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SECTION X — Operative Surgery
4. Bleeding. It occurs due to injury to nasal mucosa.
5. Air embolism. It is rare but may prove fatal. This complication can be prevented by avoiding insufflation of
air into the antrum after lavage.
Note: This operation is now being performed less
often. Most surgeons prefer to get a CT to find the middle
meatal pathology causing obstruction to sinus ostium
and deal with sinus disease and meatal pathology together by functional endoscopic sinus surgery (FESS) at the
same time.
Chapter 85
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Intranasal Inferior Meatal Antrostomy
Intranasal inferior meatal antrostomy is a process of making an opening in the nasoantral wall of the inferior meatus by intranasal route. This operation is now rarely
required and has been superseded by functional endoscopic sinus surgery.
INDICATIONS
Chronic purulent maxillary sinusitis.
CONTRAINDICATIONS
1. Irreversible change in sinus mucosa, e.g. polypoidal
hypertrophy.
2. Presence of osteitis.
3. Suspicion of malignancy.
ANAESTHESIA
Local or general anaesthesia.
POSITION
punch or reverse backbiting forceps and backwards with
Luc or straight through cut forceps. Opening should be
1.5–2 cm in diameter and as close to the floor of nose as
possible (Figure 85.1). Intrasinus pus/debris is removed by
suction. Biopsy can also be taken. Packing into the sinus
and nose may be required if there is severe bleeding.
POSTOPERATIVE CARE
Intrasinus and nasal pack is removed in 24–48 h.
COMPLICATIONS
Few complications.
1. Postoperative bleeding.
2. Injury to nasolacrimal duct.
Note: These days, intranasal antrostomy is performed
in the middle meatus. Middle meatal antrostomy is more
physiological and is performed with nasal endoscopes
and other surgical instruments used in functional endoscopic sinus surgery.
Same as in submucous resection (SMR) operation (see
Chapter 87).
TECHNIQUE
Inferior turbinate is fractured medially and upwards with
a large periosteal elevator. Nasoantral wall of the inferior
meatus is perforated with a curved haemostat and then
this opening is enlarged, forwards with Kerrison bone
Figure 85.1. Intranasal antrostomy in the inferior meatus.
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Chapter 86
DeaLing with PathoLogy.
Making naSoantraL winDow.
Packing the antruM.
cLoSure oF wounD.
https://t.me/med1917
Caldwell–Luc (Anterior Antrostomy)
Operation
Caldwell–Luc operation is a process of opening the maxillary antrum through canine fossa by sublabial approach
and dealing with the pathology inside the antrum. Operation is also called anterior antrostomy as access to maxillary sinus is made through anterior wall of the sinus.
INDICATIONS
1. Chronic maxillary sinusitis with irreversible changes
in the sinus mucosa.
2. Removal of foreign bodies or root of a tooth.
3. Dental cyst.
4. Oroantral fistula.
5. Suspected neoplasm in the antrum and its biopsy.
6. Recurrent antrochoanal polyp.
7. Fracture of maxilla or blow-out fractures of the orbit.
8. As an approach to ethmoids (Horgan’s transantral
ethmoidectomy).
9. Approach to pterygopalatine fossa for ligation of
maxillary artery.
10. Vidian neurectomy.
CONTRAINDICATIONS
Patient below 17 years of age.
ANAESTHESIA
General anaesthesia with cuffed endotracheal tube and
a pharyngeal pack. Can be done under local anaesthesia.
4.
has been opened, pathology is removed. Diseased antral
mucosa can be removed with elevators, curettes and forceps. Cyst, benign tumour, foreign body or a polyp is removed.
5.
is pushed into the antrum from the inferior meatus and
then this opening is enlarged with Kerrison’s and sidebiting forceps to make a window <1.5 cm in diameter.
6.
with liquid paraffin or Furacin™ (Furacin™ is 0.2% w/w
nitrofurazone) or any other antibiotic ointment can be
packed in the antrum and its end brought out from the
nasoantral window into the nose. Intrasinus packing is
done if there is severe bleeding. Pack is also kept in the
nose.
7.
with one or two catgut sutures.
Once maxillary antrum
A curved haemostat
Ribbon gauze, impregnated
Sublabial incision is closed
POSTOPERATIVE CARE
1. Ice packs over the cheek in the first 24 h prevent oede-
ma, haematoma and discomfort to the patient.
2. Packing in the sinus and nose can be removed in
24–48 h.
3. Antibiotics are given for 5–7 days.
4. Patient should avoid blowing his nose for 2 weeks to
avoid surgical emphysema.
5. Maxillary sinus is irrigated through the antrostomy
with saline. Patient can do it himself with Higginson’s
syringe.
POSITION
Reclining with head-end of the table raised. Patient lies
supine with face turned slightly to the opposite side.
TECHNIQUE
1. inciSion. A horizontal incision with its ends upward
is made below the gingivolabial sulcus, from lateral incisor to the second molar (Figure 86.1). It cuts through
mucous membrane and periosteum.
2. eLevation oF FLaP. The mucoperiosteal flap is raised
from the canine fossa to the infraorbital nerve avoiding
injury to the nerve.
3. oPening the antruM. Using cutting burr or gouge
and hammer, a hole is made in the antrum. Opening is
enlarged using Kerrison’s punch.
COMPLICATIONS
1. Postoperative bleeding. This can be controlled by nasal
pack.
2. Anaesthesia of the cheek due to stretching of infraorbital nerve. It may last for a few weeks or months.
3. Anaesthesia of teeth.
4. Injury to nasolacrimal duct.
5. Sublabial fistula.
6. Osteomyelitis of maxilla (rare).
PRESENT STATUS
Management of chronic maxillary sinusitis, removal of
antrochoanal polyp, biopsy of maxillary sinus tumours,
ligation of maxillary artery for posterior epistaxis and
drainage of maxillary sinus in closure of oroantral fistula
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SECTION X — Operative Surgery
Figure 86.1. Caldwell–Luc operation. (A) Incision. (B) Inside view and position of antrostomy.
can all be done through endoscopic surgery. Caldwell–
Luc operation these days may be indicated in limited
situations as (i) initial step in medial maxillectomy, (ii)
in management of complex midfacial fractures and to
repair orbital floor fractures, (iii) removal of foreign bodies which cannot be removed by endoscopic approach
and (iv) in management and staging of carcinoma of the
palate.
Note: Ever since the advent of endoscopic sinus
surgery, indications for Caldwell–Luc operation have
decreased. Functional endoscopic sinus surgery can
achieve all that can be done through Caldwell–Luc
operation.
Chapter 87
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Submucous Resection of Nasal Septum
(SMR Operation)
INDICATIONS
1. Deviated nasal septum (DNS) causing symptoms of nasal obstruction and recurrent headaches.
2. 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.
2. 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.
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 car-
tilage incision, mucoperichondrial and periosteal flap is
raised from the opposite side of the septum (Figure 87.1B).
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 the
nose or retraction of columella (Figure 87.2).
7. stitching. One or two catgut or silk stitches are applied in the initial mucoperichondrial incision.
8. packing. A ribbon gauze, smeared with an antibiotic
ointment or liquid paraffin, is packed on each side of the
nasal cavity to prevent collection of blood between the
flaps. Nasal dressing is applied.
POSTOPERATIVE CARE
POSITION
Reclining position with head-end of the table raised.
STEPS OF OPERATION
1. inFiltration oF nasal septum. It is done in its sub-
perichondrial planes with 2% xylocaine and 1:50,000
adrenaline.
2. incision. A curvilinear incision with forward convex-
ity 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 muco-
periosteal Flap. Plane of dissection is important. It
should be beneath the perichondrium and periosteum
(Figure 87.1A).
1. Patient is placed in semi-sitting position to prevent
oozing of blood. Outer nasal dressing is changed if
soaked in blood.
2. A soft diet should be taken in the first two postoperative days to minimize 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 h 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.
COMPLICATIONS
1. Bleeding. It may require repacking, if severe.
2. Septal haematoma. Evacuate the haematoma and
give intranasal packing on both sides of septum for
equal pressure.
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Figure 87.1. Submucous resection of nasal septum. (A) Incision and
elevation of flap on the left. (B) Elevation of flap on the right after incising the septal cartilage. (C) Closing the incision.
SECTION X — Operative Surgery
Figure 87.2. SMR operation. It is necessary to preserve dorsal and
caudal struts of cartilage to avoid supratip depression or columellar
recession, respectively.
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 characterized 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.
3. Septal abscess. This can follow infection of septal haematoma.
4. Perforation. When tears occur on opposing sides of
the 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.
PRESENT STATUS
These days SMR operation has been replaced by septoplasty. As much of the cartilage or bone as possible should
be retained. Sometimes straight pieces of bone or cartilage
can be put back between the mucosal flaps. Only indication for SMR is when cartilage or bone from the septum is
required for a graft.
Chapter 88
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Septoplasty
Septoplasty is a conservative approach to septal surgery;
as much of the septal framework as possible is retained.
Mucoperichondrial/periosteal flap is generally raised only
on one side. This operation has almost replaced the SMR
operation (Table 88.1).
INDICATIONS
1. Deviated septum causing nasal obstruction on one or
both sides.
2. As a part of septorhinoplasty for cosmetic reasons.
3. Recurrent epistaxis usually from the spur.
4. Sinusitis due to septal deviation.
5. Septal deviation making contact with lateral nasal wall
and causing headaches.
6. For approach to middle meatus or frontal recess in endoscopic sinus surgery when deviated septum obstructs
the view and access to these areas.
7. Access to endoscopic dacryocystorhinostomy operation in some cases.
8. As an approach to pituitary fossa (trans-septal transsphenoidal approach).
9. Septal deviation causing sleep apnoea or hypopnoea
syndrome.
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 adrenaline, 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 transfixion or hemitransfixion (Freer’s)
incision is made. The latter is septocolumellar incision
between caudal end of septal cartilage and columella.
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:
(a) Scoring on the concave side (Figure 88.1).
(b) Cross-hatching or morselizing.
(c) Shaving.
(d) 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 placed to coapt mucoperichondrial flaps.
8. Nasal pack.
POSTOPERATIVE CARE
1. Septal surgery is a daycare surgery and the patient can
go home after he fully recovers from effects of sedation with no postoperative nausea or bleeding. Patients with obstructive sleep apnoea should better be
observed overnight.
2. Avoid strenuous exercise as it may cause bleeding.
3. Pack, if kept is removed the next day and patient be
instructed not to blow the nose or sneeze hard. Secretions can be drawn backwards into the throat by snorting rather than blowing the nose.
4. Saline spray or steam inhalation are encouraged after
pack removal.
5. Xylo- or oxymetazoline drops are used if nose becomes
stuffy.
6. Nasal splints, if used, are removed on fourth to eighth
day and gentle suction of nose is done.
7. Patient should avoid trauma to nose, wipe the nose gently
and in no case push the nose from one side to another.
POSTOPERATIVE COMPLICATIONS
Same as in SMR operation.
1. Bleeding.
2. Septal haematoma and abscess.
3. Septal perforation.
4. Supratip depression.
5. Saddle nose deformity.
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SECTION X — Operative Surgery
Figure 88.1. Septal cartilage is straightened by scoring the cartilage on the concave side to remove interlocked cartilage stresses (A), or by shaving the convex side of cartilage (B). Dislocated septal cartilage can be replaced in the maxillary groove or on the anterior nasal spine by excision
of the cartilage along the floor of nose and fixing it with a suture (C).
6. Columellar retraction.
7. Persistence of septal deviation, or external nasal
deformity.
8. Cerebrospinal fluid rhinorrhoea rarely occurs if the
perpendicular plate of ethmoid is avulsed.
9. Toxic shock syndrome.
TYPES OF SEPTAL INCISIONS IN SEPTOPLASTY
1. Killian’s: In the nasal mucosa, cephalic to the caudal
end of the septum (Figure 88.2).
2. Transfixion: Through and through incision, close to
but caudal to caudal end of the septum.
3. Hemitransfixion: Same as the transfixion incision but
on one side.
4. Horizontal on the spur: For endoscopic spurectomy.
Figure 88.2. Septal incisions. (A) Killian’s incision. (B) Hemitransfixion
incision.
TABLE 88.1 DIFFERENCES BETWEEN SMR
AND SEPTOPLASTY
SMR Septoplasty
1. It is extensive dissection
of septum removing
all deformed bony
and cartilaginous parts
preserving only a caudal
and a dorsal strut of
cartilage.
2. Not done before 17
years.
3. Mucoperichondrial and
periosteal flaps raised
on both sides of the
septum.
4. Bony and cartilaginous
parts excised.
5. More chances of
complications, e.g.
supratip depression,
columellar recession or
flapping of septum.
6. Re-operation is difficult. Re-operation is easier.
Limited selective dissection
removing minimal cartilage
and bone consistent with
providing a good airway. Most
of the cartilage and bone is
preserved. Even deformed parts
are corrected and reimplanted
between mucoperichondrial or
periosteal flaps.
It can be done even in children
without affecting nasal growth.
Flaps are raised only on one side
and limited elevation on the
opposite side.
Deformed cartilage is corrected
by scoring, cross-hatching,
wedge excision and realigning
in the groove of the nasal crest.
Sometimes straight pieces
are joined outside the nose
and replaced between flaps
(extracorporeal septoplasty), and
in case of spur, only spurectomy
is done.
Less chances of complications.
Chapter 89
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Diagnostic Nasal Endoscopy
Like anterior and posterior rhinoscopy, endoscopy of
nose and nasopharynx helps in the diagnosis of diseases
of nose, paranasal sinuses (PNS) and the nasopharynx.
Because of the brighter illumination, magnification and
angled view provided by the endoscopes, it is possible to
examine all clefts and crevices of the nose and nasopharynx. It is an important part of examination of nose and
nasopharynx.
INDICATIONS
1. To diagnose any disease of the nose and PNS.
2. To diagnose source of bleeding in epistaxis.
3. To assess response to medical or surgical treatment of
the nose and PNS disease.
4. To take a precise biopsy from nose and nasopharynx.
ANAESTHESIA
Topical anaesthesia with 4% xylocaine and a vasoconstrictor (oxymetazoline), first as a nasal spray and then
nasal packs.
POSITION
Sitting or supine.
purulent discharge in the nasal cavity and colour of
the nasal mucous membrane.
2. Pass the endoscope along the floor of nose into the
nasopharynx and examine: (i) opening of eustachian
tube, (ii) walls of nasopharynx, (iii) upper surface of
soft palate and uvula and (iv) opening of eustachian
tube of opposite side. To see these structures endoscope is rotated.
3. Withdraw the endoscope slightly and examine the
margins of choana and posterior ends of turbinates.
4. Withdraw endoscope slowly and at the same time
examine inferior meatus for opening of nasolacrimal
duct and Hasner’s valve. Slight pressure over the lacrimal sac may express a drop or two of lacrimal fluid
through the nasolacrimal opening.
SECOND PASS (EXAMINATION OF THE
SPHENOETHMOIDAL RECESS, SUPERIOR
MEATUS AND OPENINGS OF SPHENOID
SINUS AND POSTERIOR ETHMOIDAL CELLS)
(FIGURE 89.1)
Endoscope is passed medial to middle turbinate to examine posterior part of middle turbinate, sphenoethmoidal recess, superior turbinate and meatus, openings of
posterior ethmoid cells (in the superior meatus) and
opening of sphenoid sinus in the posterior wall of sphenoethmoidal recess between the nasal septum and superior turbinate.
INSTRUMENTS
1. 4 mm 30° endoscope
2.7 mm 30° endoscope Required when nasal
2.7 mm 70° endoscope
2. Freer’s elevator or elevator with a suction channel
3. Suction tips
4. Biopsy forceps
5. Antifog solution or Savlon™ to prevent fogging of the
endoscopic lens.
TECHNIQUE
After nasal packs are removed, endoscopy is performed
by three passes:
FIRST PASS (EXAMINATION OF
NASOPHARYNX AND INFERIOR MEATUS)
1. First obtain a general view of the nasal cavity. Look for
any septal deviation or spurs and their size, mucous or
passages are narrow
Figure 89.1. Area of eustachian tube and sphenoethmoidal recess.
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