Septoplasty Part 2 - Procedure, Surgical Steps & Postoperative Care

👃 Septoplasty - Procedure, Surgical Steps & Post operative Care

This post covers:

• Anaesthesia in septoplasty
• Position of patient
• Surgical steps of septoplasty
• Post operative care of septoplasty

💉 Anaesthesia in Septoplasty

Local Anaesthesia - Preferred

👉 1% Lignocaine with 1:1,00,000 Adrenaline

Technique of Infiltration

• Infiltration is given under the flap
• Bevel of the needle faces the septal cartilage or bone
• Infiltrate above, over and under any ridges and spurs

What is the sign of Adequate Infiltration done in Septoplasty?

What are the advantages of Local Infiltration?

General Anaesthesia

Preferred in:

• Children
• Apprehensive adults

⭐ Hypotensive anaesthesia is the preferred choice under general anaesthesia.

🛌 Position of Patient

• Supine position
• 15° head end elevation

Why is a 15° Head End Elevation used in Septoplasty?

What does Preoperative Assessment of Septoplasty consist of?

What are the Principles of Septoplasty?

🔍 Septoplasty Procedure Steps

Following are the steps of Septoplasty:

1️⃣ Incision

The most commonly used incision is the Freer's incision, also known as the Hemitransfixion incision.

• Given exactly at the caudal border of the septal cartilage
• Given on one side only, usually the concave side of the deviation

What are the Advantages of Freer's Incision?

What are the different incisions used in septoplasty?

What is Killian's incision?

2️⃣ Deepening the Incision

The incision is deepened to include the perichondrium.

3️⃣ Elevation of Mucoperichondrial Flap

• Raised on the concave side of the deviation
• Elevated using a Freer's elevator
• Plane of elevation: Between the mucoperichondrium and the cartilage

What are the Advantages of Unilateral Flap Elevation?

What is the Extent of Flap Elevation done in a case of Septoplasty?

What are the Sites of Difficult Flap Elevation in Septoplasty? How do you deal with these areas?

4️⃣ Elevation of Mucoperiosteal Flap on the Floor

• Expose the anterior nasal spine
• Incise the periosteum on both sides of the anterior nasal spine with a No. 15 blade
• Elevate the mucoperiosteum on both sides, proceeding posteriorly

What are the structures encountered along the floor of the nasal cavity from front to back as you elevate the Mucoperiosteal Flap?

5️⃣ Joining the Subperichondrial & Subperiosteal Pockets

• The pockets are joined together slowly
• Avoid injury or perforation of the flaps
• Use sharp dissecting scissors for adherent fibrous tissue

6️⃣ Bony Cartilaginous Disjunction

The septal cartilage is mobilized and separated from its attachments to the vomer and the ethmoid bone.

• Disarticulate the cartilaginous septum from the anterior edge of the perpendicular plate of the ethmoid, by applying firm pressure on the posterior part of the septal cartilage with a Freer's elevator
• Dislocate the inferior border of the septal cartilage from the groove in the crest of the maxilla and the vomer

👉 At the end of this step, the septal cartilage is free posteriorly and inferiorly.

7️⃣ Elevation of Mucoperiosteal Flaps on Both Sides

After bony cartilaginous disjunction, both sides can be accessed from one side.

8️⃣ Correction of Cartilaginous Deviation

The septal cartilage is assessed and the appropriate method of correction is chosen:

• Scoring - Partial thickness cuts on the concave side to straighten the cartilage
• Cross-hatching
• Shaving the convex side of the cartilage
• Wedge excision - Excise a portion of the inferior part of the septal cartilage and place it back into the groove in the floor (caudal septal deviation)

👉 Reduce and reposition the septal cartilage over the vomer.

9️⃣ Correction of Bony Septum & Spur

⚠️ The anterior nasal spine must be preserved.

⭐ Bony portions, unlike cartilage, do not tend to return to their original position after repositioning.

What are the methods of correcting bony deviations in Septoplasty?

🔟 Repositioning the Septum to the Midline

The entire septum is inspected again after repositioning.

What are the causes of Septum not coming to midline after the Septoplasty procedure is done? What can be done to correct it?

1️⃣1️⃣ Repositioning of Flaps & Closure

• Reposition both the mucoperichondrial and mucoperiosteal flaps properly
• Close the Freer's incision using absorbable sutures

1️⃣2️⃣ Nasal Packing

• Both nostrils are packed
• Pack is kept for 48 hours (some centres prefer 24 hours)

🩹 Nasal Packing in Septoplasty

The pack acts as an internal splint to the septum and helps in adapting the mucoperichondrium firmly to the cartilage.

Packing should never be done under pressure, as this may cause ulceration of the mucosa.

Materials Used

• Medicated ribbon gauze
• Merocel pack (more commonly used nowadays)

What are the Advantages of Nasal Packing in Septoplasty?

🏥 Postoperative Care of Septoplasty

1️⃣ Nasal Pack Removal

• Remove after 48 hours
• Clear the nose completely

2️⃣ Patient Instructions

• Do not blow the nose
• Do not sneeze hard
• Avoid strenuous exercise that may cause bleeding

3️⃣ Medications

• Oral antibiotics
• Analgesics
• Antihistaminics
• Decongestant nasal drops
• Saline nasal douching

4️⃣ Follow-up

• At the end of one week

⭐ Exam Pearls

• Most common incision in septoplasty → Freer's incision (Hemitransfixion incision)
• Local anaesthesia of choice → 1% Lignocaine with 1:1,00,000 Adrenaline
• Position → Supine with 15° head-end elevation
• Flap elevated using → Freer's elevator
• Flap preferably elevated on → One side (concave side)
• Perpendicular plate of ethmoid → Fracture and reposition, do not excise
• Anterior nasal spine → Must be preserved
• Nasal pack acts as an internal splint and is removed after 48 hours
• Packing under pressure → Mucosal ulceration

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