Date post: | 17-Jun-2015 |
Category: |
Health & Medicine |
Upload: | ronald-agador |
View: | 9,185 times |
Download: | 9 times |
All Things Septum
Anil R. Shah MD
Epidemiology
33% of people complain of nasal obstruction
26% of those have deviated septum as the cause
Vainio-Mattila J: Correlations of nasal symptoms and signs in random sampling study. Acta Otolaryngol Suppl 1974; 318: 1-48
Septum
Essential for every otolaryngologistAppreciate role of septum in functional
surgeryUnderstand the importance of septum and
aestheticsNuances of technique and anatomy
Anatomy
Cartilaginous angles Anterior septal, middle
septal, posterior septal angles
Foundation for the nose Preserve 1.5 cm
Vasculature and Nervous Supply
Arteries Nerves What nerve at risk
with nasal spine excision and what is the manifestation?
Answer: Nasopalatine Nerve, AnesthesiaOf anterior portion of hard palate and Incisors
Bony articulations
What are the all the bones and bony interactions of the “septum”?
Bony articulations
Bony articulations Quadrangular cartilage,
vomer, perpendicular plaste of ethmoid, premaxilla, palatine bones
Superorly with frontal, nasal and sphenoid bones
What is that?
Vomeronasal organ
Vomeronasal organ for olfaction (primordial)
Aka Jacoben’s organ Located on anterior
septum Found with endoscopy
76% of the time Don’t biopsy but
recognize as normal anatomic structure
Autonomic supply of nasal cavity
What is the autonomic supply of the septum and where do the nerves synapse?
parasympathetic supply is derived from the greater superficial petrosal (GSP) branch of cranial nerve VII. The GSP joins the deep petrosal nerve (sympathetic supply), which comes from the carotid plexus to form the vidian nerve in the vidian canal. The vidian nerve travels through the pterygopalatine ganglion (with only the parasympathetic nerves forming synapses here) to the lacrimal gland and glands of the nose and palate via the maxillary division of the trigeminal nerve.
Perichondrium
Lined by thin, strong inner perichondrial layer and an outer mucosal layer
Perichondrium into flap results in biomechanically stronger flap with greater vascular supply and less likely to perforate
Physics 101 (revisited)
Flow (pressure/resistance)- laminar flow is linear, turbulent flow follows random paths
Poiseuille’s law (major determinant of resistance to airflow is the radius, airflow increases to the fourth power as radius increases)
Venturi effect (as airflow through nose increases, suction is created)
The valves of the nose and internal nasal valve are dynamic. On inspiration the nostril and the internal nasal valve narrow and on expiration the widen. T/F
Ventilation
Inspiration generates a negative pressure, nostrils enlarge (dilators of the nose) and internal valve narrows as upper lateral cartilages approximate septum
Expiration, the internal nasal valve opens and the nostrils narrow
Cole P. Nasal and oral airlfow resistors: Site, function, and assessment. ArchOtolaryngol Head Neck Surg 118:790-793, 1992
Nasal cycle
Normal phenomenon of cyclic alteration of constriction and dilatation of each side of the nasal airway
Typically 4-6 hours to complete
Preoperative assessment
History Allergies Nasal obstruction (unilateral/bilateral, constant/intermittent,
seasonal) Bilateral symptoms that change in severity (mucosal disease) Constant obstruction (fixed structural abnormality) Presence of epistaxis or rhinorrhea Prior nasal surgery Medication history (especially vasoconstrictive sprays, OC’s) Trauma Symptoms (crusting, dry mouth, frequent sore throats, sinus
problems)
Physical exam
External appearance of noseMouth breatherAdenoid facies (maxillary hypoplasia)Location of deviationTip supportNasal valve Remove all crusts (? Underlying
perforation, exophytic lesion, etc)Any abnormal crusts, ulcerations, or
polypoid changes should delay elective surgery for possible underlying systemic condition
Examine with vasoconstrictorHeadlight, speculum, endoscope
Anosmia/hyposmia
University of Pennsylvania Smell Identification Test (UPSIT) Help identify malingering and gross degree of
impairment 34% of patients scored lower postoperatively
after septal surgery 66% improved or were unchanged
Rhinomanometry
Anterior rhinomanometryPosterior rhinomanometryPernasal rhinomanometry
Objective information regarding respiratory function
Quantifies nasal air flow and pressure Nasal resistance (pressure/flow)
Acoustic rhinomanometry
Measures the cross-sectional area of the nasal cavity as a function of distance from the nostril
Sound generator, wave tube, microphone, and a computer
Optimizing acoustic rhinomanometry
Must form an acoustic seal with wave tube without distorting the nasal tip
Results represent cross sectional area as a function of distance (cm) from end of nosepiece
Does not detail shape of the airway, cannot provide information on nasal airway resistance
Goals of surgery
Exposure of the pathologic portion of septum
Removal or reconstruction of the defective portions
Preserve nasal mucosa and liningPrevent external deformity of patient
Do not fear deviations of the dorsum or L-strut (limits practice)
Classification of Septal Deviations
Mild deviationsModerate deviationsSevere deviations
Local anesthetics
Injection of local anesthetic Hydrodissection of mucoperichondrium from
cartilage Cocaine
What percentage is absorbed from cotton swabs? (30%) What is the half life of cocaine? (30-90 minutes) What is the maximum dose of cocaine? (2-3mg/kg)
Uh… Oh!!
You inject lidocaine with epinephrine and the patient becomes tachycardic, hypotensive, and syncope…
Vasovagal?, Allergic Reaction to PABA?, Intravascular Injection of Epinephrine?
Vasovagal-Bradycardic, Cool skin, Hypotensive, Impending sense of doom
Allergic Reaction-Tachycardic, Hypotensive, Flushed and warm skin
Intravascular Epinephrine-Tachycardic (from epinephrine), Hypotensive from impaired ventricular filling of heart, Peripheral Vasodilation (depending on the dose) can occur
2 I’s are amides, esters have PABA
Incisions
Kilian incision Preserves projection the best Should not be too far posterior (difficult to close)
Hemitransfixion incisionFull transfixion incisionHigh and Low transfixion incisionOpen rhinoplasty incision
Technique
Classic Submucosal TechniqueScoringMorselizationSuturesSwinging doorRemoval and replacement
Classic Book Teaching
Keystone areas
Preserve along bony cartilaginous junction
Preserve along nasal floor
Submucous resection limitations
Caudal end deformities are not addressedPoor access to nasal spineDorsal deformities not addressed
Reconstitution
Morselized cartilage replaced between flaps
Less risk of septal perforationFuture source of cartilage for rhinoplasty
and easier dissection
Scoring the cartilage
Which side do you score the cartilage on, concave or convex?
Deviated caudal septum
Caudal margin &Inferior marginto the left of themaxillary spine
Eliminate all posteriorbony attachments to mobilize the anterior septum
Shift caudal margin& inferior margin to opposite side of the Maxillary spine
CONSIDER RELAXINGINCISIONS ON CAUDALMARGIN
1.Anterior septum separated from Vomer and Ethmoid
Maxillary Spine
1.Anterior septum separated from Vomer and Ethmoid
Maxillary Spine
1.
2.
Anterior septum separated from Vomer and Ethmoid
Maxillary Spine
1.
2. 3.
Anterior septum separated from Vomer and Ethmoid
Maxillary Spine
1.
2. 3.
Anterior septum separated from Vomer and Ethmoid Anterior septum
to midline
Deviated Dorsal Septum
Crooked perpendicular plateDoes patient need spreader or onlay graftScore Dorsally on convex side and place
either a bone or cartilageResect septum and reconstruct L-Strut
Correct Dorsal septal deviation with suture suspension to nasal bone
Warping Theory
Fry H. Nasal skeletal trauma and the interlocked stresses of the nasal septal cartilage.Br J Plast Surg. 1967 Apr;20(2):146-58.
Gibson, T. Davis W.B. The distortion of autologous cartilage grafts: Its cause and prevention. Br J. Plast. Surg. 10; 257, 1958
Poor tip support
Poor tip support after a “standard septoplasty”, what do you do?
Tongue-in groove imbrication between medial crus and septum
Placement of columellar strutConsider opening nose
Septal spur
Inferiorly based tunnel Preserve mucosal
flap on nonspur side if possible
Disarticulation of Bony and cartilaginous septum Diagnose
Prominent saddling of nose Loss of stability
Treatment at low point Stabilize with suture through nasal spine 16 gauge needle to drill hole
Secure at high point Secure Cartilage to bony septum (overlap cartilage,
figure 8 cartilage, spreader/bony cartilage complex) Drill holes through nasal bones and secure cartilage
with suture K-wire fixation (show video)
Prior surgery
Look for flap on flap divisionHydrodissection assistanceDo No Harm!
Postoperative care
Nasal splints?Packing?Antibiotics?Nasal exercises for external deviations
Complications
Excessive intraoperative bleedingInfectionRecurrence of septal deformityPersistent nasal obstructionSeptal hematomaSeptal perforation
Septal Perforation
History Crusting, bleeding,
whistling if perforation is small
Rhinorrhea and disruption of lamellar flow if perforation is large
Pain signifies chondritis More anterior the
perforation the more likely the patient will become occult
Septal Perforation
Must rule out a chronic inflammatory disease process, cocaine abuse, granulomatous process in face of granulation tissue on perforation
Physical Exam
Crusting on mucosa due to dry nonlaminar flow, not necessarily at site of perforation
Bleeding at edge of perforation
Picture with endoscope and ruler to assess size of perforation
What tests do I order?
Nasal cultures for fungal and bacterial infections
Skin testing for TB, fungi and anergy
VDRL, FTA-Abs, C-ANCA
Biopsy to rule out autoimmune process
Principle
Perforation is unlikely to heal on its own
More likely to contract and create a larger opening
Medical Therapy
Petroleum based ointments
Antiseptic wash per Fairbanks (1 teaspoon salt in warm water delivered by Water-Pik device +/- glycerin to moisturize + boric acid or vinegar)
Medical button
Surgical therapy
Skin graft or buccal graft (leaves nose dry, continual crusting)
Close primarily by advancement of local tissues
More difficult if posterior, vertical, nasal dorsum
Graft selection (temporalis fasica vs alloderm)
Surgical therapy
Endonasal repair Small perforations
External approach Most perforations less than 2cm
Tissue expander
Free flap
www.shahmd.com