--- title: "Septoplasty Part 2 - Procedure, Surgical Steps & Postoperative Care" description: "ENT notes on Septoplasty - Preoperative assessment, surgical steps & postoperative care." source: "The ENT Resident" author: "Dr. Mausumi Das" canonical_url: "https://www.theentresident.com/ent-notes-lectures/septoplasty-procedure-steps-postop-care" categories: ["Rhinology", "Surgery"] video: "https://www.youtube.com/watch?v=cvsRcz5uYyM" image: "https://media.theentresident.com/og-images/septoplasty-procedure-steps-postop-care.png" --- # Septoplasty Part 2 - Procedure, Surgical Steps & Postoperative Care ENT notes on Septoplasty - Preoperative assessment, surgical steps & postoperative care. Watch the full video lecture on YouTube: https://www.youtube.com/watch?v=cvsRcz5uYyM ## 👃 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** --- ## About This Note This free ENT note on Septoplasty Part 2 - Procedure, Surgical Steps & Postoperative Care was written by Dr. Mausumi Das and is paired with a corresponding video lecture. 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