Submucous Resection of Nasal Septum And Septoplasty

Indications
1. Deviated nasal septum (DNS) causing symptoms of
nasal obstruction and recurrent headaches.
Z. DNS causing obstruction to ventilation of paranasal
sinuses and middle ear, resulting in recurrent sinusitis
and otitis media.
3. Recurrent epistaxis from septal spur.
4. As a part of septorhinoplasty for cosmetic correction
of external nasal deformities.
5. As a preliminary step in hypophysectomy (trans-septal
trans-sphenoidal approach) or vidian neurectomy
(trans-septal approach).
Contraindications
1. Patients below 17 years of age. In such cases, a conservative
surgery (septoplasty) should be done.
Z. Acute episode of respiratory infection.
3. Bleeding diathesis.
4. Untreated diabetes or hypertension.Anaesthesia
Local anaesthesia is preferred. General anaesthesia is
used in children and apprehensive adults.
Position
Reclining position with head-end of the table raised.
Steps of Operation
1. Infiltration of nasal septum. It is done in its subperichondrial
planes with 2% xylocaine and 1:50,000
adrenaline.
2. Incision. A curvilinear incision with forward
convexity is made at the mucocutaneous junction on the
left side of the septum. It cuts only through the mucosa
and perichondrium.
3. Elevation of mucoperichondrial and periosteal
flap. Plane of dissection is important. It should be
beneath the perichondrium and periosteum (Fig. 83.1A).
4. Incision of the cartilage. Cartilage is incised just
posterior to the first incision. Avoid cutting the opposite
mucoperichondrium, otherwise, it will result in perforation.
5. Elevation of opposite mucoperichondrium and
periosteum. With the elevator passed through the cartilage
incision, mucoperichondrial and periosteal flap is
raised from the opposite side of the septum (Fig. 83.1 B).
6. Removal of cartilage and bone. Now working
between the two flaps, cartilage and bone are removed.
Cartilage can be removed with Ballenger swivel knife
and bone with Luc's forceps. Bony spur or ridge can be
removed with gouge and hammer. Preserve a strip of cartilage
about 1 cm wide along the dorsal and caudal border
of the septum to prevent collapse of the bridge of
nose or retraction columella (Fig. 83.2).
7. Stitching. One or two catgut or silk stitches are
applied in the initial mucoperichondrial incision.
S. Packing. Ribbon gauze, smeared with an antibiotic
ointment or liquid paraffin, is packed in each nasal cavity
to prevent collection of blood between the flaps. Nasal
dressing is applied.
Post-operative Care
1. Patient is placed in semi-sitting position to prevent
oozing of blood. Outer nasal dressing is changed if
soaked in blood.
Z. A soft diet should be taken in the first two postoperative
days to minimise active mastication
which causes bleeding.
3. Pain, if any, should be controlled with analgesics.
4. Antibiotic cover is given for 5-6 days.
5. Nasal packs are gently removed after 24 hours and
thereafter, decongestant nasal drops and steam
inhalations are given daily for 5-6 days.
6. Silk stitch, if any, is removed on 5th or 6th day.
7. Patient should avoid trauma to the nose for
several days.
Compl ications
1. Bleeding. It may require repacking, if severe.
2. Septal haemawma. Evacuate the haematoma and
given intranasal packing on both sides of septum for
equal pressure.
3. Septal abscess. This can follow infection of septal
haematoma.
4. Perforation. When tears occur on opposing side of
mucous membrane.
5. Depression of bridge. Usually occurs in supratip area
due to too much removal of cartilage along the dorsal
border.
6. Retraction of columella. Often seen when caudal strip
of cartilage is not preserved.
7. Persistence of deviation. It usually occurs due to inadequate
surgery and may require revision operation.
8. Flapping of nasal septum. Rarely seen, when too much
of septal framework has been removed. Septum,
which now consists of two mucoperichondrial flaps,
moves to the right or left with respiration.
9. Toxic shock syndrome. It is rare after septal surgery. It
can follow staphylococcal (sometimes streptococcal)
infection and is characterised by nausea, vomiting,
purulent secretions, hypotension and rash. It should
be diagnosed early. It is treated by removal of packing,
hydrating the patient, maintaining blood pressure and
administering proper antibiotics.

SEPTOPLASTY:
Septoplasty is a conservative approach to septal surgery; as
much of the septal framework as possible is retained.
Mucoperichondrial/periosteal flap is generally ra ised
only on one side. This operation has almost replaced the
SMR operation.
Indications
1. Symptomatic deviated septum.
2. As a part of septorhinoplasty for cosmetic reasons.
3. As an approach to hypophysectomy.
4. Recurrent epistaxis due to septal spur.
Contraindications
1. Acute nasal or sinus infection.
2. Untreated diabetes.
3 . Hypertension.
4. Bleeding diathesis.
Anaesthesia
Local or general.
Position
Same as for SMR operation.Technique
1. Infiltrate the septum with 1 % lignocaine with ad renaline,
1:100,000.
2. In cases of deviated septum, make a slightly curvilinear
incision, 2-3 mm above the caudal end of septal
cartilage on the concave side (Killian's incision).
In case of caudal dislocation, a transfix ion or hemitransfixion
(Freer's) incision is made.
3. Raise mucoperichondrial/mucoperiosteal flap on
one side only.
4. Separate septal cartilage from the vomer and ethmoid
plate and raise mucoperiosteal flap on the opposite
side of septum.
5. Remove maxillary crest to realign the septal cartilage.
6. Correct the bony septum by removing the deformed
parts. Deformed septal cartilage is corrected by various
methods, such as:
(i) Scoring on the concave side (Fig. 84.1).
(ii) Cross-hatching or morcelizing.
(iii) Shaving.
(iv) Wedge excision.
Further manipulations like realignment of nasal spine,
separation of septal cartilage from upper lateral cartilages,
implantation of cartilage strip in the columella
or the dorsum of nose may be required.
7. Trans-septal sutures are put to coapt mucoperichondrial
flaps.
8. Nasal pack.
Post-operative Complications
Same as for SMR operation.
1. Bleeding.
2. Septal haernatorna and abscess.
3. Septal perforation.
4. Persistence of septal deviation, or external nasal
deformity.