Septoplasty

Septoplasty or alternatively submucous septal resection and septal reconstruction, is a corrective surgical procedure done to straighten a deviated nasal septum – the nasal septum being the partition between the two nasal cavities.

SEPTOPLASTY

Conservative approach to septal surgery; Mucoperichondrial/periosteal flap is raised only on one side; Replaced SMR.

INDICATIONS

  1. DNS
  2. As part of Septorhinoplasty
  3. Recurrent epistaxis from spur
  4. Sinusitis d/t septal deviation
  5. Septal deviation causing contact headaches
  6. For approach to middle meatus or frontal recess in FESS
  7. Access to endoscopic DCR operation
  8. Approach to pituitary fossa
  9. Septal deviation causing sleep apnoea

CONTRAINDICATIONS

  1. Acute nasal or sinus infection
  2. Untreated DM
  3. Hypertension
  4. Bleeding diathesis

ANAESTHESIA

Local or General

POSITION

Reclining position with head end of table raised.

PROCEDURE

  1. Septum infiltrated with 1% Lignocaine; Adrenaline 1:1,00,000
  2. A slightly curvilinear incision, 2-3 mm above the caudal end of septal cartilage on the concave side (Killian’s incision)

In caudal dislocation- Freer’s incision

  1. Mucoperichondrial/mucoperiosteal flap raised on one side only
  2. Septal cartilage separated from the vomer and ethmoid plate and flap raised on opposite side
  3. Maxillary crest removed to realign septal cartilage
  4. Bony septum corrected by removing deformed parts in many ways-
  5. Scoring on the concave side
  6. Cross-hatching or morselizing
  7. Shaving
  8. Wedge excision

Further manipulations may be required

  1. Trans-septal sutures placed
  2. Nasal pack

POSTOPERATIVE CARE

  1. Day-care surgery and pt. can go home if he fully recovers from sedation with no postoperative nausea or bleeding. If OSA present, better if observed overnight.
  2. Strenuous exercise to be avoided as it may cause bleeding.
  3. Pack, if kept is removed next day and pt. instructed not to sneeze/blow hard; Secretions to be drawn backwards into throat by snorting rather than blowing nose.
  4. Saline spray/Steam inhalation after pack removal.
  5. Xylo-/oxymetazoline drops if stuffy nose.
  6. Nasal splints (removed 4th/8th day) and gentle suction done.
  7. Pt. should avoid trauma to nose, wipe nose gently and in no case push nose from one side to another.

POSTOPERATIVE COMPLICATIONS

  1. Bleeding: If severe, packing required.
  2. Septal haematoma: Evacuate haematoma and give intranasal packing on both sides.
  3. Septal abscess: Follows infection of septal haematoma.
  4. Perforation: When opposite sides of mucous membrane tears.
  5. Depression of bridge: Usually at supratip area d/t too much removal of cartilage along dorsal border.
  6. Retraction of columella: Caudal strip of cartilage not preserved.
  7. Persistence of deviation: Inadequate surgery; requires revision surgery.
  8. Flapping of nasal septum: Too much septal framework removed; flapping right or left with respiration
  9. Toxic shock syndrome: Staphylococcal/streptococcal surgery following septal surgery

TYPES OF SEPTAL INCISIONS

  1. Killian’s: In the nasal mucosa, cephalic to the caudal end of the septum
  2. Transfixion: Through and through incision, close to but caudal to caudal end of the septum.
  3. Hemitransfixion: Same as the transfixion incision but on one side.
  4. Horizontal on the spur: For endoscopic spurectomy.

DIFFERENCE BETWEEN SMR AND SEPTOPLASTY

SMR Septoplasty
Extensive dissection of septum Limited selective dissection
Not done before 17 years Can be done even in children without affecting nasal growth
Flaps raised on both sides of septum Flaps raised only on one side and limited elevation on the opposite
Bony and cartilaginous parts excised Deformed cartilage is corrected
More complications seen Less complications seen
Re-operation difficult Re-operation easier
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