1. Basic Format Septoplasty
Procedures
STST p. 609:
Procedures of the nose are most often done to improve breathing—restore function.
Sometimes septoplasty is accompanied by turbinectomy and for cosmetic reasons, rhinoplasty.
Basic Format
Septoplasty

2. Objectives
Assess the anatomy, physiology, and pathophysiology of the Septoplasty.
Analyze the diagnostic and surgical interventions for a patient undergoing a _______________.
Plan the intraoperative course for a patient undergoing_____________.
Assemble supplies, equipment, and instrumentation needed for the procedure.

3. Objectives Choose the appropriate patient position
Identify the incision used for the procedure
Analyze the procedural steps for_____________.
Describe the care of the specimen
Discuss the postoperative considerations for a patient undergoing _______________ .

4. Terms and Definitions Anosmia Epistaxis Hyperosmia
Naris (plural nares)
Nasal (Latin for nose)
Nasal Chonchae (turbinates)
Nasal septum
Olfactory
Paranasal sinus
Parosmia
Rhinitis
Rhino
Sinus
MAVCC Unit 7 OBJ 7

5. Definition/Purpose of Procedure
Excision and resection of the septum to correct any deviation as a result of injury or a congenital nasal deformity; to improve the functioning capabilities of the nose—to improve breathing
The cartilaginous or osseous portions of the septum that lie between the flaps of the mucous membrane and the perichondrium are straightened; cartilage & bony spurs may block the meatus and compress the middle turbinate on that side, resulting in an obstruction of the sinus opening
Other names: nasal septal reconstruction (NSR), submucous resection of the septum (SMR)
Alexander: Objective: to establish an adequate partition between left and right nasal cavities, thereby producing a clear airway through both the internal and external cavities of the nose.
The name SMR tells us that the mucous membrane lining the nasal cavity will be incised, and the underlying perichondrium or periosteum lifted. Then the structures underneath the mucous membrane will be removed to help restore normal breathing.

6. Relevant A & P: External nose—lateral and anterior views
STST p. 601

7. Relevant A & P: Nasal Septum & Related Structures
The nasal cavity is divided into 2 chambers by the nasal septum (above). Anteriorly, the septum is cartilaginous, posteriorly, the septum has bony attachments to the ethmoid and vomer bones. The septal cartilage is also known as the quadrilateral cartilage.
Each nasal cavity, or fossa, has a series of 4 bony projections called conchae or turbinates. The chonchae are osseous ridges on the lateral walls of the cavity. They are named by location: supreme, superior, middle, & inferior. The oriface of each eustachian tube enters the nasal cavity posterior to the turbinates.

8. Relevant A & P: Blood Supply to Nose
STST SEE p Shows that branches of the internal and external carotid arteries provide blood supply to the nose.. The main source is the internal mammary artery, which is one of the terminal divisions of the external carotid.
A common site for epistaxis is Kiesselbach’s plexus—at the terminal end of the anterior ethmoid artery and the corresponding veins in the anterior septum..

9. Pathophysiology
Alexander: Septal deviations tend to cause sinus disease and nasal polyps.
Allrefer.com:
The main indications for nasal surgery are:
nasal airway obstruction
septal spur headache
uncontrollable nosebleeds
nasal septal deformity in the presence of other intranasal surgery
Nasal airway obstruction is usually the result of a septal deformity that causes breathing by mouth, sleep apnea, or recurrent nasal infections that are slow to respond to antibiotics. A septal spur headache is defined as a headache secondary to pressure from the nasal septum on the linings in side the nose (septal impaction) and relieved by topical (applied to a localized area of the skin) anesthesia on the septal impaction. Other intranasal surgery indicating septoplasty includes polypectomy (removal of a polyp), ethmoidectomy (operation on the ethmoid bone at the superior part of the nasal cavity), turbinate surgery (operation on the concha nasalis), and tumor removal.
Also done in conjunction—surgeon may perform a Turbinectomy:
Removal of portions of the inferior and middle turbinates to increase aeration and drainage and to relieve pressure against the floor of the nose.

10. Diagnostics Exams Preoperative Testing Rhinoscopy: Direct vision
STST p. 605: Will use special illumination equipment—headlamp and nasal speculum

11. Surgical Intervention: Special Considerations
Patient Factors
Pt should know before hand that he/she will be mouthing-breathing postoperatively because of postop nasal packing 1-3 days post-op
Pt should understand that application of ice will reduce swelling and brusing around eyes and nose postopertively
If under local, keep noise to a minimum in the OR
Advise pt to remain still and to expect vibrations caused by bone remodeling (mallet and osteotome)
Be aware of drapes on face—minimize claustrophobia and facilitate respiration
This is a clean case—use best technique
Room Set-up
Surgeon may prefer bed turned to 90 degrees of anesthesia for greater access to head
Separate Mayo set up for surgeon to use for preop anesthetic and cocaine nasal packing

12. Surgical Intervention: Anesthesia
Method: Local, Regional, General
Local with IV sedation and analgesia is typical
General for the very apprehensive
Equipment
Note that anesthesia should ensure pt eye protection using ointment & protective eyewear

13. Surgical Intervention: Positioning
Position during procedure
Supine, head tilted back
HOB may be slightly elevated (reverse Trendelenburg)
Pt comfort: flex hip and knees w/OR table settings or pillow under knees/lower legs
Tuck arms to sides; use protective arm sleds and padding
Supplies and equipment
Foam headrest or donut for head stabilization
Special considerations: high risk areas
Ulnar nerves where arms are tucked
Head is raised to reduce bleeding and prevent edema
Pillow under knees alleviates lumbar strain.

14. Surgical Intervention: Skin Prep
Method of hair removal: N/A
Anatomic perimeters: face—avoid solution from getting in or near eyes and ears; do not prep interior of nose
Solution options: may use betadine paint –avoid hibiclens at mucous membranes; may not ask for prep

15. Surgical Intervention: Draping/Incision
Types of drapes
Usually turban-type head wrap or 3 towels arranged triangularly
Order of draping
Remove paper strips from disposable drapes with adhesive edges
Place bar drape across pt forehead & allow remainder of drape to fall toward floor covering the head of OR table
Place U-drape on upper lip. Bring edges of U lateral to the nose and eyes. Extend the rest to cover pt’s body
Special considerations
State/Describe incision
Intranasal incision into mucous membrane and perichondrium

16. Surgical Intervention: Supplies
General
Head and Neck (ENT) pack; suction tubing, ESU pencil, raytex, 4 pk hand towels, needle magnet, syringe for cleaning suction
Specific
Suture & Blades: Fine (4-0) absorbable (atraumatic); # 15 x 2
Medications on Mayo stand: Lidocaine w/epi 1: 100, 00 usually for injection to nares (also have available on back table); Cocaine (1 sm bottle) for nasal packing
Catheters & Drains
Packing & Nasal splints: may use Iodoform or Vaseline or Xeroform gauze packing in addition to plastic nasal splint material (plastic or Silastic) post-op. May be manufacturer’s kit.
2x2’s and ¼” hypoallergenic tape

17. Surgical Intervention: Instruments
General
Specific (see following slides)

18. Surgical Intervention: Instruments
Nasal Instrumentation
Yankauer Suction Tip
# 3 scalpel handle
# 7 scalpel handle
Curved-sharp point Plastic surgery scissors

19. Surgical Intervention: Instruments
Joseph nasal scissors—straight and curved
Metzenbaum scissors (delicate pattern 5 ½ in)
Metzenbaum scissors (delicate pattern 7 in)
Adson tissue forceps (with teeth/angled)

20. Surgical Intervention: Instruments
Graefe tissue forceps
Wilde dressing forceps
Halsted mosquito forceps (straight and curved)

21. Surgical Intervention: Instruments
Backhaus Towel Clamp (3 ½ in)
Halsey needle holder
Frazier Ferguson suction tip

22. Surgical Intervention: Instruments
Aufricht retractor
Senn Retractor
Us Army Navy Retractors

23. Surgical Intervention: Instruments
Joseph single hook
Joseph double hook
Baby Allis tissue forceps

24. Surgical Intervention: Instruments
Farrell Applicator
Vienna nasal speculum

25. Surgical Intervention: Instruments
Killian septum speculum
Cottle septum speculum

26. Surgical Intervention: Equipment
General
Specific
Operating headlight

27. Surgical Intervention: Procedure Steps
An incision is made internally on one side of the nasal septum. After the mucous membrane is elevated away from the bone, obstructive parts of bone and cartilage are removed, and plastic surgery is performed as necessary. Then the mucous membrane is returned to its original position.
Overview: (allrefer.com)
An incision is made internally on one side of the nasal septum. Afterwards, the mucous membrane is elevated away from the cartilage and bone, obstructive parts are removed, and plastic surgery is performed as necessary. Then the mucous membrane is returned to its original position. The tissues covering the septum are maintained in the midline by either sutures or packing.

28. Surgical Intervention: Procedure Steps
Before the surgical scrub, the surgeon will place cocaine-soaked cottonoids into the nares and inject of local anesthetic (usually lidocaine w/epinephrine)
* STSR will set up medicine cup, cottonoids, speculum and bayonet forceps on Mayo for surgeon to pack the nose. The circulator will pour the 4% Cocaine and count cottonoids with the STSR and ensure 27 g.local/needle and Luer-lock syringe is available
Surgeon opens nostril w/speculum, incises the mucoperichondrium w/nasal knife, then deepens the incision w/ fine, sharp dissecting scissors.
* Provide surgeon w/nasal speculum of appropriate size. Have cottle clamp available to aid incision process. Use # 15 blade on a #7 handle for incision.

29. Surgical Intervention: Procedure Steps
For retraction, small skin hooks are placed
Surgeon elevates the mucoperichondrium from the septal cartilage using a fine (Freer) elevator, & removes any spurs from the septum or nasal bone w/nasal/septum cutting forceps (punch, ronguer, or cutting forceps)
* Provide suction as needed. Most likely, the sharp end of the Freer elevator will be used.
* Have chisel (or gouge) & mallet available. STSR may be asked to “tap” the chisel held by the surgeon w/ the mallet. This may not be considered within your scope of practice at your facility—find out before hand.
* Have bayonet or Takahashi forceps available to extract tissue remnants. Surgeon may reinsert bone and cartilage to refashion the nasal cavity and to strengthen weakened areas (keep moist w/NS on the back table in a small basin)

30. Surgical Intervention: Procedure Steps
With the mucochondrium fully elevated, the surgeon removes the septal cartilage w/ a nasal forcep. Examines septal tissue & reshapes as needed w/scissors, rasp, or special bone crusher that flattens cartilage.
Surgeon replaces the septal cartilage within the nose.
Hemostasis is achieved.
* Have suction, hemostatic agents, &/or ESU pencil available.
Surgeon closes the incision w/suture &/or hold cartilage in place with packing material (petroleum gauze & nasal splints)
*Have splint material ready—surgeon may cut to fit the patient using Heavy scissors. It may be sutured in place.

31. Surgical Intervention: Procedure Steps
Dressing may include external splints and “mustache dressing”
Secretions are removed from pharynx to reduce risk of aspiration * provide Wieder retractor and Yankauer tip.
For Turbinectomy
Turbinectomy is performed to remove a hypertrophic turbinate, usually the inferior turbinates. What is the cause of hypertrophied turbinates? They are often a result of chronic rhinitis. Recurrent inflammations cause the structure to lose its elasticity.
A submucosal approach is used. The nasal mucosa along the edge of the affected turbinate is incised. All or some of the bones of the turbinate are removed. The mucosa is repositioned and held in place w/intranasal packing.

32. Counts Initial: Sponges and sharps (raytex and cottonoids)
First closing
Final closing
Sponges
Sharps

33. Dressing, Casting, Immobilizers, Etc.
Types & sizes
Mustache dressing –have 2x2’s available and ¼” silk or micropore tape
External Splint of surgeon’s preference (eg. Denver splint kit)
Type of tape or method of securing—least irritating to skin
Have ice pack available (can make using 2 gloves tied together w/crushed ice)

34. Specimen & Care Identified as nasal cartilage
Handled: routine in formalin

35. Postoperative Care Destination Expected prognosis (Good) PACU
Outpatient Discharge
Expected prognosis (Good)
Full restoration of nasal function
Return to normal activities about 7 days

36. Postoperative Care Potential complications
Hemorrhage
Infection
Other: Damage to….perforate septum, cause weakened septum which could lead to future deformity
Surgical wound classification: II

37. Resources Alexander’s pp. 759-762 MAVCC Unit 7 OBJ 7, 8, 9, 10, 11
STST pp
Fuller pp
Goldman p ;

38. Case Studies in STSR Study Guide
Case Studies in Text
Case Studies in STSR Study Guide