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NASAL AIRWAY SURGERY: MANAGEMENT OF SEPTAL DEFORMITIES
Table 38.1 Special considerations in septoplasty approaches
Endoscopic septoplasty • Used for limited septal excision
• Good visualisation
• Requires minimal access
• Can be performed at the same time of sinus surgery to improve
access
External (open)
septoplasty
Septal Surgery
Submucosal Resection (SMR)
is technique addresses deviation at the body of the septum (not the L-strut). A Killian incision
is placed about 1 cm from the caudal septal edge and the ap is raised. e deviated part of the
septum is excised aer being freed from its peripheral attachments. e harvested bony or cartilaginous septum can then be used as a gra or it can be straightened and reinserted in its place.
Septoplasty
A number of stud ies have shown septoplasty to have a good eect on nasal blockage a nd to be costeective compared with non-surgical management. In most cases of septal deviation, the septal
L-strut is involved and the approach should allow adequate exposure. e surgical approach is
oen through an endonasal route; however, other approaches are available (Table 38.1):
• Mostly used when the dorsal L-strut deformity requires correction
• It can improve surgical access
• It is favourable in complex septal reconstructive cases such as
extracorporeal septoplasty
1 Hemitransxion incision is placed at the caudal edge of the septum.
2 Mucosal ap is raised on the concave side.
3 In certain deformities (e.g. S-shaped deformity), both mucosal aps are raised.
4 When the osseocartilaginous junction is reached, depending on type of deformity,
this junction can be disarticulated, and a segment of bone or cartilage removed.
5 Disarticulation of the septal cartilage from the maxillary crest allows the septum to
move to midline (the 1 cm of bony-cartilaginous junction at the L-strut is le undisturbed if possible).
e deviated septum can be addressed by a variety of techniques. Here, the most commonly
employed techniques are described:
Scoring of the septal cartilage on the concave side allows the septum to become
•
straight. is technique is not reliable as under-scoring or over-scoring can occur;
splinting the septum against a batten gra adds security. (Figure 38.2)
Septal batten gras (harvested from the septal cartilage or bone) can be used to keep
•
the deviated septum in a straight line. Spreader gras can be used as batten gras to
straighten the deviation of the dorsal L-strut.
Paediatric Septoplasty
Controversy remains regarding the optimal age and extent of septal surgery in the paediatric population. Studies have demonstrated that septal surgery performed in children as
young as 6 years old provides long-term satisfactory outcomes. Delaying surgery in children
with bilateral nasal blockage and septal deformities may adversely aect nasofacial growth.
Conservative cartilage resection with preservation is essential to avoid disruption of important endochondral ossication plates.
Nasal Valve
Nasal valve is the area caudal to the nasal bones and it contains the narrowest section of the
nasal airway (i.e. internal nasal valve) as well as a mobile collapsible lateral nasal sidewall
198 Rhinology and Facial Plastic Surgery
NASAL AIRWAY SURGERY: MANAGEMENT OF SEPTAL DEFORMITIES
(a)
Ex
in deviated position
the septum
e
Batten
graft
Anterior
nasal spine
cess septal length
Figure 38.2 ‘Swinging door technique’ is a reliable method in dealing with caudal septal devia-
tions. (a) Septal convexity to the right has resulted in excess caudal septal length. (b) The excess
length of the septum is excised. (c) The height of septum is restored after scoring of the concave
side. (d) The weakened septum is splinted against a batten graft and secured to the midline.
e nasal valve has traditionally been divided into two three-dimensional (3D) areas: (1)
internal valve and (2) externa l valve. is div ision is arbitrary as there is no clear line bet ween
them. Nasal valve angle refers to the angle between the ULC caudal edge and the septum, and
it is measured at 10–15° in Caucasian noses.
Obstruction at the nasal valve can occur due to either static narrowing (the airway is constantly restricted due to deformed anatomy) or dynamic collapse (the nasal airway gets
blocked on inspiration due to collapse of the nasal sidewall).
A thorough nasal examination is essential in diagnosing the cause of nasal blockage. e misting
test is not a reliable way to assess nasal blockage secondary to nasal valve collapse as it relies on
nasal expiratory ow, whereas dynamic collapse occurs on inspiration. A nasal speculum can be
used to examine the anterior nasal cavity; however, the nasal airway and the valve area should be
examined by an endoscope in its neutral position. Cottle’s manoeuvre (i.e. gently pulling the cheek
lateral ly) has little specicity. However, a modied version of Cottle’s manoeuvre where the ULC is
gently lied by a probe is a more reliable way to detect the structural cause of nasal valve collapse.
(b)
Excess septum
excised
(c)
Scoring, straightening
and lengthening of
(d)
Septum fixed to
anterior nasal spin
Nasal Valve Surgery
e two commonly employed graing techniques are described here.
Dressing and Splints
Postoperative nasal packing remains a varied practice. Some surgeons use septal splints to
prevent adhesions or to provide extra support for the septum. Most surgeons apply an external splint aer external (open) septoplasty.
Complications
e rate of complications varies in dierent studies and it depends on the operator and
whether turbinate surgery is performed at the same time of septoplasty. ese complications
include the following:
Spreader gras are used to reconstruct the dorsal ‘T’ junction between the ULC and
•
septum. (Figure 38.3) eir use is both for functional and aesthetic purposes (some
argue the magnitude of their functional advantage).
Strut/batten gras are usually taken from the septal or conchal carti lage and attached
•
to the lateral crus of the lower lateral cartilage (LLC) to strengthen the collapsing
lateral nasal sidewall.
Bleeding (5 –10%)
•
In fection (2–3%)
•
Septal perforation (1–7%)
•
Rhinology and Facial Plastic Surgery 199
NASAL AIRWAY SURGERY: MANAGEMENT OF SEPTAL DEFORMITIES
Figure 38.3 Spreader grafts are placed between the upper lateral cartilages and the septum to
reconstruct the dorsal septal ‘T’ segment.
Adhesion (1–7%)
•
Adverse nasal shape, e.g. saddle deformity, nasal tip depression (4–8%)
•
Septal haematoma and septal abscess (1–2%)
•
Hy pos mia (1–2%)
•
Upper middle incisors anaesthesia and discolouration (0.1%)
•
KEY POINTS
• Nasal obstruction can be caused by septal deection, which can be developmental or
secondary to trauma.
• The misting test assesses the nasal airway in expiration; it does not test the dynamic
elements of nasal obstruction which occur in inspiration.
• The nasal airway should be examined before and after topical decongestion to assess
the effect of mucosal swelling.
• The patient’s nasal airway should be examined in the neutral position using an endoscope.
• Nasal airway surgery requires attention to the nasal septum as well as nasal valve areas.
• Nasal valve dilator devices and nasal steroid medications play a part in the non-surgical
management of nasal valve obstruction.
• In septoplasty, the attention is more on reconstruction rather than excision.
• When septal deviation involves the L-strut, SMR is not effective as it cannot
address the caudal and dorsal struts; septoplasty techniques are needed in these
circumstances.
• In certain situations, especially where the dorsal L-strut deformity is concerned,
external approach septoplasty can improve surgical access (with the septum in situ or
through extracorporeal techniques in severely distorted cases).
• Most nasal valve procedures will have an aesthetic effect and the patient should be
warned of these prior to the operation.
• There remains controversy about the optimal age and extent of septal surgery in the
paediatric population.
The most important aspect of paediatric septal surgery is to resect the cartilage
conservatively and to avoid disrupting the endochondral ossication plates.
200 R hinolog y and Facia l Plastic Surgery
NASAL AIRWAY SURGERY: MANAGEMENT OF ENLARGED TURBINATES
39. NASAL AIRWAY SURGERY: MANAGEMENT OF ENLARGED TURBINATES
Introduction
e inferior turbinates are dynamic structures that form a crucial part of the normal functional nose but being relatively easy to access, they have been subject to numerous operative
techniques in attempts to alleviate nasal obstruction. Inferior turbinate surgery is a frequently performed ear, nose and throat (ENT) procedure for nasal obstruction. e evidence
base for surgery is weak and there is currently no ideal surgical procedure.
Pathogenesis of Inferior Turbinate Enlargement
Rhinitis and rhinosinusitis will accentuate the eect of the nasal cycle and nasal reexes,
inducing a sensation of nasal obstruction. Severe allergic rhinitis causes marked large, pale
oedematous inferior turbinates.
Frequent self-medication with xylometazoline may induce rhinitis medicamentosa with
increased nasal congestion that persists aer vasoconstriction.
Compensatory hypertrophy of the inferior turbinate is associated with deviation of the nasal
septum to the opposite side.
Hyperplasia generally aects the whole structure, but enlargement can sometimes be localised to the anterior head or posterior section of the turbinate.
Clinical Assessment
Patients with enlarged inferior turbinates require a full rhinological history and nasal endoscopy to determine the cause:
1 Nasal examination (before and aer mucosal vasoconstriction to dierentiate between
hyperplastic or just congested turbinate)
2 Assessment of impact on quality of life (QoL) using validated the questionnaire Nasal
Obstruction Symptom Evaluation (NOSE) prior instigating any treatment
3 If available, objective assessment of nasal obstruction including acoustic rhinometry,
anterior rhinomanometry, rhinospirometry and the peak nasal inspiratory
Management of the Enlarged Inferior Turbinate
e primary treatment of enlarged inferior turbinates is medication. is will generally
include topical nasal steroids for a minimum period of 3 months. Surgery should be considered if symptoms persist.
Informed consent should include a discussion of possible outcomes and warn patients that
symptom relief may be short-lived, but reduction surgery can be repeated.
ere is much diversity in opinion and practice of inferior turbinate surgery and the terminology of surgery lacks standardisation: turbinectomy refers to any degree of resection but
turbinoplasty strictly means changing the shape of the turbinate. It can also refer to a specic
procedure that includes resection of the conchal bone. A simple system of classifying turbinate operations is shown in Table 39.1.
Turbinate Surgery in Various Clinical Situations
Rhinosinusitis and Endoscopic Sinus Surgery
Mucosal congestion from chronic rhinosinusitis (CRS) may induce enlargement of the inferior turbinates. Mucosal inammation within the sinuses should improve signicantly aer
endoscopic sinus surgery and continued medication, which should reduce congestion of the
turbinates. Should inferior turbinate surgery still be deemed necessary, the authors would
suggest submucosal turbinoplasty.
Rhinology and Facial Plastic Surgery 201
NASAL AIRWAY SURGERY: MANAGEMENT OF ENLARGED TURBINATES
Table 39.1 Simple system of classifying inferior turbinate operations
Category of
surgery Technique
Mucosal
preservation
Mucosal
destructive
reduction
Turbinate
excision
procedures*
*
Complete or subtotal of the inferior turbinate is not recommended and risks causing prolonged
nasal crusting or inducing an empty nose syndrome.
Submucosal
diathermy
Mini-
microdebrider
surgery
Radiofrequency The radiofrequency needle is advanced submucosally from
Coblation The Coblation wand is inserted submucosally and
Turbinoplasty The mucosa is lifted off the IT laterally and the conchal bone
Lateralization by
outfracture
Supercial
electrocautery
Chemocautery
with chromic acid
or trichloroacetic
acid
Cryosurgery The cryoprobe is activated along sections of the IT,
Laser surgery Supercial lesions are induced by the laser, either directly
Direct
mucosal reduction
Partial The anterior third of the IT is divided by scissors and
Subtotal* Angled scissors are used to excise a length of the IT. It is
Posterior end
The diathermy needle is advanced submucosally from the
anterior end to the posterior section of the inferior turbinate
(IT). It is then slowly withdrawn over several seconds. Two to
three different passes are often performed.
The tiny blade is inserted submucosally and passed to the
posterior section of the IT. The blade is used in oscillation
mode to reduce the submucosal erectile tissue and
steadily withdrawn. A couple of passes may be needed.
the anterior end to the posterior section of the IT. It is
then slowly withdrawn over several seconds. Two to
three different passes are often performed.
advanced posteriorly. It is activated in bursts of about 12
seconds in three to four sites along the IT.
removed. The mucosa is laid down against the reduced IT.
A suitable elevator is used initially to infracture and then
gently outfracture the IT.
The diathermy needle is applied to the surface of the IT.
Application of chemicals is now rarely performed.
forming an ice ball at each site.
with a exible KTP laser or indirectly by mirror for CO2.
The standard microdebrider blade is used to remove
redundant mucosa from the IT.
removed. The tissue if often crushed initially to limit
bleeding.
advisable to leave some tissue posteriorly.
Septoplasty and Septorhinoplasty
Compensatory enlargement of the inferior turbinate is oen observed on the opposite side to
a septal deection. Histological studies of the inferior turbinate have shown that the enlargement of the turbinate on the contralateral side to the septal deviation may be due to an
increase in the conchal bone as well as increased mucosal thickness. Recent ndings favour
turbinoplasty in patients with clinically conrmed unilateral inferior turbinate hypertrophy.
Some surgeons will routinely excise the inferior turbinates at the time of doing septorhinoplasty to maximise the chance of improving nasal obstruction. However, this will increase
202 R hinolog y and Facial Plastic Surgery
NASAL AIRWAY SURGERY: MANAGEMENT OF ENLARGED TURBINATES
the potential for post-operative epistaxis and nasal adhesions, but it is unlikely to result in
any signicant long-term advantage.
Sleep Disordered Breathing
ere is a cogent argument to maximise the nasal airway in patients with sleep disordered
breathing, particularly when there may be a problem of compliance with continuous positive
airway pressure (CPAP) due to nasal obstruction. is is an instance where there may be a
tendency for surgeons to be radical in their approach to the inferior turbinate and to excise
the turbinates whilst correcting septal deformity. However, there is a lack of evidence to support radical excision in this situation and a conservative approach is recommended.
Inferior Turbinate Surgery in Children
Most children with nasal obstruction have rhinitis or adenoid enlargement. Rhinitis is mostly
allergic and generally improves following treatment with anti-a llergic medication, allergen avoidance and in some cases, immunotherapy. Turbinate reduction surgery would be indicated where
there is signicant nasal obstruction and large inferior turbinates. Children w ith sleep disordered
breathing or obstructive sleep apnoea may also benet from inferior turbinate surgery
Complications
e most common complications include
1 Severe haemorrhage (particularly aer turbinate resection)
2 Prolonged nasal crust formation
3 Adhesions or synechiae between the turbinate and the septum
e incidence of individual complications in clinical practice is typically not analysed or
published, so actual gures are generally unavailable.
Visual change and tempora ry blindness a er monopolar diathermy is reported but extremely
rare. Hypothesised mechanisms are excessive use of monopolar diathermy to reduce the
posterior end of the turbinate and/or epinephrine injected under pressure into the mucosa
causing a retrograde ow through the anterior ethmoidal artery into the ophthalmic artery,
vasospasm, hypoperfusion and optic nerve neuropathy.
Total or excessive resection of the inferior turbinate carries a risk of inducing ‘empty nose
syndrome’, which induces a sense of nasal obstruction.
Outcomes
ere is overwhelming data supporting the ecacy of turbinate surgery but few studies have
reported on both subjective and objective results, or compared dierent surgical techniques.
Recent studies (e.g. e Nasal AIRway Obstruction Study [NAIROS]) have focused on the
ecacy of septoplasty with or without turbinate reduction surgery for nasal airow obstruction. ere is a decit of published randomized controlled trial (RCT) research or controlled
studies in the literature, and the evidence base for the ecacy of turbinate surgery as a standalone procedure for nasal airow obstruction remains low.
KEY POINTS
1. Carefully consider the need for turbinate surgery (especially in children), and defer
surgery until following suitable medication has been trialed.
2. Look for underlying causes of enlarged inferior turbinates such as nasal allergy or CRS.
3. Use minimal intervention if possible and ideally preserve mucosa.
4. Warn patients about bleeding, recurrent obstruction and the possibility of revision
surgery.
5. Avoid excessive bilateral resection that may lead to persistent crusting and/or a
sense of nasal obstruction (the empty nose syndrome).
Rhinology and Facial Plastic Surgery 203
EPISTAXIS
40. EPISTAXIS
Background
Epistaxis is one of otolaryngology’s most common and most dicult to treat emergencies.
Key Anatomical Areas
Ninety percent of epistaxis occurs from Little’s area (anastomoses of vessels at the
•
anterior nasal septum).
Two-thirds of adult bleeds originate from the septum and remaining one-third from
•
the lateral wall.
Posterior bleeding is predominantly from nasal septum.
•
Anterior ethmoidal artery runs between ethmoid fovea and lamina papyracea where
•
iatrogenic damage/trauma can result in retraction of the bleeding end into the orbit
with subsequent pressure haematoma and risk of visual loss. Open approach is oen
indicated (Figures 40.1 and 40.2).
U-shaped notch in the palatine bone, the sphenopalatine foramen, is the entry portal
•
for major arterial supply located lateral to pterygopalatine space and is key to endonasal endoscopic sphenopalatine artery ligation (ESPAL)
Classication of Epistaxis
Clinical Classication
Adult or childhood epistaxis: bimodal distribution in the age of onset of epistaxis
•
Childhood (>16 years) or adult (<16 yea rs)
•
Primary or secondary
•
Primary: 80% of all cases of epistaxis are idiopathic
•
Secondary: caused by clear and denite causes such as trauma, surgery or anti-
•
coagulant overdose
Figure 40.1 Open approach to ligate left anterior ethmoidal artery (AEA). ALC, anterior lacrimal
crest; PLC, posterior lacrimal crest.
204 R hinolog y and Facial Plastic Surgery
EPISTAXIS
Figure 40.2 Operative eld in ligation of anterior ethmoidal artery (AEA; left). AEA, anterior
ethmoidal artery with titanium clips applied; L AEF, lamina papyracea and anterior ethmoidal foramen; R on BF, retractor on bulbar fascia.
e distinction between primary and secondary epistaxis is important as the management of each type is dierent, e.g. bipolar cautery is unlikely to be successful in warfarin
overdose.
Classication Based on Site of Bleeding
is classication includes terms anterior and posterior epistaxis, which are imprecise,
inconsistent and less useful.
Anterior epistaxis: easy to identify bleeding source located anterior to the plane of the pir-
•
iform aperture (anterior septum, rarely the vestibular skin and mucocutaneous junction)
Posterior epistaxis: challenging epistaxis situated posterior to the piriform aperture
•
Adult Primary Epistaxis
Demography
Occurs at any age but is mainly a disease of the elderly.
•
Seven to 14% of adults have epistaxis at some time, but only 6% of cases are seen by
•
otorhinolaryngologists.
Peak presentation is the sixth decade, and there is a slight male predominance.
•
Most cases are minor, self-limiting or easily managed anterior bleeds. However, a signicant
number require admission to the hospital. Aer head and neck cancer, epistaxis stands out
as a prominent cause of mortality in ear, nose and throat (ENT) patients
Aetiological Factors
Greatest frequency of admissions in the autumn and winter months (environmental
•
temperature and humidity)
A circadian rhythm: hospital admissions are peaking in the morning and late evening
•
Non-steroidal anti-inammatory drug (NSAID) use (mechanism via an anti-platelet
•
aggregation eect)
Alcohol consumption (especially within 24 hours of admission): prolonged bleeding
•
time despite normal platelet counts and coagulation factor activity
Rhinology and Facial Plastic Surgery 205
EPISTAXIS
Population studies have failed to show a causal relationship between hypertension and epistaxis. Elevated blood pressure is observed in almost all epistaxis admissions, but this may
be a result of anxiety associated with hospital admission and the invasive techniques used to
control the bleeding.
Secondary Epistaxis
e following causes of secondary epistaxis deserve special mention:
Tra uma: Its origin and severity are almost innitely variable. Severe haemorrhage
•
refractory to packing should be managed by open ligation. (Figures 40.1 and 40.2).
Post-surgical: Minor epistaxis requiring observation is common, severe haemorrhage
•
occurs in between 3 and 9% of turbinate surgery where re-exploration and ESPAL is
oen required.
Nasal tumours present with recurrent blood-stained discharge, which should be dis-
•
tinguished from epistaxis per se (rare).
Hereditary haemorrhagic telangiectasia:
•
Autosomal dominant condition aecting blood vessels in skin, mucous mem-
•
branes and viscera.
Recurrent epistaxis occurs in 93% of cases.
•
Management involves packing, cautery, anti-brinolytics, systemic or topical
•
oestrogens, coagulative lasers, septal dermoplasty, ligation and embolization and
as a last resort permanent surgical closure of the nostrils (Young’s operation).
Drug related:
•
Warfarin-related bleeding constitutes 9–17% of epistaxis admissions.
•
Packing may be required as bleeding is oen from multiple sites.
•
If international normalized ratio (INR) is within the therapeutic range and
•
bleeding is controlled, it may be safe to continue the warfarin, otherwise consult
haematology.
New oral anti-coagulants (target-specic oral anti-coagulants [TSOACs] rivarox-
•
iban, dabigatran): Reversal is dicult and can be incomplete, hence liaison with
haematology team is required.
Aspirin should not be discontinued if there is a history of cardiovascular dis-
•
ease or vascular gra surgery; otherwise temporary cessation of aspirin may be
required to allow the recurrent bleeding to settle.
Patients using topical nasal medications frequently report minor recurrent bleeds
•
which are mainly caused by damage to septal mucosa induced by the nozzle.
Management
Eective management follows an incremental sequence of interventions (Figure 40.3). Ideal
treatment identies the bleeding point and directly controls the bleeding, at source. First,
the patient is resuscitated, bleeding slowed, the nasal cavity examined and a treatment plan
established.
Resuscitation
Sixty-ve percent of cases had already some form of therapy by an accident and emer-
•
gency team.
First aid is performed by pinching ala nasi in anterior bleed.
•
Intravenous access and baseline blood estimations are taken.
•
Detailed history should be taken with a focus on predisposing factors.
•
Routine coagulation studies in the absence of a positive history are not indicated.
•
Assessment
Performed in semi-recumbent position and nursing assistance is mandatory.
•
Protective visors and clothing should be worn.
•
206 Rhinology and Facial Plastic Surgery
EPISTAXIS
Management strategy
RESUSCITATION
Initial examination
Vessel NOT located
Endoscopy
Vessel NOT located
INDIRECT therapy
eg. Anterior packs
Figure 40.3 Management algorithm for epistaxis.
Continued bleeding
• Posterior packs
• Septal surgery
• Ligation
Continued bleeding
• Angiography and embolization
• Repeat above steps
• Check for secondary factors
Vessel located
DIRECT therapy
eg. Bipolar
Bleeding controlled
• Packs 48 hours minimum
• Direct, same day discharge
Basic equipment includes couch or reclining chair, headlight, suction, vasoconstrictor
•
solutions (lignocaine and pseudoephedrine) and a selection of packs, tampons and
cautery apparatus.
Nasal endoscopy equipment and bipolar electrodiathermy is recommended.
•
Direct or Indirect Therapies
Indirect treatments do not require identication of the bleeding point.
•
Direct treatments are superior, and a committed search for the bleeding vessel should
•
always be undertaken.
Direct Management
ere has been a slow but steady uptake of direct strategies throughout the United Kingdom.
Despite this, a minority of cases there are managed by direct control of the bleeding point.
Reluctance to use direct approaches reects the fact that over 70% of cases are managed by
the most junior members of the specialty. Anterior epistaxis is usually very straightforward
to treat and over 90% can be controlled with silver nitrate cautery or bipolar. e use of packing for primary anterior epistaxis should be strongly discouraged.
Rhinology and Facial Plastic Surgery 207
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