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

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