored to reduce the likelihood of memory in the cartilage, which can cause poor results. After the cartilaginous structure is fixed, septal flaps are approximated with a horizontal mattress (plicating) absorbable suture. If the field is not completely dry, an incision is made along the ventral aspect of the mucoperichondrial flap, to provide a drainage site to avoid a hematoma. Obviously, if the flap has any tears from the elevation, this step is unnecessary. Silastic septal splints can aid in preventing synechiae, especially when septoplasty has been combined with turbinate resection or endoscopic sinus surgery. The splints are held in place with simple transseptal suture of 5-0 nylon. Splints are by no means, however, essential. The hemitransfixation incision is closed with two mattress sutures of 4-0 chromic catgut. Nasal packing is often used to prevent the postoperative septal hematoma.

The advent of the nasal endoscope has widened the horizons of otolaryngology. Its value in approaching the sinuses, skull base, orbit, and pterygopalatine fossa is unquestionable. Often during common nasal procedures and during these special occasions, the surgeon’s view is obstructed with narrow access due to septal spurs or septal deviations. These occasions dictate a localized removal of the spurs or the deviation. In these situations, the surgeon may prefer to use the endoscope to assist in localized removal by making an incision just over the spur (Fig. 23.3). The flap is then elevated above and below the spur and the spur is removed (Figs. 23.4 and 23.5). Although the use of endoscope may limit the surgeon’s ability to use both hands during surgery, the advantages of good visualization and magnification surpass its limitation. This technique is limited to localized areas of obstruction due to a spur. The incision usually does not need to be closed.

The most challenging septal surgery is the revision septoplasty, in which previous surgical resection and scarring alters the surgical plane. In these situations, elevation of the mucoperichondrial flaps is taxing and often results in perforation of the septal flaps.

Meticulous dissection with a sharp knife and the careful separation of flaps are key in the procedure. Once the flaps are separated, the deflected portion is addressed. Prior to the revision surgery, the surgeon should discern the cause for the persistent deviation. Sometimes it is wise to address the issue of nasal obstruction by performing an endoscope-assisted localized spur removal, as mentioned previously. In cases in which there is persistence of caudal deflection following previous septal surgery, an option may be to widen the area by orbital suspension of the nasal valve (described later in the chapter), instead of elevating septal flaps in an area that is already scarred by previous surgery.

When revision septoplasty is essential, the surgeon should first palpate the septum and outline areas of absent cartilage. The flap elevation should begin in areas where cartilage or bone is present. This may require the use of a nonstandard incision more posterior to the Killian incision. Sometimes the incision may be made over the bony septum. Once flap elevation is accomplished, the prior steps of repair are the same as standard septoplasty.

In combination with septoplasty, nasal fractures can also be reduced. It can be combined with rhinoplasty, which serves as an external compliment. This can be performed either through the intranasal or external route. Rhinoplasty is extensively discussed later in the textbook.

The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) performed a nationwide study: Nasal Obstruction Septoplasty Effectiveness (NOSE) study. This was a multicenter study performed in 14 sites, involving 16 investigators from July 2001 through January 31, 2003. Fifty-nine patients underwent nasal surgery. Only 6% of patients reported that they were not pleased by the procedure, and the rest were satisfied with the improvement. This improvement was unchanged at 6 months. Patient satisfaction was very high, and patients used significantly fewer nasal medications (2).

The major complications following septoplasty are tabulated in Table 23.4. Although complications are rare, they can be very significant. Failure to correct the patients’ symptoms is not considered a complication, and this should be stressed to the patient. Hemorrhage and the potential morbidity associated with control of the bleeding is probably the most common complication. Anosmia is rare but is the most serious permanent complication. Loss of dorsal support and subsequent saddle deformity is a serious cosmetic complication. Septal perforation is always a risk and may cause significant morbidity. Every patient is at risk for all these and the other listed complications.

Most hematomas and abscesses can be adequately evacuated with topical anesthesia supplemented by local infiltration. Confirm the presence of hematoma by compressing the area with a cotton-tipped applicator. The bulge
from the hematoma is compressible with the applicator. It should not shrink with the application of a topical vasoconstrictor.

As soon as the diagnosis is confirmed, the sutures should be removed and the hematoma should be drained. The clot or the abscess is then evacuated with suction irrigation if needed. A bilateral hematoma can usually be evacuated from one side by gentle pressure to the contralateral side. A ventral incision along one side of the septal mucoperichondrium may help in drainage and may prevent reaccumulation. A wick of 1/8-inch iodoform gauze is inserted through the incision. Care should be taken to ensure that the wick is flat between the mucoperichondrium and the cartilaginous septum. One should not pack the cavity with the wick. This will allow continuous drainage. Apply bilateral nasal packs following the successful drainage of a septal hematoma. Packing inhibits reaccumulation of the hematoma. Proper follow-up is vital to preventing any infectious process or cosmetic deformity. All patients should be reevaluated within 24 hours and again in 48 hours for removal of the nasal packs. These patients will require pain control and broad-spectrum antibiotic coverage.

Most of these procedures can be performed on an outpatient basis unless they are combined with other operative procedures, such as septoplasty, wherein they can be performed in the operating room. In an outpatient setting, the patient is placed in the sitting position. The anterior
nasal cavity is anesthetized with a topical local anesthetic with epinephrine, and then cotton pledgets with the same solution are placed along the anterior and middle aspects of the inferior turbinate. Transpalatal sphenopalatine ganglion blocks are then performed bilaterally with 1% lidocaine within 1/100,000 epinephrine. After approximately 5 minutes, the anterior aspect of the inferior turbinate is injected with 3 to 5 mL of 1% or 2% lidocaine with epinephrine. The injection provides anesthesia and enlarges the diameter of the turbinate to prevent mucosal injury if radiofrequency is used. It also assists in hydrodissection and elevation of the plane, in cases of submucosal turbinate reduction.

Conservative submucous turbinate resection, also known as inferior turbinoplasty, has been shown to yield at least 3 to 5 years of relief from mucosal and bony hypertrophy. However, submucosal turbinate resection alone cannot be used to manage nasal obstruction, because of chronic hypertrophy of the nasal mucosa. The physician must address the underlying cause of mucosal hypertrophy to achieve good surgical success.

Submucous resection is performed when the inferior turbinate projects medially and obstructs the nasal cavity or when hypertrophic turbinate mucosa remains unresponsive to vigorous medical management. When performed as an isolated procedure, inferior turbinate resection proceeds after vigorous anesthesia and vasoconstriction of the turbinate and lateral nasal wall. After a posterior to anterior incision is made along the inferior aspect of the inferior turbinate (Fig. 23.11), the mucoperiosteum is elevated off the medial and lateral aspects of the turbinate bone. The turbinate bone is fractured and reduced with Jansen-Middleson rongeur (Fig. 23.12), Takahashi forceps, or turbinate scissors. We prefer the turbinate scissors. The superior and inferior mucoperiosteal flaps are carefully preserved, redundant mucosa is trimmed from the inferior mucoperiosteal flap, and the superior mucoperiosteal flap is placed laterally over the resected inferior turbinate. The mucoperiosteal flap is gently packed in place for 24 to 48 hours with antibiotic impregnated petrolatum gauze, to ensure proper adhesion and healing of the mucoperiosteum to the resected turbinate bone. An alternative is to place horizontal (plicating) mattress sutures through a minimally resected turbinate, to obviate uncomfortable nasal packing.

Most of the techniques described involve treatment of submucous tissue with sacrifice of mucosa for access to the target area. Techniques such as partial or total inferior turbinectomy, cryosurgery, electrocautery, and laser destroy the mucosa, thereby interfering with nasal physiology. Classic submucous resection of the inferior turbinates is a technique designed to preserve the mucosa, but it is a misnomer because the resection includes some mucosa. The main goal of this type of surgery should be the preservation of mucosal surfaces, with reduction of the submucosal and bony tissue. Powered instrumentation used in a functional approach to inferior turbinates offers advantages over traditional techniques with regard to complications and mucosal preservation. In addition, resection with classical technique can often result in overcorrection and possible atrophic rhinitis.

An incision is made with a no. 15 blade in a vertical manner, in the anterior aspect of the inferior turbinate. A submucosal pocket is created with sharp dissection on the medial surface of the bony turbinate. The straight microdebrider (4-mm tip with tricut blade) is applied through the incision. Alternatively, a specially designed turbinate microdebrider blade is available from Medtronics (Minneapolis, MN). It includes a knife for sharp elevation and a 3-mm blade for turbinate reduction. The bony turbinate and some of the submucosal tissue is debrided at
5,000-cps oscillating mode in a ventrocaudal manner. Debridement should be performed with the blade positioned laterally from the submucosal plane. The 6,000-cps forward mode is used when the bony turbinate is hard to debride. Particular attention should be paid to preserve the mucosal flap. Hemostasis can be achieved under direct vision with suction electrocautery, when necessary. The incision need not be closed. The reduction in size of the inferior turbinate is usually recognized immediately after the procedure. This technique allows for incremental controlled submucosal turbinate reduction. Light nasal packing is helpful for 24 hours, to avoid postoperative bleeding. As in any procedure, the technique requires a learning curve, to know how much of the tissue or the bone can be resected to achieve an effective airway, without leading to complications such as atrophic rhinitis.

Studies conducted by the senior author indicate that out of 120 patients who underwent this technique, 75% had complete resolution of their symptoms of nasal obstruction, and the rest had some resolution of their symptoms (complained of minimal nasal obstruction postoperatively). Synechiae occurred in 5% of the patients. None of the patients studied suffered crusting, foul odor, or nasolacrimal duct injury complications (6).

The recent advance of radiofrequency energy has given further advantage for otolaryngologists in the reduction of turbinate hypertrophy. Temperature-controlled radiofrequency delivers a current of 460 kHz, by a high-frequency alternating current flow into the tissue, creating ionic agitation. This ionic agitation heats the tissue, and as the temperature rises higher than 47°C, protein coagulation and tissue necrosis ensue. Collagen deposition begins approximately 12 days after injury, and at 3 weeks, chronic inflammation, fibrosis, and tissue volume reduction from scar contracture occur. This can be performed either by using unipolar or bipolar radiofrequency probes that can be delivered to the anterior, and if required, to the middle aspects of the inferior turbinate. Approximately 300 to 550 J of energy is delivered, and after the probe is removed, a cotton pledget with oxymetazoline is placed along the anterior turbinate for hemostasis. Some advocate a bipolar probe as better in terms of instant tissue reduction, but no study has clearly shown that one technique is superior.

The posttreatment findings after inferior turbinate radiofrequency include nasal swelling for 24 to 72 hours. Final reduction is complete in 3 to 4 weeks, and retreatment can be performed if nasal obstruction persists. Bleeding, crusting, dryness, adhesions, and infection are rare complications. The advantage of this procedure is that it is less time-consuming and more efficient than other historical procedures for chronic mucosal hypertrophy, such as cryotherapy, electrocautery, and laser ablation. It does not require nasal packing, which is an advantage over submucosal microdebrider reduction.

Carbon dioxide laser vaporization of the turbinate had previously been accepted as a common treatment for allergic rhinitis. Usually, only a single procedure is applied to minimize trauma. However, repeated procedures on separate days are often required to achieve an adequate effect. Holmium (Ho): Yttrium aluminum garnet (YAG) laser treatment is used in the turbinate reduction and is efficacious, but has poor long-term efficacy (7). Potassium-titanyl-phosphate (KTP/532) laser, a useful tool in endoscopic intranasal operations, has been investigated in endoscopic inferior turbinate reduction and appears to be an alternative in the management of turbinate hypertrophy. Although it achieves better results in controlling nasal obstruction, the results are less promising in treating postnasal drip and rhinorrhea (8). Further, many of these laser techniques ablate the mucosa, whereas ideally one would always want to preserve the mucosa to preserve the mucociliary function.

Comparison of the effects of radiofrequency tissue ablation, CO₂ laser ablation, and partial turbinectomy applications on nasal mucociliary functions was performed by Sapci et al. (9). They found that at 12 weeks after surgery, the nasal mucociliary transport time was 25.60 minutes on the side where laser ablation was applied and 11.40 minutes on the side where partial turbinectomy was applied. In the patients on whom radiofrequency tissue ablation and partial turbinectomy were applied, the average nasal mucociliary transport time was 10.33 minutes on the radiofrequency tissue ablation side, whereas it was 11.33 minutes on the partial turbinectomy side. They concluded that radiofrequency tissue ablation to the turbinate is effective in improving nasal obstruction objectively and in preserving nasal mucociliary function. Laser ablation of the turbinate is effective in improving the nasal obstruction; however, it disturbs the mucociliary function significantly. With the partial turbinectomy technique, results obtained were similar to the results with the radiofrequency tissue ablation technique.

Ablative turbinate surgery, such as radiofrequency and laser ablation, is used only to reduce obstructive hypertrophic nasal mucosa. Used alone, these procedures reduce nasal obstruction due to mucosal hypertrophy but not anatomic deviation. After turbinate ablation, if the source of nasal irritation and mucosal hypertrophy is not eliminated, such as removal of sources of dust or mold allergy or alteration of diet to exclude suspected allergens, the physician should anticipate a recurrence of mucosal hypertrophy.

The nasal valve area is examined prior to injection of local anesthesia to avoid distortion of tissue. Two points representing the caudal and cephalad margins of the collapsed area are marked. An incision is made through the mucosa connecting the two points (Fig. 23.13). A natural skin crease along the orbital
rim is marked (Fig. 23.14). We have used an external incision in almost every patient, with no significant scarring. The incision is so small, and its placement within a natural skin crease makes the external incision the recommended choice. Local anesthesia with epinephrine is then injected into the valve area, along the maxilla, near the infraorbital nerve, along the orbital rim. A 3-mm incision is made in the medial aspect of the orbital rim. The skin incision is through skin only, orbicularis oculi muscle fibers are pushed, and periosteum is incised and elevated. Rarely is bleeding encountered, but if it is, bipolar cautery is used to control it. The periosteum is elevated away from the orbital rim to expose a 3 × 3 mm area. The Mitek soft tissue anchor system (1.3 mm Micro Quick Anchor, Ethicon, Inc., Piscataway, NJ), which includes the drill bit, bone anchor, and attached suture, is used to anchor a suture to the orbital rim. A small drill hole is made into the bone (Cordless Driver 2, Stryker Corporation, Kalamazoo, MI) and the Mitek anchor is then easily inserted into the bone (Fig. 23.15). The longer end of the suture is then passed with a curved needle (Richard-Allan 1/2-inch, curved, tapered needle) to the nasal valve area and passed through the cephalic point. It is important to place the hole medial and high at the orbital rim where the bone is thick enough so that the anchor does not enter the sinus. The needle pass should be as close to the maxillary bone as possible and not in the soft tissue of the face. The incision that was made initially connecting the two points buries the suture. After identifying the collapse site and the intended site of suspension, the needle is then rethreaded and passed from the caudal point toward the anchor (Fig. 23.16). The suture is then tightened and tied with the proper amount of tension to open the valve but to avoid significant distortion of the external valve area (Figs. 23.17 and 23.18). Occasionally, two bone anchors and four points of fixation are needed for adequate correction.

The most common complication following the procedure is the foreign body reaction to the Mitek anchor system. Sometimes, abscesses can form over the incision site. This requires aspiration of the abscess, which should be subjected to culture and sensitivity and treated with the appropriate antibiotic. In other cases, granuloma formation has been known to occur. In 5% of these patients, suture removal is required. Other, less common complications include hematoma following injury to the angular vein during placement of the anchor into the maxillary sinus (Table 23.6).

Our experience with the orbital suspension technique was from 2001 to 2004. All patients had minor changes in their external appearance that were either considered an improvement or inconsequential. Nearly all patients (91.7%) had significantly improved airways in a short-term study. The only complication reported was the foreign body reaction following the procedure that eventually required removal. Long-term results are not available (13).