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suturing
splints
Anterior nasal spine
and straightened
anterior nasal spine
Baten graft
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3. Should not produce iatrogenic deformity.
4. Should not compromise the osteomeatal
complex.
5. Should relieve all the contact areas.
6. Must have the scope for a revision surgery if
required later.
Contraindications:
1. Acute URTI
2. Bleeding/Clotting disorders
3. Uncontrolled DM/HTN
9.1.6.1 Steps ofSurgery
1. Sub-Mucosal Resection (SMR)
A Killian incision is placed- about 1cm cephalad from the caudal end of the septum.
Mucoperichondrial and the mucoperiosteal
ap is elevated on the side of the incision.
Cartilage is incised just posterior to the mucosal incision and aps are elevated on the opposite side. Septal cartilage removed leaving a
dorsal and caudal strut. The deviated part of
the bony septum is freed from its attachments
and removed. The aps are replaced and
sutured at the incision site. Nasal packing,
nasal splints, or trans-septal suturing can be
used to support the aps (Fig.9.4).
2. Septoplasty
Hemi-transxation incision is placed at the caudal end of the septum. The mucoperichondrial
ap is raised on the concave side. The degree of
mucoperichondrial ap elevation depends upon
the location and extent of the deviation. The
bony osseo-cartilaginous junction is disarticulated to reach the opposite side of the bony septum. The mucoperiosteal aps on both sides are
elevated. The quadrilateral cartilage is disarticulated from the maxillary crest. A piece cartilage
is removed to allow for the straightening and
lengthening of the quadrilateral cartilage.
Deviated part of the bone is also removed.
The rest of the cartilage is straightened in-
situ by (Fig.9.5):
Elevation
of flaps
Trans-septal
Fig. 9.4 The line diagram is showing different stage of
submucosal resection with suturing technique and nasal
splint placement
Removal of
deviated segment
Nasal
Flaps
repositioned
Deviated septum
Fig. 9.5 The diagram is depicting ways of septal correction in the septoplasty technique
Excess septum excised
Septum scored
Septum sutured to
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(a) Scoring of the cartilage.
(b) Scoring and suturing—sutures are tightened
till septum is straight.
(c) Scoring and splinting—a batten graft is used
to support the scored cartilage.
Tackling the septal spur is performed by
mucoperichondrial ap elevation over the
quadrilateral cartilage and the bony septum
making an anterior tunnel over the spur. A
subperiosteal tunnel is raised posterior to the
septal spur. The mucosa left attached to the
spur is then elevated by sharp dissection
(Fig.9.6).
Modications
Historical Overview:
1. Metzenbaum (Swinging Door) technique:
Technique was used to correct the caudal
deviation of septum. The deviated cartilage is
removed, the septum is swung into midline
and inferior end of the cartilage is anchored
with sutures to the anterior nasal spine.
2. Doorstop technique: The excess caudal nasal
septum is transposed over the nasal spine and
xed.
3. Peer: Complete removal of the caudally deviated cartilage and reinsertion of the cartilage
as a free graft.
4. Galloway: Single free autograft after removal
of entire nasal cartilage, xed with traction
sutures.
5. Vilar Sancho: L shaped cartilage graft to support back and tip of nose.
6. Rees: Relocate entire quadrangular cartilage.
7. Gubisch: Used in combination with closed
rhinoplasty. Entire quadrangular cartilage is
removed, and the septum is re-created by
using cartilage pieces.
Endoscopic Septoplasty:
The advent of the endoscope ushered in a new
era in nasal surgery. Endoscopes may be used in
nasal septal surgery as the primary or as an accessory tool. They are extremely useful in more
cephalic and isolated deviations which can be
directly visualized. It allows for localized incisions to be made, obliterating the need for excessive ap elevation. It can also be used along with
a conventional technique to tackle the posterior
part of the septum which is not otherwise visible.
It can be used along with endoscopic sinus and
skull base surgery and is also an effective teaching tool for residents.
External Approach Septoplasty:
This is a favorable approach for dorsal L-strut
deformity and in complex septal reconstructive
cases. Incision is made over the columella and
the anterior end of the septum is exposed. This
technique can be used along with a rhinoplasty
procedure.
Extracorporeal Septoplasty:
Intact septum is excised and replaced by
either:
1. Re-orientation: L-strut is harvested from the
excised septum and it is reinserted in place.
2. Reconstruction: Pieces of the septum are
splinted against the perpendicular plate of the
ethmoid and then reinserted into its position.
Grooves are made onto the maxillary crest
and the anterior nasal spine where the septum
is secured.
Septal spur
Posterior
tunnel
Fig. 9.6 The gure is showing the creation of tunnel
anterior and posterior to spur follow by joining of both
tunnels so that chances of mucosal perforation is reduced
A
Pediatric Septoplasty:
The age and extent of septal surgery in the
B
pediatric population is still controversial.
Delaying surgery can affect nasal and facial
growth and lead to prolonged nasal obstruction.
Early intervention carries the risk of disturbance
of the ossication centers leading to nasal and
facial deformity. A range of techniques from
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closed reduction to the extracorporeal technique
has been used. Resection of the cartilage should
be conservative, and disruption of the endochondral ossication plates needs to be avoided [3].
Complications [4]
1. Bleeding
2. Infection
3. Saddle deformity
4. Columellar retraction
5. Supratip deformity
6. Adhesion
7. Septal Perforation
8. Septal hematoma/abscess
9. Sensory changes including upper dental
anesthesia
9.1.7 Nasal Septal Perforation
It is dened by through and through defect of the
nasal septum which may be more than one in
number. It may be asymptomatic, especially if
the perforation is small and located in the posterior part of the septum. It can lead to crusting,
blockage, epistaxis, whistling sound while inhaling air, a feeling of dryness, emptiness in the
nose, or a general feeling of discomfort. Huge
perforations may cause rhinolalia aperta [5].
Causes:
1. Traumatic causes—nasal surgery, nose picking, nasal packing for epistaxis, septal hematoma/abscess, foreign body, etc.
2. Surface irritants—cocaine insufation, heroin
inhalation, lime, cement, glass, salt, dust,
nasal decongestants, etc.
3. Infections—syphilis, TB, typhoid, diphtheria,
rhinoscleroma, leprosy, mucormycosis, aspergillosis, etc.
4. Neoplastic—melanoma, adenocarcinoma,
squamous cell carcinoma, lymphoma, etc.
5. Inammatory—sarcoidosis, Crohn’s disease,
rheumatoid arthritis, SLE, dermatomyositis,
etc.
The prevalence after submucous resection
operations is higher (17–25%) compared to sep-
toplasty procedures (1.4–5%). Septal perforations may also be surgically created in complex
nasal and skull base endoscopic surgeries to provide a bi-nostril approach.
Management:
Conservative/Medical—The aim is to reduce
drying, crusting, and epistaxis. Alkaline nasal
douches, saline sprays, and petroleum-based
ointments are commonly used.
Obturator—The principle of obturation is to
cover the inamed mucosal margin. It helps by
controlling whistling and epistaxis.
Surgical—Variety of techniques and materials
has been described to close the perforation.
• Free Grafts:
– Autografts
– Allografts
• Pedicle Flaps:
– Local nasal mucosal
– Buccal mucosal
– Composite cartilage and mucosa or carti-
lage and skin
• Rotation/advancement of mucoperichondrial
or mucoperiosteal aps.
The selection of surgical approach is based on
the size of perforation. Endonasal approach is
good for small size perforation (5mm to 1cm).
Medium size perforation (1 to 2 cm) requires
wider exposure and approach is external rhinoplasty. Large size (more than 2cm) can be managed by midfacial degloving approach.
Factors that affect the outcome are:
1. The amount of mucosa available in the nasal
cavity can be mobilized.
2. The use of an interposition graft to support the
mucosal repair.
9.2 Part B: Adenoid Hypertrophy
andManagement
William Meyer coined the term Adenoid for vegetations in the nasopharyngeal cavity in 1870. It
is also called as pharyngeal tonsil. It forms the
central part of the inner Waldeyer’s ring.
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Embryology The adenoid develops as a midline
structure by the fusion of two lateral primordial
that become visible during early fetal life.
Adenoid tissue is fully developed by the seventh
month of gestation and continues to grow until
the fth year of life often causing some airway
obstruction then it gradually atrophies with airway improvement. It is lined by respiratory ciliated epithelium.
Function The function of adenoid is to produce
antibodies like IgG and IgA. It also plays vital
role in the development of immunological memory in younger children [6].
Etiology
Adenoid hypertrophy is mainly caused
by infections which includes
1. Coronavirus, Cytomegalovirus, EBV, HSV,
Rhinovirus, etc.
2. Infection—Alpha, Beta, Gamma Haemolytic
Streptococci, Haemophilus inuenza,
Moraxella catarrhalis, Staphylococcus
aureus, Corynebacterium diphtheriae, etc.
3. Infectious causes that can lead to adenoid
hypertrophy are GERD, allergy, etc.
4. Lymphoma, Sinonasal malignancy.
Blood Supply
Arterial supply is mainly derived
from ascending palatine artery, ascending pharyngeal artery, the pharyngeal branch of internal
maxillary artery, ascending cervical branch of
thyrocervical trunk. Venous drainage usually
drains into the pharyngeal plexus, pterygoid
plexus of veins, and also into the internal jugular
vein. Lymphatic drains to upper jugular nodes
directly or via retropharyngeal nodes.
Clinical Features Chronic nasal obstruction is the
commonest symptom which leads to nasal discharge, sinusitis, open mouth breathing, an elongated face, dental malocclusion [7]. Aural symptoms
include otitis media with or without effusion,
decreased hearing, otalgia, etc. Other symptoms
include sleep apnea, hyposmia, failure to thrive,
excessive daytime sleepiness, impairment of cognitive functions, poor school performance, and psychosocial problems [8]. Adenoid faces is the term
used to denote certain features in prolonged cases
which include dull looks, pinched nostrils, open
mouth, narrow maxillary arch, retracted upper lip,
high arch palate (Fig.9.7).
Diagnosis
Clinical examination including exami-
nation of the external nose, anterior rhinoscopy,
Fig. 9.7 The clinical
photograph is showing
features of adenoid faces
(Courtesy—Dr. Hitesh
Verma, Associate
Professor, AIIMS, New
Delhi, India)
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Fig. 9.8 Endoscopic view is shwoing grade 2 adenoid
hypertrophy
oral and ear examination with the neck. Posterior
rhinoscopy is relatively uncomfortable for young
children. Hence imaging is helpful in making
diagnosis which includes lateral neck radiography.
Computerized scan or magnetic resonant imaging
is indicated in doubtful diagnosis. Nasal endoscopy is the gold standard in the modern era for
diagnosis and grading of adenoid hypertrophy
(Fig. 9.8). Rhinomanometry and polysomnography are indicated in OSA patients. For reex associated adenoid hypertrophy, pH monitoring is
indicated.
9.2.1 Clinical Grading ofAdenoid
Clinical grading system is based on part of choana is ll by adenoid tissue on endoscopic
examination.
• Grade I—adenoid tissue lling one-third of
the vertical portion of the choana.
• Grade II is when adenoid tissue lling onethird to two-thirds of the choana.
• Grade III lls from two-third to nearly complete obstruction of the choana.
• Grade IV there is complete choanal
obstruction.
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Fig. 9.9 Adenoid hypertrophy is assessing by measuring
distance at maximum convexity from skull base
(Courtesy—Dr. Hitesh Verma, Associate Professor,
AIIMS, New Delhi, India)
9.2.2 Radiological Staging
1. Johanneson proposed in the year 1968.
Adenoid hypertrophy is assessed by measuring the distance from skull base at maximum
convexity (Fig.9.9).
2. Cohen and Konak method: The airway-tosoft-palate ratio is a comparison between the
width of the airway immediately behind the
soft palate and the width of the soft palate
1 cm below the hard palate (Fig. 9.10).
Patients then were categorized into one of
three groups:
(A) Normal (airway-to-soft-palate ratio ≥1)
(B) Mild-to-moderate hypertrophy (airway-
to- soft-palate ratio between 0.5 and 1)
(C) Severe hypertrophy (airway-to-soft-
palate ratio <0.5) [9]
2-A-N ratio: This ratio is calculated by measuring the maximal thickness of adenoid tissue and distance measured along the line from
posterior–superior to spheno-occipital synchondrosis on skull base (Fig.9.11) [10]. AN
ratio greater than 0.80 can be the indicator of
enlarged adenoids.
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3. Crepeau etal. [11] graded adenoid hypertrophy
by measuring maximum thickness of adenoid
tissue and the shortest distance between the
anterior aspect of adenoid with the posterior
wall of maxillary antrum (Fig.9.12).
9.2.3 Management
Medical Management Breathing exercises,
steam inhalation, regular nasal douches and
Valsalva or reverse Valsalva maneuver are the
conservative method. Lifestyle modication
such as regular exercise and avoidance of pre-
Fig. 9.10 The distance between point a to b is soft palate
thickness and in between b to c is airway width
(Courtesy—Dr. Hitesh Verma, Associate Professor,
AIIMS, New Delhi, India)
a
Nasal cavity
Fig. 9.11 The line diagram is showing assessment of the
nasopharynx (posterior–superior edge of the hard palate
to spheno-occipital synchondrosis on skull base—black
line). Spheno-occipital synchondrosis point can also
dene by the uppermost point of posterior margin of the
pterygoid plate (red line). Adenoid is measure by assess-
Fig. 9.12 The red line representing adenoid thickness
and the blue line is showing distance between anterior
aspects of the adenoid with choana. (Courtesy- Dr. Hitesh
Verma, Associate Professor, AIIMS, New Delhi, India)
b
ing from point of maximum convexity to right angle point
from the imaginary line from anterior border of basisphenoid and basi-occipit. X-ray lateral view of the neck
showing enlarged grade 3 adenoids (A-N radio) blocking
the nasopharyngeal airway (Courtesy—Dr. Hitesh Verma,
Associate Professor, AIIMS, New Delhi, India)
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served food for reux induced adenoid hypertrophy. The selection of pharmacotherapy is
based on the history of the patient. Antiinammatory treatment (antihistaminic, steroid nasal spray, etc.) is indicated in recurrent
or persistent rhinosinusitis. Steroid based nasal
spray is the usual prescription for allergic and
persistent nasal obstruction secondary to adenoid hypertrophy. Mometasone based nasal
spray is approved above 2year of age whereas
the majority of other spray is approved above
5years of age. Decongestant nasal drops can
be advice for both acute and chronic cases for
not more than 7days. Antibiotics are reserved
for patient with purulent nasal discharge and
for complicated adenoiditis. Proton pump
inhibitors and antacids are indicated in reux
cases. Leukotriene receptor antagonist (montelukast) has shown to be effective in reducing
the size of adenoids and respiratory-related
sleep disturbances in children with mild OSA.
Surgical Management
Adenoidectomy is
mainly indicated when there is no response to
conservative treatment. But surgery should be
done early in grade 3 and grade 4 obstruction
cases and also when adenoid hypertrophy
induces sequelae because of its mass effect. Up
to grade 2 adenoid hypertrophy, the surgical
selection is based on the response to medical
management.
9.2.4 Indications
A. Infection—Purulent adenoiditis, adenoid
hypertrophy associated with complications
such as otitis media with effusion, chronic
recurrent otitis media, chronic otitis media
with perforation.
B. Obstruction—Adenoid hypertrophy associ-
ated with excessive snoring and chronic
mouth breathing, sleep apnea or sleep disturbances, adenoid hypertrophy associated with
cor pulmonale, failure to thrive, dysphagia,
speech abnormalities, craniofacial growth
abnormalities, occlusion abnormalities.
C. Other—Suspected neoplasia, adenoid hyper-
trophy associated with chronic sinusitis.
Contraindications Cleft palate, velo-
pharyngeal insufciency, and bleeding diathesis.
Systemic review in cases of palatal abnormality
showed partial adenoidectomy is safe and effective procedure in problematic cases [12].
9.2.5 Surgical Techniques
1. Conservative (Cold) Technique: For cold
technique, the patient should be placed in
Rose’s position after induction of general
anesthesia and Boyles Davis mouth gag is
applied for oropharyngeal exposure. Red
rubber tube or catheter can be used to retract
the soft palate for better visualization of the
nasopharynx. The size of the adenoid can be
assessed either by nasopharyngeal mirror or
by digital palpation. Use of endoscopes
increases visualization by both trans-nasal
and per-oral route. For the appropriate selection of curette, the width of incisors needs to
be assessed. Curette is held in dagger-like
fashion and placed high in the nasopharynx,
abutting the posterior aspect of the nasal septum and neck is exed in the neutral position
to avoid injury to posterior pharyngeal wall
and dens. Then adenoid pad can be curetted
with care taken not to penetrate deeply into
the prevertebral region. Care needs while
removing tissue far laterally to avoid trauma
to eustachian tube. Endoscopic assessment
can be done in between procedure to conform
tissue excision and for prevention of injury to
normal structures. Packs can be placed into
the nasopharynx for hemostasis [13]. Other
techniques include suction diathermy ablation
of the adenoid, radiofrequency adenoidectomy. Suction diathermy ablation is safe with
minimal blood loss however it is slow and has
the risk of cicatrization and burns to surrounding tissue [14].
2. Endoscopic Powered Technique includes
adenoidectomy by microdebrider. Power-
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assisted adenoidectomy allows more precise, rapid, safe, and it achieves complete
removal of adenoid tissue. It is especially
useful in removing adenoid tissue that
extends through the choana and into the
nasal cavity. It can be done with multiple
blades with different angles ranging from 30
to 90° either through the nasal cavity or
through the oral cavity. Due to the suction
and shaving action of microdebrider, it can
remove the tissue down to the less vascular
fascial plane. Oscillation cutting action of
the blade minimizes the bleeding [15].
3. Coblation Adenoidectomy: It utilizes a system of radiofrequency bipolar electrical current that passes through a medium of normal
saline, which results in the production of
plasma eld of sodium ions. These ions break
down intercellular bonds and effectively
vaporize tissue at a temperature of only
60°C. The coblator consists of a handpiece
with a suction irrigation tip that transmits the
radiofrequency current and dissects tissue. It
also has cautery for hemostasis. With this
technique, separate suction cautery device is
not necessary. It also ensures the complete
removal of adenoid tissue with minimal
bleeding. Coblation has advantages like very
limited depth of penetration, minimal collateral tissue damage, localized effect, controlled volumetric tissue removal, low surface
temperature. To reduce the operating duration, the surgeon combines microdebrider
with coblator.
Among all technique, simultaneous use of nasal
endoscopes reduces complication to great
extent and conventional technique is rapid as
compared to other techniques. Powered instruments are more precise, less traumatic to surrounding structures [16].
9.2.6 Complications
ofAdenoidectomy
1. Bleeding
2. Dental trauma
3. Infection
4. Grisel syndrome
5. Velopharyngeal dysfunction
6. Regrowth of adenoids
Bleeding is mainly reactionary with the rate
of 0.7%. It can be managed by proper hemostasis. Rarely, post nasal packing is required.
Secondary hemorrhage is very rare. It may be
due to bleeding from the aberrant ascending
pharyngeal artery or by infection in the postoperative cavity. Unusual reactionary or secondary bleeding raises the possibility of clotting or
coagulation defect. Nasopharyngeal blood clot
may get pooled in the nasopharynx during the
procedure. Failure to clear this clot may cause
fatal acute airway obstruction which is called
Coroner’s clot. Infection is relatively uncommon and rarely retropharyngeal and mediastinal abscesses may occur. Grisel Syndrome is
non-traumatic atlantoaxial subluxation seen
more commonly with curette adenoidectomy.
Velopharyngeal dysfunction is rare but can
cause signicant problems with hypernasal
speech and swallowing. It is mandatory to
assess the palate and uvula for submucous cleft
prior to surgery. Regrowth of adenoid is usually seen more commonly with curettage
adenoidectomy.
9.3 Part C: Epistaxis
andManagement
Epistaxis, or bleeding from the nose, is the commonest emergency in ENT practice. It affects up
to 60% of the population in their lifetime, and in
6%, it requires medical attention. It can be life
threatening in elderly patients and can cause
major concern in parents of young children.
Nasal cavity mucosa is supplied by the terminal
branches of the internal and external carotid
artery (Fig. 9.13). Nasal bleeding most commonly occurs from Kiesselbach’s plexus or
Little’s area, which is supplied by both systems.
Woodruff’s plexus lying in the posterior part of
nasal cavity just inferior to posterior-most end of
the inferior turbinate. It is generally responsible
for posterior epistaxis.
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Fig. 9.13 The line diagram is showing the nasal cavity blood supply
9.3.1 Causes
(c) Juvenile nasopharyngeal angiobroma
(d) Squamous cell carcinoma
The etiology of epistaxis can be divided into
local and general causes; however 80–90% of
cases are idiopathic.
(e) Inverted papilloma
4. Granulomatous disorder
(a) Sarcoidosis
(b) Wegener’s granulomatosis
9.3.1.1 Local
1. Trauma
(a) Nasal fracture
(b) Nose picking
(c) Foreign body
(d) Continuous positive airway pressure
2. Inammatory Conditions
(a) Allergic rhinosinusitis
(b) Bacterial rhinosinusitis
(c) Common cold
3. Neoplasia
(a) Septal and turbinate hemangioma
(b) Nasal papilloma
(c) Tuberculosis
5. Structural
(a) Septal Spurs
(b) Septal perforation
6. Iatrogenic
(a) Functional endoscopic sinus surgery
(b) Septoplasty
(c) Turbinate reduction
(d) Nasogastric tube insertion
(e) Nasotracheal intubation
7. Drugs
(a) Nasal steroids
(b) Cocaine abuse
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9.3.1.2 General
1. Hematological
(a) Coagulopathies
(b) Thrombocytopenia
(c) Platelet dysfunction, e.g., Von Willebrand’s
disease
(d) Hemophilia
(e) Aplastic anemia
(f) Hereditary hemorrhagic telangiectasia/
Osler Weber Rendu disease
2. Hypertension
3. Environmental factors
(a) Humidity
(b) Altitude
(c) Temperature
(d) Pollution
4. Drugs
(a) Anticoagulants like heparin, warfarin
(b) Antiplatelets like ecosprin, clopidogrel
5. Organ failure
(a) Uremia
(b) Cirrhosis
6. Atherosclerosis
7. Alcoholism
Epistaxis can be classied on the basis of eti-
ology. Epistaxis is called primary when no cause
is identify whereas secondary when cause is
available. When the site of bleeding is visible on
anterior rhinoscopy or anterior to pyriform aperture, it is called anterior epistaxis. When the site
of bleeding is not visible by anterior rhinoscopy
or behind the pyriform aperture, it is called posterior epistaxis.
9.3.2 Risk Factors
Risk factors for recurrent epistaxis include the
following:
1. Hypertension and diabetes mellitus are minor
risk factors for recurrent epistaxis as both these
conditions are known to induce atherosclerotic
changes in the vasculature system [17].
2. Congestive heart failure is the cause of recurrent epistaxis because of the increased venous
pressure in the nasal vessels.
3. Anatomical abnormalities like septal deviations and spurs are also responsible.
9.3.3 Management
The initial most management is resuscitation. It
includes correction of volume loss by intravenous uid administration. Blood transfusion
should be considered if hemoglobin levels fall
below 9 g/dl. Detailed history and examination is
helpful to diagnose the cause of bleeding. After
primary resuscitation, necessary blood investigation is advised on the basis of history. Blood
grouping and cross-matching is must for moderate to severe epistaxis cases. For anterior epistaxis, the patient should be asked to pinch the
lower cartilaginous part of the nose while leaning
forward over a bowl as bleeding into the nasopharynx is more uncomfortable. Also, the blood
will not be swallowed causing subsequent nausea. The treatment policy is followed in the form
of four line of management. First line of management is indicated when the site of bleeding is visible either by anterior rhinoscopy or by nasal
endoscopy. Bleeding point can be cauterized by
electric or by chemical application and it is
known as the direct method. Chemical cautery
with silver nitrate is more useful for bleeding
points in anterior part of the nose. Bipolar or
monopolar suction cautery is an alternative if
bleeding is more posterior, rigorous, or if refractory to chemical cautery (Fig. 9.14) [18].
Simultaneous bilateral cautery on the nasal septum should be avoided to minimize the risk of
septal perforation.
When the site of bleeding is not visible or it is
generalized, then second line of management is
applicable. It is an indirect method and nasal
packing is done to control bleeding. The different
kinds of packing materials are mentioned in
Chap. 1. In this chapter, we are discussing packing technique. Newer absorbable and nonabsorbable packing materials are generally
effective in low to moderate amount of epistaxis.
Absorbable packs offer greater patient comfort
and are more desirable in patients with thrombocytopenia or coagulopathy. They create less
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