Master Techniques in Otolaryngology - Head and Neck Surgery Rhinology [1 ed.]

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Editor David W. Kennedy MD, FACS, FRCSI Rhinology Professor Department of Otorhinolaryngology—Head and Neck Surgery Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania

Series Editor Eugene N. Myers MD, FACS, FRCS Edin (Hon) Distinguished Professor Emeritus and Emeritus Chair Department of Otolaryngology University of Pittsburgh School of Medicine Professor Department of Oral Maxillofacial Surgery University of Pittsburgh School of Dental Medicine Pittsburgh, Pennsylvania

Contributors Nithin D. Adappa, MD Assistant Professor Division of Rhinology and Skull Base Surgery Department of Otorhinolaryngology— Head and Neck Surgery Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania A. Simon Carney, MBChB, BSc(Hons), FRCS, FRACS, MD Professor of Otolaryngology—Head and Neck Surgery Flinders University Director Adelaide Sinus Centre Adelaide, South Australia Ricardo L. Carrau, MD, FACS Professor Department of Otolaryngology—Head and Neck Surgery Director of the Comprehensive Skull Base Surgery Program The Ohio State University Medical Center Columbus, Ohio

Paolo Castelnuovo, MD Professor and Chair of the Department of Otorhinolaryngology—Head and Neck Surgery University of Insubria Varese, Italy Noam A. Cohen, MD, PhD Associate Professor Department of Otorhinolaryngology— Head and Neck Surgery Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania James A. Duncavage, MD Professor of Otolaryngology Rhinology Fellowship Program Director Vanderbilt University Medical Center Nashville, Tennessee Vikram D. Durairaj, MD, FACS Professor Director, Oculoplastic and Orbital Surgery Department of Ophthalmology University of Colorado School of Medicine Aurora, Colorado Berrylin J. Ferguson, MD Professor Department of Otolaryngology Director Division of Sino-nasal Disorders and Allergy University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania Oren Friedman, MD Associate Professor, Department of Otorhinolaryngology Director, Facial Plastic Surgery University of Pennsylvania School of Medicine Philadelphia, Pennsylvania Grant S. Gillman, MD, FRCS

Grant S. Gillman, MD, FRCS Associate Professor Department of Otolaryngology University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania Richard J. Harvey, BSc (Med), PhD (Surgery) Head Associate Professor University of New South Wales Macquarie University Rhinology and Skull Base Applied Medical Research Centre St Vincent's Hospital and University of New South Wales Sydney, Australia Steven M. Houser, MD, FAAOA Assistant Professor Case Western Reserve University School of Medicine Director Allergy and Paranasal Sinus Medicine and Surgery MetroHealth Systems Cleveland, Ohio Peter H. Hwang, MD Professor Chief, Division of Rhinology and Endoscopic Skull Base Surgery Department of Otolaryngology—Head and Neck Surgery Stanford University School of Medicine Stanford, California Ken Kazahaya, MD, MBA, FACS Associate Director Division of Pediatric Otolaryngology Children's Hospital of Philadelphia Endowed Chair in Pediatric Otolaryngology Children's Hospital of Philadelphia Director Pediatric Skull Base Surgery Medical Director Cochlear Implant Program

Co-Lead Surgeon Pediatric Thyroid Center Children's Hospital of Philadelphia Associate Professor of Clinical Otorhinolaryngology—Head and Neck Surgery Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania David W. Kennedy, MD, FACS, FRCSI Rhinology Professor Department of Otorhinolaryngology— Head and Neck Surgery Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania Todd T. Kingdom, MD, FACS Professor and Vice Chair Clinical Affairs Director, Rhinology and Sinus Surgery Department of Otolaryngology—Head and Neck Surgery Department of Ophthalmology University of Colorado School of Medicine Aurora, Colorado Andrew P. Lane, MD Professor of Otolaryngology—Head and Neck Surgery Director, Johns Hopkins Sinus Center Fellowship Director Johns Hopkins Outpatient Center Baltimore, Maryland William Lawson, MD Professor Department of Otolaryngology—Head and Neck Surgery Mount Sinai Medical Center New York, New York John M. Lee, MD, FRCSC, MSc Assistant Professor Department of Otolaryngology—Head and

Neck Surgery University of Toronto St. Michael's Hospital Toronto, Ontario, Canada Valerie J. Lund, CBE, MS, FRCS, FRCS (Ed) Professor of Rhinology University College London Honorary Consultant ENT Surgeon Royal National Throat, Nose and Ear Hospital London, England Ralph Metson, MD Program Director Rhinology Fellowship Massachusetts Eye and Ear Infirmary Harvard Medical School Boston, Massachusetts Hiroshi Moriyama, MD Professor and Chair Department of Otorhinolaryngology The Jikei University School of Medicine Tokyo, Japan Piero Nicolai, MD Professor and Chairman Department of Otorhinolaryngology— Head and Neck Surgery University of Brescia Brescia, Italy Metin Onerci, MD Professor of Otorhinolaryngology Faculty of Medicine Hacettepe University Ankara, Turkey Richard R. Orlandi, MD, FACS Professor, Otolaryngology—Head and Neck Surgery University of Utah Salt Lake City, Utah John F. Pallanch, MD, MS, FACS

Division Chair of Rhinology Department of Otolaryngology Mayo Clinic Rochester, Minnesota James N. Palmer, MD, FACS Director Division of Rhinology Co-Director Skull Base Center Professor Department of Otorhinolaryngology Professor of Neurosurgery Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania Daniel M. Prevedello, MD Associate Professor Department of Neurological Surgery Wexner Medical Center at The Ohio State University Columbus, Ohio Edmund deAzevedo Pribitkin, MD Professor Department of Otolaryngology— Head and Neck Surgery Thomas Jefferson University Philadelphia, Pennsylvania John C. Price, MD Attending Otolaryngologist—Head and Neck Surgeon, Retired Greater Baltimore Medical Center Baltimore, Maryland Gerhard Rettinger, MD Professor and Head Department of Otorhinolaryngology University Hospital Ulm, Germany Michael Setzen, MD, FACS, FAAP Chief Rhinology Section North Shore University Hospital

Manhasset, New York Clinical Associate Professor of Otolaryngology NYU School of Medicine Adjunct Clinical Assistant Professor of Otolaryngology Weill Cornell University College of Medicine Daniel B. Simmen, MD Professor in ORL—Head and Neck Surgery ORL-Zentrum Klinik Hirslanden Zürich, Switzerland Aldo C. Stamm, MD, PhD Associate Professor Department of Otolaryngology—Head and Neck Surgery Federal University of Sao Paulo Head—Department of Otolaryngology Professor Edmundo Vasconcelos Hospital São Paulo ENT Center São Paulo, Brazil James Stankiewicz, MD, FACS Professor Department of Otolaryngology Loyola University Medical Center Maywood, Illinois Paul H. Toffel, MD, FACS Clinical Professor Department of Otolaryngology—Head and Neck Surgery University of Southern California School of Medicine Lieutenant Commander (Ret) United States Naval Medical Corps Glendale, California Elina M. Toskala, MD, PhD Professor Department of Otolaryngology—Head and

Neck Surgery Director of Allergy Temple University School of Medicine Philadelphia, Pennsylvania David E. Tunkel, MD Professor of Otolaryngology Department of Otolaryngology—Head and Neck Surgery Johns Hopkins Medical Institutions Baltimore, Maryland Eduardo Vellutini, MD, PhD DFV Neurosurgery São Paulo, Brazil Kevin C. Welch, MD Associate Professor Department of Otolaryngology—Head and Neck Surgery Loyola University Chicago Stritch School of Medicine Maywood, Illinois Bradford A. Woodworth, MD James J. Hicks Associate Professor of Surgery Division of Otolaryngology University of Alabama at Birmingham Associate Scientist Gregory Fleming James Cystic Fibrosis Research Center Birmingham, Alabama Peter John Wormald, MD, FRACS, FCS (SA), FRCS Edin (Hon) Professor of Otolaryngology Chair Department of Otolaryngology—Head and Neck Surgery Adelaide and Flinders Universities Adelaide, Australia Adam M. Zanation, MD, FACS Director of Practice Development Associate Professor Co-Director, Head and Neck Oncology

Fellowship Co-Director, Rhinology and Skull Base Surgery Fellowship Department of Otolaryngology—Head and Neck Surgery University of North Carolina at Chapel Hill Chapel Hill, North Carolina

2016 Lippincott Williams & Wilkins Philadelphia Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103 USA 978-1-4511-7557-8

Acquisitions Editor: Brian Brown Product Development Editor: Dave Murphy Senior Production Project Manager: Alicia Jackson Design Coordinator: Steven Druding Manufacturing Coordinator: Beth Welsh Marketing Manager: Daniel Dressler Prepress Vendor: SPi Global Copyright © 2016 Wolters Kluwer All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at [email protected], or via our website at lww.com (products and services). 987654321 Printed in China Library of Congress Cataloging-in-Publication Data Head and neck surgery. Rhinology / [edited by] David W. Kennedy. — First edition. p. ; cm. — (Master techniques in otolaryngology) Rhinology Includes bibliographical references. ISBN 978-1-4511-7557-8 I. Kennedy, David W., 1948- , editor. II. Title: Rhinology. III. Series: Master techniques in otolaryngology. [DNLM: 1. Nose Diseases—surgery. 2. Nasal Surgical Procedures—methods. WV 300] RD521 617.5′1—dc23 2014028713 This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work. This work is no substitute for individual patient assessment based upon healthcare professionals' examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions,

medication history, laboratory data and other factors unique to the patient. The publisher does not provide medical advice or guidance and this work is merely a reference tool. Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments. Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should consult a variety of sources. When prescribing medication, healthcare professionals are advised to consult the product information sheet (the manufacturer's package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infrequently used or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work.

Dedication This series of books is dedicated to Barbara, my wife and best pal. Our daughter, Marjorie Fulbright, her husband Cary and their sons, Alexander F. Fulbright and Charles J. Fulbright. Our son, Jeffrey N. Myers, MD, PhD, his wife Lisa and their sons Keith N. Myers, Brett A. Myers, and Blake D. Myers. All of whom I love and cherish. Eugene N. Myers

Dedication I would like to dedicate this book to my wife and partner, Elina, and to my children, Garrett, Kirin, Paavali, and Aurora. They are the love of my life. I also want to recognize all my teachers and mentors during my career to date; the book is a compilation of your wisdom and of those international experts who have generously contributed their work to this volume. David W. Kennedy

Series Preface Since its inception in 1994, the Master Techniques in Orthopedic Surgery series has become the go to text for surgeons in training and in practice. The user-friendly style of providing and illustrating authoritative information on a broad spectrum of techniques of orthopaedic surgery obviously filled a need in orthopaedic educational materials. The format has become a standard against which others are compared, and there are now 13 volumes in the series with other volumes in the planning phase. When I was approached to be the series editor, I already knew what a daunting task it would be from my previous experience with editing surgical texts, but I felt this unique approach could become a valuable fixture in the catalogue of literature on surgery in all the subspecialty fields of Otolaryngology. This first edition includes volumes on Head and Neck Oncology, Reconstructive Surgery of the Head and Neck, Cranial Base Surgery, Rhinology, Aesthetic Surgery, and Otology and Lateral Skull Base Surgery. I have recruited real masters to be volume editors including Robert L. Ferris, Eric Genden, Carl H. Snyderman and Paul Gardner, David Kennedy, Wayne Larrabee and James Ridgeway, and J. Thomas Roland, respectively. Having a separate volume on Reconstructive Surgery of the Head and Neck as a separate companion piece for the volume on Head and Neck Oncology is somewhat nontraditional but enabled us to include more topics. I do hope that you will find the Master Techniques to be a useful addition to your surgical armamentarium for the benefit of your patients. Eugene N. Myers, MD Series Editor

Preface The goal of this series of books, Masters in Otolaryngology is to provide more than just a surgical atlas, but rather to also include some background to each procedure, the typical patient presentation and indications, as well as the surgical technique and postoperative care. Each chapter is written personally by the true experts for each technique—individuals who are well recognized for their teaching in these respective procedures. In each chapter, the author describes the appropriate considerations in preoperative planning, the postoperative care, expected results, and potential complications, as well as the instruments to have available. The surgical procedure itself is detailed much as though it would be in an operative report for a procedure done by that surgeon, and the Pearls and Pitfalls during the planning, surgery, and postoperative care for each procedure are highlighted. Finally, the “master” lists the instruments that he or she feels to be the most important to have available for that procedure and provides a list of recommended additional reading. We believe that this creates more than just a surgical atlas. However, it is the detail and richness of the surgical procedure descriptions and the accompanying color illustrations by Bernie Kida that I believe that otolaryngologists and residents will find most helpful. In addition, many descriptions are accompanied by surgical videos. The growth within the field of rhinology in recent years has been truly amazing. Not only have we started to refine our understanding of some of the inflammatory disease mechanisms but also surgical techniques have extended well beyond what we initially envisioned when we started, with trepidation, to extend endoscopic surgery into the realm of oncology and orbital surgery in the late 1980s. This volume focuses on both basic and advanced rhinologic procedures as well as the common endoscopic skull base approaches. The book is divided into a number of sections and includes such areas as surgery for neoplasms, orbital surgery, and open surgery. Although most of the procedures described in the book are in common use today, we also have tried to include some less common techniques that surgeons will find helpful to have in their armamentarium and that they may need to review from time to time. Senior experts, the true masters, generously contributed their time to make this book an important learning tool for residents practicing otolaryngologists. I hope that you, the reader, will find this volume educational and an excellent reference from which to refine surgical techniques. David W Kennedy, MD, FACS, FRCSI Professor Department of Otorhinolaryngology—Head and Neck Surgery Perelman School of Medicine University of Pennsylvania Philadelphia, Pennsylvania

Video Content Video 5.1

Technique for Prosthetic Closure of Large Nasal Septal Perforations: Cases 1, 2 &3

Video 7.1

Left Inferior Turbinate Microdebrider

Video 7.2

Left IT outFx

Video 7.3

The Surgical Management of the Inferior Turbinates: Right IT Rf and outFx

Video 8.1

Sphenopalatine Artery Ligation in PPF

Video 8.2

Sphenopalatine Artery Ligation

Video 9.1

Convoluted Course of the AEA in the Orbit

Video 9.2

Anterior Ethmoid Artery Bleeding

Video 11.1

Balloon Sinus Dilation R Frontal

Video 13.1

Endoscopic Ethmoidectomy

Video 14.1

Sphenoidotomy

Video 16.1

Post pituitary 3 weeks

Video 16.2

Post pituitary 3 months

Video 16.3

Pituitary

Video 17.1

Draf 2 Frontal Sinusotomy

Video 20.1

Closure of Skull Base Defects and Encephaloceles, Video 1

Video 20.2

Closure of Skull Base Defects and Encephaloceles, Video 2

Video 20.3

Closure of Skull Base Defects and Encephaloceles, Video 3

Video 24.1

Endoscopic Medial Maxillectomy

Video 25.1

Endoscopic Transmaxillary Approach to the Pterygopalatine Fossa

Video 27.1

Endoscopic Pituitary and Suprasellar Surgery, Case 1

Video 27.2

Endoscopic Pituitary and Suprasellar Surgery, Case 2

Video 31.1

Optic nerve decompression

Video 32.1

Technique for Endoscopic Orbital Decompression: Entering Lamina

Video 32.2

Technique for Endoscopic Orbital Decompression: Removing Orbital Floor

Video 32.3

Technique for Endoscopic Orbital Decompression: Entering Periorbita

1 Technique for Reduction of Nasal Fractures Paul H. Toffel

INTRODUCTION Management of nasal fractures has evolved substantially in recent decades. Whereas closed reduction of nasal fractures was frequently attempted in the past, then followed up by secondary open reduction when inadequate correction was noted, now most experienced rhinologists and otolaryngologists will be prepared to do a definitive open reduction of nasal and septal fractures as the primary correction with much more reliable functional results. The spectrum of injuries to the nose and septum have responded much better to early open correction and prevented late obstructive and crooked pyramid sequelae. This is the philosophy best taught in current training and is becoming an improved standard of care.

HISTORY The accurate diagnosis of severity and degree of nasal external and internal structure deformity depends on the history of causation and severity of forces involved in the injury. A fist or fall injury may be less severe than motor vehicle accidents, and the suspicion of trauma to adjacent structures must be entertained (i.e., facial, orbital fractures, neck injuries) and ruled out or treated in the emergency setting. Time since injury, degree of pain, and perceived nasal obstruction and epistaxis should all be noted.

PHYSICAL EXAMINATION Physical examination of nasal and septal fractures requires first gross visual assessment of ecchymosis and degree of obvious deformity. Then, palpation of the external nasal structures, including bony and cartilaginous vault, should be done to detect displacement, tenderness, crepitus, and mobility. Internal examination of the nasal vault is best done with a nasal speculum and bright headlight illumination, supplemented by nasal endoscopy when feasible. Suction and topical vasoconstriction facilitate the visual internal examination. Notation of the status of the septum is essential, that is, fractures and dislocations of the septum, mucosal tears, and septal hematoma that might need immediate drainage to prevent septal abscess and necrosis. Paramount is notation of septal displacement holding the nasal pyramid also in displacement without the ability to easily mobilize to the midline. Photography is an essential documentation of the nasal physical examination findings and status for the assessment and medical record. Nasal radiographs are traditionally done and help in decision making if obviously positive, but in no way counterpositive physical findings if the radiographs are negative. If the facial trauma is severe enough, maxillofacial CT scans including the nose and sinuses are indicated and can provide more detail than plane radiographs in assessing external and internal nasal structures. P.2

INDICATIONS

If findings of nasal deformity and obstruction are confirmed, the patient should be taken to the operating suite either before edema and bruising have set in or, if present, should be delayed until they have subsided. The operating suite is the best facility in which to manage nasal and septal fracture repair, as adequate correction can be done in the proper environment without compromise. Consent should allow the surgeon to do whatever procedures are necessary, including closed or open reduction of fractures, which is a key element of informed consultation with the patient and family prior to corrective surgery.

CONTRAINDICATIONS There are no definite contraindications to performing necessary reduction surgery, whether closed or open, for nasal and septal fractures based on local factors; however, comorbidities must be considered, especially aged, debilitated, or demented patients and associated cardiovascular, kidney, or pulmonary disease. In weak and debilitated patients, deformity may have to be accepted, but usually some degree of closed reduction can be accomplished.

PREOPERATIVE PLANNING In the treatment of the displaced nose, closed reduction has traditionally been considered adequate management. Within the specialty of rhinology, however, closed reduction is acceptable in only the most minimally traumatized nose and nasal septum. There should be no hesitation in performing an open reduction of nasal and septal fractures if the closed reduction attempt is inadequate for straightening the nasal pyramid and restoring the intranasal respiration. Timing of the repair is an inpatient consideration. Closed reductions may be successful in the first 10 days after trauma, but beyond that time, open reduction may be required to provide adequate alignment and repair of both nasal pyramid and septal structures because of potential healing in displaced positions. Preoperative management of the typical patient with a nasal and septal fracture waiting for edema to resolve, prior to operative procedure, requires administering a prophylactic antibiotic, usually an oral cephalosporin, to diminish the risk of intranasal infections, especially if there have been mucosal tears. Analgesics may also be given to diminish discomfort in the acute postinjury phase. Anesthesia for the nasal/septal reduction procedure, in the outpatient operating suite, can be selected as either IV analgesic or, for younger patients or challenging adults, general endotracheal anesthesia. In both situations, delicate and complete local anesthesia with a topical decongestant and infiltrated dilute Xylocaine with epinephrine solution is effective for vasoconstriction during the anatomic correction. The cephalosporin antibiotics are administered IV at the time of the procedure and continued postoperatively orally, especially if light postoperative splinting or packing support is necessary.

SURGICAL TECHNIQUE In patients with confirmed septal dislocation and nasal fracture with displacement, the septum should first be explored surgically and realigned during the same procedure as the nasal pyramid so that reconstitution can be controlled in the operating room environment in order to promote good healing, alignment, and nasal respiration and to prevent bony malunion in a crooked position. If present, a septal hematoma should be drained expeditiously to avoid sequelae such as absorption of septal cartilage with a resultant saddle nose deformity. The stepwise reduction begins after adequate anesthesia of the nose and septum is obtained with inspection

and attempted closed reduction of the septal displacement and nasal fractures. The nasal pyramid can be mobilized using a narrow, Freer elevator or a knife handle. Placement of the instrument under the depressed aspect of the nasal bones with counterpressure by the opposite hand is most effective during the anterior and midline movement of the elevator. If the septum can be mobilized into the midline position and the nasal bones realign with a “snap,” the closed reduction may be complete. If inspection and palpation of the bony pyramid seem normal, and resolution of intranasal airway has been accomplished, the closed reduction could be judged successful and no open steps are necessary. However, if the septum does not mobilize to midline and the nasal dorsum is held crooked by the deflected septum, open reduction should be the next technique to be used. Typically, a hemitransfixion or Killian incision is made on the concave side of the septum, and meticulous elevation of a mucoperichondrial and mucoperiosteal septal flap is developed. The flap should extend beyond the dislocated and telescoped area, and separation of the dislocated cartilage from the bony cartilaginous junction, P.3 with removal of small amounts of cartilage or bone adjacent to the junction, allows the septum to mobilize and regain the midline. Always try to maintain the 2-cm dorsal septal strut of cartilage and bone to maintain nasal support and prevent a saddle nose deformity.

FIGURE 1.1 Padgett-type 2-mm and 3-mm delicate nasal osteotomes. After septal alignment, if the nasal pyramid is not in the midline, attention is directed to the open reduction. Small

intranasal access incisions can be made in the pyriform aperture and under the dorsal skin to gain the required access for medial and lateral “freeing” osteotomies, as needed. The osteotomies should be done with minimal dorsal elevation to maintain the attachment of the periosteum and perichondrium to the underlying bony and cartilage structures. A major help in delicately completing reduction of nasal dorsal fractures to allow good mobilization is the use of 2-mm and/or 3-mm unguarded osteotomes (Padgett Orthopedic series) (Fig. 1.1). Using these delicate microosteotomies causes very little new ecchymosis, and the instruments can be guided within the periosteal covering of the nasal bones very accurately during the medial and lateral osteotomies (Fig. 1.2).

An Example of the Technique Follows Preoperative Diagnosis Nasal and septal fracture deformity secondary to injury with obstruction to respiration.

FIGURE 1.2 Delicate intraperiosteal medial and lateral osteotomies with 2-mm or 3-mm Padgett osteotomes. Mobilize to match depressed contralateral nasal bone.

P.4

Postoperative Diagnosis Nasal and septal fracture deformity secondary to injury with obstruction of respiration.

Operation Performed Open reduction of nasal and septal fractures. Anesthesia General endotracheal anesthesia supplemented with topical application of 4% cocaine solution and infiltration of 50% Xylocaine with 1:200,000 epinephrine solution. Findings This 20-year-old male patient with the complaint of a nasal injury sustained a few days ago when he was struck on the left side of his nose with a fist during an altercation. Since that time, there has been an obvious nasal deformity with obstruction of respiration. Clinical examination and office nasal rhinoscopy revealed bilateral nasal respiratory obstruction of greater than 80% with the nasal pyramid deviated to the right, nasal septum markedly deviated to the right, and markedly hypertrophic inferior turbinates. Nasal CT scans confirmed the deviated nasal septum to the right consistent with fracture injury. Because of the severity of the posttraumatic nasal and septal fracture deformity with obstruction of respiration confirmed on clinical examination and CT scans, it was suggested to the patient that he have corrective nasal fracture procedures. At the procedure, the clinical findings were borne out. The nasal septum was dislocated markedly toward the right. The nasal pyramid was deviated toward the right approximately half a bridge width. At the conclusion of the operative procedure, the patient had restoration of satisfactory nasal alignment and respiration.

Procedure After securing adequate general anesthesia, the patient was prepped and draped in the usual manner for open reduction surgery of the nose. A right Killian incision was performed, and a mucoperichondrial and mucoperiosteal septal flap was developed. The inferior aspect of the quadrilateral cartilage was dislocated into the right floor of the nose and was amputated, and a disarticulation was completed where there was bony and cartilaginous telescoping at the bony cartilaginous junction. Portions of the vomer and ethmoid deflected to the right posterior to the bony cartilaginous junction were removed with Takahashi forceps, and the remainder of the vomer and ethmoid septum were realigned in the midposition with an infracture maneuver using an Ash forceps. The fractured elevated right nasal bone was mobilized with medial and lateral osteotomies using 2-mm Padgett osteotomes through pyriform aperture stab incisions. The Killian and pyriform aperture incisions were then closed with interrupted sutures of 4-0 chromic. A Bridgemaster nasal splint was then applied to the elevated nasal pyramid, and a drip pad dressing was applied. In the acute postinjury nasal and septal fracture reduction surgery, dorsal hump and tip refinement, if present, are typically not done. If the reduction is delayed several months, these elements could be addressed, but it should be understood with the patient and payers that these portions of the correction are cosmetic and are the patient's financial responsibility. Mobilizing osteotomies, however, are part of the posttraumatic fracture reduction procedure.

POSTOPERATIVE MANAGEMENT Depending on the mobility of the fragments, a Merocel pack may be used to stabilize the nasal bones high up in the nasal vault to prevent internal displacement of the bones. Thin plate septal splints can also be used to stabilize and narrow the septum postoperatively. Typically, an aluminum articulated (Bridgemaster; Medtronics, Minneapolis, Minnesota) dorsal splint is applied over a paper tape dressing. These are usually removed in a few

days. As stated prior, cephalosporin-type antibiotics are maintained while packing and splints are in place.

COMPLICATIONS Postoperative infections can occur with nasal and septal fracture repair, especially where tears have occurred in the intranasal mucosa and packing systems need to be used. Therefore, I strongly believe in the use of prophylactic cephalosporin antibiotics while packing or splinting is present. The most common complication of nasal/septal fracture repair is inadequate reduction, often when closed reduction was attempted and early open reduction was deferred. I would strongly advise the accomplished P.5 rhinologic surgeon to do the appropriate and indicated open reduction procedures when there is any question about the efficacy of the closed attempt. Lastly, be sure that adjacent facial and orbital fractures are evaluated acutely and ruled out with physical examination and CT scanning, to prevent late facial complications.

RESULTS In the modern era of rhinology, with the use of CT scans, nasal endoscopes, and much better gentle techniques of nasal and septal fracture repair and especially, using primary open reductions for cases in which a deviated nasal pyramid and septum are even minimally suspected, the long-term results of nasal and septal fracture repair are excellent. I cannot emphasize enough the advantage of open reduction surgery for most significant nasal and septal fractures to prevent late sequelae especially nasal deformity.

PEARLS Be “open” to using precise, controlled open reduction to correct the typical acute fractured nose and nasal septum deformities. The true closed reduction is indicated only in the minority of cases. In children, controlled minimal trauma open reduction should be used instead of closed reductions with their inadequacies. Many studies have shown no growth sequelae to minimally open reduction nasal and septal fracture maneuvers in children. Delicate 2-mm or 3-mm atraumatic microosteotomes are reliably successful for “completion” osteotomies in children or adult fracture cases.

PITFALLS In managing nasal injuries, always be careful to evaluate for associated maxillofacial fractures especially a minimally displaced or unappreciated Le Fort I fracture, which could give an occlusive malunion. As a rhinologist, do not use the emergency room closed reduction too often to correct fractured noses, as your reputation may be followed by too many crooked outcomes. Early open reduction produces reliably better long-term results.

INSTRUMENTS TO HAVE AVAILABLE (FIGS. 1.1 AND 1.3) Padgett-type 2-mm and 3-mm delicate nasal osteotomes Aufricht retractor-speculum: manufacturer unknown

FIGURE 1.3 Instruments (from left to right). •Aufricht retractor-speculum: manufacturer unknown •4-prong dull rake (Cottle 4-prong retractor): Storz •2-ball tip retractor (Fomon nostril elevator-retractor): Storz •2-mm and 3mm Chisel: Padgett •Osteotomes: V. Mueller •Fine rasp: Snowden-Pencer •Coarse rasp: V. Mueller •Quisling osteotome: manufacturer unknown •Large-angled scissors: V. Mueller •Small-angled scissors: SnowdenPencer P.6 4-prong dull rake (Cottle 4-prong retractor): Storz 2-ball tip retractor (Fomon nostril elevator-retractor): Storz 2-mm and 3-mm Chisel: Padgett Osteotomes: V. Mueller Fine rasp: Snowden-Pencer Coarse rasp: V. Mueller Quisling osteotome: manufacturer unknown Large-angled scissors: V. Mueller Small-angled scissors: Snowden-Pencer Curved tip: V. Mueller

SUGGESTED READING

Goode RL, Spooner TR. Management of nasal fractures in children: a review of current practices. Clin Pediatr 1972;11:526. Facer GW. Management of nasal injury. Postgrad Med 1975;57:123. Pirsig W, Lehmann I. The influence of trauma on the growing septal cartilage. Rhinology 1975;13:39. DeLacey GJ, Wignall BK, Hussain S, et al. The radiology of nasal injuries: problems of interpretation and clinical relevance. Br J Radiol 1977;50:412. Staffel JG. Basic Principles of Rhinoplasty. Washington, DC: American Academy of Facial Plastic Reconstructive Surgery; 1996. Tardy MR Jr. Rhinoplasty: The Art and the Science. Philadelphia, PA: WB Saunders; 1997.

2 Septoplasty Grant S. Gillman

INTRODUCTION Accounts of surgical procedures designed to establish a normal anatomic nasal airway can be found as far back as the late 19th century. In fact, some of the most recognized names in surgery have been associated with descriptions of surgical techniques and innovations to improve nasal airway surgery, including Asch, Killian, Freer, Metzenbaum, Cottle, Converse, and Goldman among others. Nonetheless, success and patient satisfaction rates reported within the literature often hover around 70%. This would suggest that the way we think about the problem and the teaching of the surgical correction of the nasal airway must be revisited, broadened, and continually honed. Any number of structural deformities might affect the nasal septum. The obstruction might be cartilaginous, bony, or both. One might see tilts to the septum, curves, spurs, twists, angulations, telescoping segments, or any combination of these. Septal deviations might occur within a nasal framework that is externally straight, crooked, twisted, or collapsed. The airway might be compromised at the internal nasal valve, the external nasal valve, both, or neither. Considered in this light, it is simplistic to think that there might be one operation to correct all nasal airway problems. Furthermore, it becomes self-evident that routinely applying a single “standard” operation to all patients presenting with nasal obstruction and a deviated septum is doomed to fail in a significant number of cases from the outset. In essence, there is no “one-size-fits-all” solution to this variable, complex, and often underappreciated challenge. “Septoplasty” is best thought of as a reconstructive procedure. Only then does one begin to do away with the notion of any single “standard” excisional procedure and instead proceed more creatively to design an operation tailored to the particular needs of and unique deformity in each patient. At the same time, this very construct makes it virtually impossible to describe how to address all possible circumstances that the surgeon might encounter. At the very least, however, a foundation for more thoughtful, considered surgery will provide a basis upon which surgical experience can be developed, and with greater surgical experience, more consistent outcomes and more grateful patients will inevitably follow. With that in mind, I will endeavor to provide some general guidelines for the more basic or routine deformities. Equally importantly, I will endeavor to provide some recommendations on how to identify circumstances that are less routine and that would warrant more advanced surgical intervention in order to minimize failure and maximize success rates.

HISTORY Relevant documentation for the patient presenting with complaints of nasal airway obstruction should include the following: Duration of the symptoms A history of previous nasal surgery P.8 History of nasal trauma Identification of the more subjectively symptomatic side, if there is one The presence or absence of environmental allergies or triggers for nasal congestion. The patient with

allergic rhinitis and a deviated septum must understand that surgery can only relieve the obstructive structural component and that ongoing treatment of the inflammatory (allergic) congestion component will be necessary if one is to optimize the nasal airway. Discussing this prior to surgery (and not afterward) will set appropriate expectations and should better facilitate compliance with postoperative medical management. Any trial of and response to oral antihistamines, oral decongestants, nasal steroid sprays, nasal antihistamines and nasal dilating strips. This can help alert the clinician to possible allergic rhinitis and nasal valve issues respectively. Use of over-the-counter nasal decongestant sprays Any history of recurrent or chronic sinusitis Any history of recurrent or prolonged epistaxis Any history of sleep-disordered breathing/sleep apnea The patient's impression of his/her sense of smell History of cocaine use (if suspected)

PHYSICAL EXAMINATION First and foremost, the physical examination of the patient presenting with nasal airway obstruction should be an open-minded evaluation of all possible sources of obstruction. I begin with observation of the patient from both a frontal view and base view, without a speculum in place, with the patient breathing normally and naturally through the nose in order to identify any instability of the nasal sidewall or dynamic inspiratory collapse of the nasal valve. From the base view, one can also identify caudal septal deflections and asymmetry of the nostrils. I then proceed to anterior rhinoscopy. The importance of a careful and very deliberate examination of the nasal valve cannot be overstated. Unrecognized nasal valve compromise is a common reason for which surgeons might fail to correct a nasal airway issue with a septoplasty—particularly valve compromise in the region of either the dorsal or caudal septal struts. If a speculum is passed into the nose too far and too quickly, the examiner can easily overlook or bypass pathology of the nasal valve. As such, anterior rhinoscopy must be a patient, thoughtful and critical appraisal of all potential sites of obstruction. Deviations of the septum should be described in as specific and detailed a fashion as possible (see section on Preoperative Planning). If a septal perforation is identified, it should be documented and pointed out to the patient. I routinely do nasal endoscopy so that I do not inadvertently overlook a less obvious source of obstruction beyond a more readily apparent septal deflection. An ear curette or the wooden stick end of a cotton-tipped applicator can be used either to stabilize the collapsing nasal sidewall (upper or lower lateral cartilage) if present or to lateralize an already collapsed (medialized) sidewall segment during inspiration. This can determine whether or not such a maneuver is beneficial to the patient with suspected nasal valve compromise or instability of the nasal sidewall. With a gloved hand straddling the columella between the thumb and index finger, I palpate the caudal septum of every patient. I am often surprised by the frequency of involvement of the caudal segment of the quadrangular cartilage. Subtle caudal septal deflections can easily be “hidden” behind the columella (and are therefore less apparent on visual evaluation). Nonetheless, such deflections can have a significant impact on the airway if this segment of the cartilage is bowing to one side or the other and impinging on the nasal valve angle or displaced off the anterior nasal spine and maxillary crest. Furthermore, by palpating the

septum I can appreciate whether the underlying cartilage is weak and flimsy, or firm and more supportive. In any patient who has had prior surgery, I palpate further back along the septum with a cotton swab in an effort to determine how much or how little septal cartilage is still present to work with. To summarize, the physical examination of the patient with a deviated septum should focus on the broader configuration of the cartilaginous and bony septum itself, with particular attention paid to the dorsal septum/internal nasal valve, the caudal septum/external nasal valve, the stability of the nasal sidewall, and the presence or absence of alternative sources of nasal airway obstruction such as a mass, polyp, or adenoid hypertrophy.

INDICATIONS The primary indication for nasal septoplasty surgery is to improve the nasal airway and therefore the diseasespecific quality of life in the patient with a symptomatic nasal septal deviation. Other indications might include Facilitating access to the middle meatus in endoscopic sinus surgery Enabling the management of epistaxis occurring posterior to a deflected septal segment Facilitating access to the pituitary through the sphenoid sinus P.9 Facilitating harvest of septal cartilage for reconstructive purposes, as in nasal reconstruction Contributing as part of a more comprehensive approach to reducing upper airway resistance in the patient with sleep apnea/sleep-disordered breathing Relieving headaches or facial pain presumed to originate from septal contact points (controversial)

CONTRAINDICATIONS The primary contraindication to septal surgery would be a patient in whom medical comorbidities make that patient unsuitable for a general anesthetic. Patients taking anticoagulants that cannot be held or those with any bleeding disorder would merit deferral of surgery. Active and frequent overuse of any topical over-thecounter nasal decongestant sprays and/or cocaine abuse would contraindicate surgical intervention at that time. Lastly, patients whose goals or expectations regarding surgical outcomes are completely discordant with the measurable objective of the surgical procedure (e.g., those seeking resolution of postnasal drip, cure of a headache in the absence of any symptomatic nasal obstruction, or elimination of chronic cough) are likewise not good candidates for surgery as it may well be impossible to meet their unrealistic expectations.

PREOPERATIVE PLANNING Upon completion of the physical examination, the surgeon should be able to describe or classify the septal deformity in detail. Limited descriptions such as “deviated nasal septum (DNS), left” or “nasoseptal deviation (NSD), right” are so vague in specifics as to be meaningless for they offer little guidance for the operation. It would be akin to saying simply “cancer, head and neck” or “disease, middle ear,” which would provide no direction to the head and neck surgeon or otologist, respectively.

If all septal deflections were fundamentally similar and one generic operation could be used for all patients, then perhaps such nondescript narratives would suffice. If, on the other hand, we go back to the concept that the correction of septal deflections is a calculated reconstructive procedure individualized for each particular patient, then detailing observations such as angulations, curvatures, spurs, findings within the valve region, and caudal septal irregularities will inevitably begin to focus a more targeted surgical strategy, which in turn should result in improved outcomes. Imaging is not routinely necessary to diagnose septal or nasal valve pathology but is warranted if there is any suspicion of an alternative obstructive or inflammatory nasal mass. In order to succeed, the surgeon must begin by knowing when the “routine” septoplasty will fail. The preoperative identification of more complex, high-risk circumstances or sites of potential failure is therefore paramount. With the physical examination complete, the surgeon should ask the following questions: Is there a problem with the nasal valve? Is there a dorsal deviation? Is there a caudal septal deviation? Are there complex deformities in regions critical to nasal support that cannot be treated with excisional techniques and may require reconstruction or reimplantation of cartilage? Can the patient's problem be corrected endonasally, or does the patient really need a functional external approach septorhinoplasty? And finally—given all this information, is the correction of this patient's deformity within the surgeon's skill set, or should this be referred on to someone with the requisite experience needed for this particular case?

Informed Consent Informed consent should, at a minimum, include mention of the risks of: Excessive bleeding. Wound infection. Sinusitis secondary to placement of the splints. The need for secondary/revision surgery, that is, insufficient improvement of the nasal airway. Septal perforation. Inadvertent changes to the appearance of the nose—particularly in the region of the supratip/dorsal septum. Infrequently “settling” can occur in this area, particularly with more involved manipulation of the caudal septum. Anosmia (very rare). P.10

SURGICAL TECHNIQUE The patient is seen preoperatively in the holding area to review the goals of the operative procedure and the postoperative care and to verify elements of the physical examination that are best done in the awake patient such as nasal sidewall stability with inspiration. After consent is signed, the patient is instructed to use a nasal decongestant spray (e.g., oxymetazoline)—two sprays to each side of the nose, about 15 minutes prior to being taken back to the operating room.

Following the induction of general anesthesia, an oral RAE tube, secured down the midline, is used since the preformed contour allows it to sit easily and tension free in the midline. A standard endotracheal tube, on the other hand, is generally taped to one side or the other and can exert at least some pull on the nasal base and columella toward that side, which is felt to be counterproductive to the goal of establishing a centered nasal septum. A single dose of an intravenous antibiotic is given prior to making the incision. I then once again use a nasal speculum to examine the nose to confirm the observations from the initial office consultation, and I palpate the caudal septum to reevaluate its strength, stability, and orientation. Beginning posteriorly, I inject the nasal septum (and turbinates if reductions are planned) bilaterally with 1% lidocaine with 1:100,000 epinephrine. In order to benefit from the vasoconstrictive effect of the epinephrine, it is more important to widely distribute the local anesthetic through multiple points of injection than it is to concern oneself with attempting to forcefully distribute the local anesthesia via a single injection site at the caudal septum. The volume of the injection can also be used constructively to inflate or hydrodissect the septal mucosa from within deep grooves, angles, or crevices if present. Once the intranasal injections are completed, oxymetazoline-soaked pledgets are placed in each side of the nose. The operating table is then turned and the patient positioned appropriately for surgery and prepped and draped in a sterile fashion. Through a hemitransfixion incision (Fig. 2.1) made at the free edge of the caudal septum, complete bilateral submucoperichondrial and submucoperiosteal flaps are elevated. As a right-handed surgeon, I prefer to start with a left hemitransfixion incision, but if the caudal septal edge is moderately or significantly displaced to the right side making it relatively inaccessible from the left, then a right-sided incision is made without hesitation. Flap elevation can be done using a Woodson, Freer, Cottle or suction elevator. I prefer to begin with a Woodson elevator (very sharp edges, very useful for getting into the proper plane of dissection and for teasing tethered mucosa from fracture lines or deep grooves), and I transition to a Cottle elevator further posteriorly in the nose when it becomes difficult to see over the curve of the spatulated end of the Woodson elevator.

FIGURE 2.1 A and B: Killian and Hemitransfixion septal access incisions

P.11 Some surgeons prefer a Killian incision (an incision through septal mucoperichondrium parallel and 5 to 8 mm cephalic to the hemitransfixion incision just above the mucocutaneous junction) arguing that it preserves the mucosal attachments and blood supply to the caudal septum (Fig. 2.1). For septal deflections requiring any kind of manipulation or adjustment of the caudal septum, however, this access is limiting. More importantly, oftentimes subtle (but clinically relevant) abnormalities of the caudal septum are not fully apparent until complete exposure is achieved. By choosing to limit exposure of the caudal septum through a Killian incision, the surgeon risks leaving an unappreciated caudal septal deflection unaddressed. Furthermore, if one is planning on elevating complete flaps from both sides of the septum (which I do routinely), a hemitransfixion incision allows one to transition around the caudal edge of the septum with greater ease. There are three reasons to routinely elevate bilateral mucoperichondrial flaps off of the septum as opposed to working through the elevation of one side only. Exposure. If we are to aspire to maximizing success rates, no matter what the operation, all surgeons would agree that the operation in question is better done by optimizing the exposure. Achieving the best possible exposure of the surgical field is a fundamental principle of surgery. The septoplasty operation is no different. Why begin by compromising exposure? A better 3-D look at the septum from two sides will surely enhance one's appreciation of what structural abnormalities are present within the nasal airway if for no other reason than by allowing the brain to interpret curves, angles, and shifts from two views. By enabling oneself to visually examine the underlying cartilaginous septum, the bony septum, and the position of the maxillary crest from both sides throughout the entire course of the operation, one can better identify, better diagnose, more easily adjust, and more accurately evaluate septal alignment and the effect of changes made. Release. The position and configuration of the nasal septum are influenced by multiple intrinsic and extrinsic forces. Deformations, angulations, telescoped segments, curves, and spurs that are inherent to the septum itself would be thought of as “intrinsic” deforming forces. Forces extrinsic to the actual cartilage and bone of the septum that might affect the position of the septum include displaced nasal bones, collapsed or twisted upper lateral cartilages that attach to the dorsal septum, and the firmly adherent nasal mucoperichondrium and mucoperiosteum. The nasal mucosal envelope is a very tightly bound sleeve that drapes from the floor of the nose, over the lateral aspect of the maxillary crest and along the septum to the roof of the nasal cavity before turning laterally to the nasal sidewall. There is little laxity to the mucosa, as evidenced by the difficulty encountered by the surgeon trying to mobilize mucosa to close even small septal perforations. When the septal cartilage is displaced over the maxillary crest to one side, the mucosa of the opposite side follows the cartilage and is therefore tightly draped OVER the dorsal aspect of the crest—essentially occupying or preventing access to the midline space (Fig. 2.2). At its extreme, this is visualized as the deep groove one often sees over the crest on the side opposite the obstructed nasal airway. Completely elevating the mucosa from both sides of the septum, therefore, allows for maximal release of tension across the entirety of the septum and opens up the midline space completely (by coming right off the maxillary crest), thereby making it possible for the surgically corrected septum to move into that space. Consider the treatment of scar contractures—one of the fundamental principles of surgical management is scar release. In a similar fashion, there is tremendous underappreciated benefit to the release of mucosal tension on the septum, which then more readily allows for all elements to redrape and realign independently.

FIGURE 2.2 Right and left endoscopic views demonstrating a septal deviation to the left with mucosa draped deep within the groove over the maxillary crest on the right side. Only by elevating the mucosa from within the groove on the right side does the midline become accessible for complete septal repositioning. Failure to do so will inevitably leave the septum in a position biased to the left of the midline. (MC, maxillary crest; MT, middle turbinate; S, septum.) P.12 Access. While bilateral exposure allows for bilateral access to all parts of the septum, this becomes most advantageous for reconstruction or reinforcement of the caudal septum in particular. Being able to support the caudal septum from either side, to place reinforcement (batten) grafts or complete replacement grafts from either side, or to stabilize a midline position with sutures is much easier when the surgeon has optimized the access. Ultimately, the idea should be to make it as easy as possible to do whatever is necessary without hindrance. Some specifics with respect to the technical challenge of flap elevation merit further elaboration. Making one's way around spurs and sharp angulations and through deep grooves can be difficult to do without tearing the mucosal flaps. Specific recommendations in that regard are as follows: Low spurs (above or along the maxillary crest) are often best left until last. In this way there is maximal elevation and “relaxation” of the mucosa that might make it easier to get around the spur than if the flap were still tightly bound or tethered elsewhere. In fact, in some cases, elevation of the flap over the lateral edge of a spur might be easier to do later in the operation once cartilage has already been removed from the crest above the spur. This then allows the surgeon to work from the dorsal aspect of the crest proceeding carefully around the edge of the crest to a more lateral position. From the dorsal aspect, one is able to firmly palpate the bony surface to get one's “footing,” then hugging the bone as the dissection proceeds around the lateral aspect of the spur. If instead one tries to dissect toward the floor of the nose around a spur with all cartilage still in place, by default the dissection takes a more lateral (parasagittal) approach around the apex of the cartilaginous portion of the spur where the mucosa is typically quite thin, attenuated, and more likely to tear. Sharp or acute angulations of the cartilage can sometimes be gently “coerced” into a straighter configuration using a longer speculum, thus allowing the flap elevation to continue beyond that point unimpeded. This is generally the case when the cartilage is softer and the angulation not extreme. In addition, oftentimes angulations of the quadrangular cartilage will flatten out somewhat more anteriorly along the septum (toward the nasal dorsum). In such cases, raising the flap along a tunnel more toward the dorsum first will allow the surgeon to get above and beyond the angle in the septum, from which point it becomes easier to come down over the angle and complete the elevation of the flap.

In the worst of cases—severe angles/fracture lines, firm unyielding cartilage—it becomes necessary to elevate the ipsilateral flap only to the apex of the angulation, proceed with complete flap elevation on the opposite side, and then incise the cartilage through the fracture line from the contralateral side. At this point, the surgeon can carefully peel the cartilage from the overlying mucosa (rather than lifting mucosa off cartilage as we are more accustomed to doing) and frequently complete flap elevation free of tears. It is critical to recognize, however, that severe angulations, particularly if they extend right up to the nasal dorsum, are often best dealt with and reconstructed through an external rhinoplasty approach to obtain optimal correction. In such cases, the surgeon is obliged to consider preoperatively whether or not he or she is likely to succeed with the correction of such a nasal airway endonasally before subjecting the patient to an operation through an approach that might have a higher risk of failure. Raising the mucosa from within very deep grooves (Fig. 2.2)—often seen over the maxillary crest on the side contralateral to the obstructed airway—is fundamental to opening the midline space if one hopes to enable the cartilage to assume a true midline position at the end of the operation. The surgeon needs to develop a comfort level with elevating mucosa from within such grooves so that they are seen as an obstacle to deal with rather than as a deterrent to avoid. As noted earlier, the hydrodissecting effect of the local anesthetic injection will occasionally be very helpful in ballooning the mucosa from within the groove to facilitate easier flap elevation. Generally, I have found that the best approach is to begin by elevating the flap from dorsally down to the groove that generally lies at the maxillary crest. The next move is to begin at the most anterior aspect of the crest (toward the anterior nasal spine) and dig an elevator into the bone on the flat, lateral (vertical) aspect of the crest. From here, a tunnel can be elevated inferior to the level of the groove, working from anterior to posterior. At this point, there will be a flap elevated dorsal to the groove and a tunnel below the groove with the remaining mucosa tethered only within groove itself. The two tunnels can then be joined by teasing the mucosa from within the groove, working from front to back using the broad aspect of the elevator. Using this approach, one will consistently succeed in elevating mucosa from within deep grooves without any tears. If instead the surgeon attempted to elevate from the dorsum down the cartilage and through the groove (without elevating the inferior tunnel first), the tension with which the mucosa is bound into the groove will almost always lead to a tear in the septal mucosa. Once the flaps are elevated, I then proceed with a broad intraoperative assessment of where the various septal deflections center and what deforming forces or structures need to be overcome to realign the septum. To ensure success with this operation, it is critical that the surgeon must have a system in place for evaluating the nasal airway as the surgery progresses. Such a system should be routinely applied for each and every case and referred to throughout the case. In most operations, the surgeon knows the end point of the surgery (e.g., tonsillectomy), what has to be removed to get there (e.g., tonsils), and how to visually evaluate the surgical field to know when the surgery is “complete” (e.g., both tonsils removed, hemostasis in tonsil bed). In septoplasty surgery, the end point is clear (a straight septum and patent nasal airway), but what has to be removed to get there is not at all clear. In fact, it can vary greatly from one case to the next. So how does P.13 one know when the surgery is “over?” Having a mental checklist that the surgeon applies throughout the case will insure that the surgeon's attention is focused in a deliberate and thoughtful way so that if something more needs be removed or reconstructed it is attended to and so that little or nothing is overlooked. If the surgeon is committed to this kind of routine inquiry, success rates will improve. The mental checklist that I use asks the following questions: Is the nasal airway open posteriorly? Is the nasal airway open up through the nasal valve?

Is the airway open along the floor of the nose? Is the caudal septum straight and maintaining a midline position? The back of the nose, nasal valve, floor of the nose, caudal septum. Structures further posterior in the nose (i.e., bony septum) can be removed or altered with less concern for detrimental effects on dorsal or tip support than is the case for structures positioned more anterior or caudal (i.e., quadrangular cartilage). In addition, often adjustments made further posterior in the nose (e.g., removal of bony septum) reduce the torque of those parts of the septum on more caudally positioned segments, allowing them to better align and thus enabling adjustments in one's intraoperative strategy in response to that effect. The latter may lead to preservation of more cartilaginous support in some cases. Finally, working from back to front will leave maneuvers that are potentially more destabilizing (adjustments to the caudal septum) until last. If the caudal septum has to be reinforced, reconstructed, replaced, or adjusted in any way, it is preferable not to have to a whole lot of work remaining to be done further posteriorly in the nose that can potentially jeopardize the stability of that reconstruction. Once the assessment is complete, the quadrangular cartilage is routinely separated from the bony septum (perpendicular plate of the ethmoid) posteriorly (Fig. 2.3A and B). Only if the perpendicular plate is felt to be perfectly straight is this not done (as in, e.g., a patient whose sole obstruction is within the caudal septal P.14 segment), but in the more “typical” septal deviation, this is done routinely. The separation is taken quite far anteriorly to within 1 to 1.5 cm of the dorsum, but not so far as to disarticulate the two altogether.

FIGURE 2.3 A: Endoscopic view of right nasal cavity prior to removal of deflected bony septum—note that view of right middle turbinate is completely obscured. B: Endoscopic view between mucosal flaps, from right side of the septum, prior to bone cuts. Arrow indicates perpendicular plate of ethmoid bone after separation of bony cartilaginous junction. C: Endoscopic view between mucosal flaps, from right side of the septum, after removal of deviated bony septum. Arrows indicate remaining upper and lower perpendicular plate. D: Endoscopic view of right nasal cavity after removal of deflected bony septum—right middle turbinate is now easily visible. (S, septum; M, mucosal flap; C, quadrangular cartilage; MT, middle turbinate) Superior (anterior or dorsal) and inferior (near the maxillary crest) incisions are made in the bone using doubleaction scissors, and the intervening segment is removed with the double-action rongeur (Fig. 2.3C). The bony resection is not often conservative, and it is important to understand the underlying rationale for this. The bone and the quadrangular cartilage are joined at a suture line. The rigid bone will naturally dictate the position of the softer, more pliable cartilage rather than the opposite way around. If the bone is at all off center, and the two are left attached, it will force the alignment of the cartilage off center making it impossible to achieve a straight septum. For this reason, the bony septum must be addressed in a more definitive fashion. To leave it completely intact or to just nibble at it inferiorly in the nose will inevitably lead to failure in circumstances in which the bony septum is noticeably off center. The impact of the position of the bone on the cartilaginous alignment must therefore be diminished in a meaningful way (Fig. 2.3D).

Bone spurs in the inferior aspect of the nose posteriorly (vomer) should be identified and addressed. To get the angle to do so surgically might first require removal of some of the cartilage or the maxillary crest. Regardless, once the bone work is complete, one should be able to visually confirm that the nasal airway is open posteriorly (see mental checklist discussed earlier). I continue to evaluate the alignment of the septum for position, curves and angulations. Typically, if the cartilage remains displaced, I make incisions within the cartilage parallel to the dorsal septum and parallel to the caudal septum using a no. 15 blade. At the very least, a 1-cm cartilaginous strut must be preserved dorsally and caudally for dorsal and tip support, although by no means does this imply that all patients should be reduced to this extent. The cartilaginous resection can be done incrementally with interval assessment of the nasal airway, taking more if necessary. However, if I anticipate requiring cartilage for supportive or replacement grafting, it is often wise to plan a maximal harvest (to 1 cm struts) so that one has sufficient cartilage with which to fashion the necessary grafts. If desired, once grafting is complete, unused straight segments of cartilage can always be repositioned between the septal flaps prior to closure (above the caudal strut and behind the dorsal strut so as to avoid overlap) to leave the patient with greater midline support of the nose. Referencing the mental checklist, at this point the surgeon should ask “Is the nasal cavity open up through the nasal valve?” This involves examining the nasal cavity (not between the flaps, but the nasal airway itself) anteriorly (i.e., toward the dorsum) through the nasal valve angle. Care should be exercised to not mistakenly place a speculum too far back in the nose or open it too wide because in either case one may actually bypass that area or stent it open. Think of what the patient breathes through, and try to insert the speculum just far enough and open just wide enough (but not more) to afford a view of that area. I use the root of the middle turbinate as a useful visual landmark for this part of the evaluation. If the root of the middle turbinate is easily visualized, I am reassured that air will pass easily through the internal valve region. If there is even a hint of the root of the middle turbinate being visually obscured, then more action is necessary. Frequently in such circumstances all that is required is to take slightly more of the perpendicular plate of the ethmoid bone (often resecting only what is contained within one bite of the rongeur) or slightly more reduction (4 to 5 mm) of the dorsal septal strut, assuming resection to this point has not been maximal. This can often make a noticeable and substantial difference in patency of the angle of the nasal valve and confirm for the surgeon that the nasal airway is now open up through the nasal valve. A reassessment of the nasal airway then follows. Is the airway open along the floor? If the airway is open along the floor and no bone spurs exist, then no action is required. However, if there is a significant bone spur impinging on the nasal airway or nasal vestibule, removal of the spur is advised. It is important to insure that the mucosal flap is reflected off of the lateral aspect of the maxillary crest. The height of the crest is then reduced and the bone spur resected using either a double-action rongeur or straight chisel. A reassessment of the nasal airway follows once again. Is the caudal septum straight and maintaining a midline position? In some cases, this will be obvious. The caudal strut might be angulated or bent to one side along a fracture line through it, or it may be grossly torqued or twisted on the dorsal septal strut. In others, a subtle bend or bowing of the caudal septum—anchored posteriorly at the anterior nasal spine and anteriorly to the dorsal septal strut—may be less apparent. This can often be overlooked when the surgeon inserts the nasal speculum, inadvertently pushing the bowed caudal septum to the opposite side to see what looks like a patent airway and then repeating the same exercise on the opposite side (now pushing the bowed caudal septum over the other way). By inadvertently displacing the caudal septum with the speculum, the examiner falsely sees both sides of the airway as being patent. Instead, one should view the nasal vestibule/caudal nasal airway without a speculum in place. If it seems like one side looks narrower, the surgeon should palpate or nudge the caudal strut on that side with a Cottle elevator to see if it “snaps” or springs into the opposite side of the nose. If indeed the caudal septum does so, now resting in the previously “open” side, the surgeon should recognize that the caudal septum

is bowed to one side or the other. A bowed caudal septum can impinge upon the nasal valve angle anteriorly toward the nasal dorsum. Techniques for correcting caudal septal abnormalities can be simple or very complex giving rise to a litany of techniques that have been described in the literature. Suffice it to say, however, that most nasal surgeons will agree that this segment of the septum is perhaps the most frustrating, vexing and troublesome to address. As the caudal segment functions as a support mechanism for the tip and dorsum is it is only natural that manipulating P.15 the deviated caudal septum should provoke some uneasiness in the operating surgeon. For this reason— because manipulation of the caudal septum can be destabilizing—I prefer to do this part last in the sequence of correcting the airway. The idea is to not have work to be done further posteriorly in the nose once the caudal septum is corrected and stable in a midline position so as to minimize any undesirable disruption of that segment. It should be stated here that the correction of severe caudal septal deflections—which should be readily apparent to all clinicians on preoperative evaluation—should be undertaken only by those surgeons very experienced in reconstructive nasal airway surgery and in many cases functional rhinoplasty techniques. It can often involve explanting the caudal strut altogether and rebuilding it in an extracorporeal fashion before replacing it. To do so, one must be comfortable with that degree of disruption of nasal support and with reestablishing proper and enduring support in the nose upon completion of surgery. A complete description of all such advanced structural rhinoplasty techniques is beyond the scope of this chapter. However, if upon examination the caudal septum is simply tilted off the midline or has a gentle bowing to one side or the other, a very effective correction can reasonably be achieved in a much simpler fashion. So the onus is on the surgeon to determine preoperatively, as much as is possible, whether the patient has a caudal septal deflection that might be corrected with straightforward endonasal techniques or whether the deformity is more likely to require a more complex caudal septal reconstruction (Fig. 2.4). In order to reposition the caudal septum over the nasal spine in the case of the caudal septum mildly subluxed or tilted off (lateral to) the anterior nasal spine, the strut typically has to be shortened—nominally. With elevation of bilateral mucosal flaps, the surgeon has completely freed up the midline space to allow room for that shift in position to occur. The caudal septum is then straddled with a medium speculum to maximize visibility and access. Excision of a narrow wedge of cartilage from the posterior aspect of the strut where it lies lateral to the anterior nasal spine will allow the caudal segment to be moved back into the midline (Fig. 2.5). One should excise only as much cartilage as is necessary to allow the caudal segment to be moved back into position on top of the crest and no more. This is often done incrementally to prevent overresection. The goal is to have the septum resting atop the crest, but not hanging or swinging freely well above the anterior nasal spine. Typically the excision is no more than 2 to 3 mm. I generally do it in a wedge-shaped fashion (wider cephalically and narrower caudally toward the most inferior part of the caudal septum) to minimize the actual amount of resection along the caudalmost edge. Any time that that the caudal septum is reduced in this fashion, there is a risk of posterior shift (retrodisplacement) of the caudal segment with settling of the supratip dorsum and a subtle but visible dorsal depression. It is for this reason that the resection must be minimized to only as much as is necessary. Furthermore, before doing any such resection the surgeon should look at the nose and very critically assess the height of the nasal dorsum in profile so that even a mild settling can be appreciated. If reducing the caudal septum has created a dorsal depression, a gently morselized thin cartilage onlay graft can be fashioned from cartilage that has been removed and placed into position through an intercartilaginous incision to camouflage and correct the secondary deformity. If upon inspection, rather than tilting the caudal septum appears to gently bow to one side or the other as it

extends from the anterior septal angle to the anterior nasal spine, it should be apparent that the segment is too lengthy along its anteroposterior vector. This is effectively what creates the arc, or bowing of the caudal strut. In such a case, two options exist. One option is to once again shorten the caudal strut—nominally—above the anterior nasal spine (Fig. 2.6). This will release the spring that exists in the bowed segment, and by shortening it allow that segment to straighten out along the anteroposterior vector and resume the normal anatomical position in the midline tension free. The other option that should be considered arises if the caudal bowing is in fact more of an angulation of the caudal strut (rather than a curvature) such as one might see along a fracture line. In this instance as well, the caudal segment is too lengthy along its anteroposterior vector. Under these circumstances, however, removing a small wedge of cartilage just above the anterior nasal spine would allow the angulation to persist. It is preferable, P.16 P.17 therefore, to not disrupt the attachment to the anterior nasal spine and instead transect the caudal strut through the fracture line (along a cephalocaudal vector). The caudal strut is thus divided into two pieces—one anterior (contiguous with the dorsal strut) and one posterior (attached at the nasal spine) (Fig 2.7). The two segments can then be overlapped and sutures secured to one another, which will take out the excess length and at the same time strengthen the caudal strut by virtue of the overlap. Generally one has to trial the two overlap options (the anterior segment to the right of the posterior segment and vice versa) to determine which is more favorable in terms of airway patency before suturing the overlap.

FIGURE 2.4 Caudal septal deflections—the patient on the left with mild-moderate left-sided caudal septal tilt that may be amenable to endonasal correction. On the other hand, the patient on the right has severely angulated caudal septal segment to his right that is more likely to need reconstruction/replacement via an external rhinoplasty approach.

FIGURE 2.5 For the caudal septum tilted off the anterior nasal spine (A), a very conservative cartilage wedge excision will allow the caudal septum to reposition in the midline (B). Care must be taken to insure that the resection is incremental and not excessive so that the caudal septum sits immediately atop the nasal spine.

FIGURE 2.6 Conservatively shortening the bowed caudal septum (A) above the anterior nasal spine will release the bowing and allow for the bowed caudal segment to release, straighten, and adopt a midline position (B).

FIGURE 2.7 The angulated caudal septum can be divided at the apex of the angulation (A). The anterior and posterior segments can then be overlapped and suture secured, or aligned end-to-end and stabilized with an

overlying sutured-in-place reinforcement graft (B). With such maneuvers, attention must be paid to preservation of dorsal support and dorsal height. The surgeon can choose to avoid an overlap altogether and size the two segments to fit end-to-end by resecting the overlap excess. In this case, the overlap is reinforced and stabilized by fashioning a reinforcement batten graft from harvested cartilage to span the two segments and suturing that in place over the two segments on one side or the other (Fig. 2.7). Again, one must pay attention to dorsal septal height on profile prior to any such manipulation. In either case where the septum might be shortened above the anterior nasal spine—the tilted or bowed caudal septum—once the caudal strut sits centered on the nasal spine tension free it can be suture-fixated to the soft tissue in that region for added security, although this is not absolutely necessary. Quilting the septal flaps from either side to one another across the caudal segment will confer the necessary stability to the caudal strut, as will the attendant scar tissue that develops naturally as part of the healing process. If proper care has been exercised to insure that the caudal segment is properly positioned on the nasal spine and not floating, then it should heal in the midline between the flaps. Although it might add further stability, the risk of suturing to the soft tissue over the anterior nasal spine is inadvertently pulling the caudal segment too far posteriorly, which might create a secondary supratip dorsal depression. P.18 As regards the caudal septum, however, the reader should be cautioned that the variants described herein (tilt, bowing, angulation) do not represent all possible variants. In particular, severe angulation or angulation where the apex of the angle extends all the way out to the nasal sidewall should be recognized preoperatively as one that might require construction of a complete replacement graft and placement either endonasally or through an external rhinoplasty approach. Likewise the caudal strut that is severely twisted or torqued off the axis of the dorsal septal strut. Put simply, the more extreme or displaced the caudal deformity, the more likely it is to require more complex intervention. The surgeon uncomfortable with such techniques is strongly encouraged to refer such patients rather than intervene and potentially fail. To fail risks leaving the revision surgeon with very little usable cartilage for construction of graft material and often having to harvest cartilage from a second site (ear, rib). Finally, a reassessment of the nasal airway is once again carried out. Is the nasal airway open posteriorly? Up through the nasal valve area? Along the floor? At the caudal septum/nasal vestibule? If minor adjustments are needed at this point, they are addressed. Once the surgeon is satisfied with the alignment of the septum, the septal flaps are reapproximated to one another with a through-and-through quilting 4-0 plain gut suture. Quilting the septal flaps helps control edema, eliminate dead space, and allow for closure of any incidental mucosal tear. I feel that by eliminating the dead space the potential for septal hematoma is minimized and that prevention of blood/fibrin clot from accumulating between the flaps limits the chance that such clot might promote further scar tissue, thickening the septum and leading to space compromise. The hemitransfixion incision is closed with simple interrupted 5-0 chromic or 5-0 plain gut sutures. Silastic (Doyle) splints are placed in each side of the nasal cavity to further stabilize the septum and control edema. These are secured in place with a single through-and-through 3-0 Prolene suture. A small 2 × 2-inch gauze drip pad is taped in place beneath the nose, and the patient is then roused from the anesthetic and taken to the recovery room.

POSTOPERATIVE MANAGEMENT Discharge medications routinely include a 7-day course of antibiotics to cover the patient while the splints are in place. Typically Amoxil 500 mg t.i.d. is used, or in the penicillin-allergic patient azithromycin is a reasonable

alternative. Oral analgesics are prescribed. The patient is advised to avoid blowing the nose and not to take medications that might promote bleeding such as aspirin-containing products or nonsteroidal anti-inflammatory drugs. Instructions are given to clean the nasal vestibule of dry, caked blood three to four times daily using a cottontipped swab soaked in hydrogen peroxide for swabbing the inside of the nostril. This is followed by application of an antibiotic ointment to the nasal vestibule on a cotton swab. All of this is done caudal to the nasal splints. The patient is asked to irrigate the nasal splints with a saline solution four to six times daily in order to keep the splints clear. An 8-ounce bottle of over-the-counter saline rinse (NeilMed Sinus Rinse) is used completely for each irrigation. Anecdotally, patients using this technique have reported much greater comfort and much more success at keeping their splints clear right up until splint removal as opposed to those using an over-the-counter saline spray. The patient is seen 5 to 7 days postoperatively for removal of the splints. The patient is then free to resume his or her usual activity. If there are no particular concerns at that point, then further follow-up is scheduled for approximately 6 to 8 weeks thereafter.

COMPLICATIONS Potential complications of surgery should be covered with the patient in a preoperative discussion of informed consent as noted earlier in this chapter. Excessive bleeding (approximately 1% to 2% incidence) may settle with a nasal decongestant spray or packing with an absorbable hemostatic mesh (Surgicel) placed over and lateral to the nasal splints. In the face of substantial bleeding, however, splint removal may be necessary in order to better examine the nasal cavity and manage the bleeding site directly whether with cautery or packing. In some cases, a return to the operating room and endoscopic evaluation is warranted to enable definitive management. Bleeding between the mucosal flaps can lead to a septal hematoma. The attendant separation of the vascular mucosa from the underlying septal cartilage increases the risk of cartilage necrosis and loss of septal support. This is followed by the development of a supratip depression or saddle deformity. Insuring proper hemostasis prior to closure is critical. Through-and-through septal quilting sutures offer the additional advantage of closing the dead space between flaps, thus decreasing the likelihood of hematoma and flap separation. Treatment of a septal hematoma demands reexploration for evacuation of the clot and management of any obvious discrete source of bleeding. Sinusitis (approximately 2% to 5% incidence) can result from the mechanical obstruction of sinus outflow tracts due to surgical edema and the splints themselves. In such cases, patients may report drainage beyond P.19 normal surgical expectations, malodorous drainage, facial/dental pain and pressure or the delayed presentation (1 to 2 weeks post-op) of increasing nasal congestion despite a patent nasal airway in the earlier postoperative period. Treatment is the same as that for a routine sinusitis. Septal perforations may not be readily apparent at first follow-up. Most commonly, perforations result from traumatic elevation of the mucosal flaps with opposing tears in the flap on either side. Careful and meticulous elevation of the flaps is the key to prevention as is making the effort to close any mucosal tears at the end of surgery when quilting the septum. Small perforations with well-mucosalized edges may not require any intervention at all, and may not have any impact on the nasal airway per se. Patients are advised in the application and use of topical emollients to minimize potential bleeding or crusting. Surgical repair of a septal perforation, if indicated or desired, is delayed well beyond the initial healing period (6 to

12 months at a minimum). Changes in the external appearance of the nose are uncommon but can occur. Typically this would be a slight settling of the dorsal septum reflecting a loss of underlying support that manifests as a supratip depression. This usually has more of a cosmetic than functional implication and can easily be corrected if the patient is bothered by it, with the use of cartilaginous dorsal onlay grafting through an endonasal approach. Anosmia or hyposmia is most often temporary and edema related. Permanent anosmia resulting from nasal surgery, as reported in the literature, is very uncommon (quoted at approximately 1 in 1 million). Persistent symptomatic septal deviation (nasal obstruction) may be apparent early or may present at a later date. The surgeon owes it to the patient to reexamine the nasal airway in a thoughtful and open-minded fashion with particular attention paid to the nasal valve areas. I have seen many patients who would benefit from revision surgery with legitimate persistent (and correctable) structural issues who expressed frustration and anger toward their primary surgeon who they felt to be dismissive of their concerns. Revision surgery, if warranted, should be done by a surgeon well experienced in such cases and typically not before 6 months after the initial surgery.

RESULTS Nasal airway obstruction is one of the most frequent presenting complaints to the otolaryngologist. Deviations of the nasal septum are extremely common—in fact, anatomic studies of human skulls have reported that 75% to 80% of all humans have a septal deviation to some degree. Accordingly, it should come as no surprise that septoplasty is one of the operations most frequently performed by otolaryngologists throughout the world. Outcomes reported in the literature have been widely variable but often hover in the range of 70% patient satisfaction rates. Much of the literature predated our understanding and appreciation of the nasal valve and the importance of valve patency and stability to the nasal airway. Furthermore, many reports in the literature were plagued by limitations in study design (e.g., retrospective; chart reviews), use of nonvalidated outcome measures (e.g., physician ratings; telephone questionnaires), or use of validated outcome measures not specifically targeting nasal obstruction. In 2004, Stewart et al introduced a validated outcome measure specific to nasal obstruction known as the NOSE scale (Nasal Obstruction Symptom Evaluation). Since that time, the NOSE scale has been increasingly used to evaluate interventions on the nasal airway, and the surgeon is encouraged to use such an instrument pre- and postoperatively to track his/her own outcomes. The single most important fundamental to improving results as discussed earlier is identification of those patients in whom the application of traditional septoplasty techniques are likely to fail. This is something that should be apparent to the thoughtful clinician preoperatively and not something that the surgeon grudgingly concedes intraoperatively. The implications of failure of the primary operation go well beyond persistent nasal obstruction alone. Prior surgical intervention, mucosal scarring, flap thinning, prior cartilage harvest, and alteration of the microcirculation can set the stage for a difficult revision scenario with more limited surgical options and potential compromise in outcome as compared to a properly executed primary operation. On the other hand, outcomes can be very favorable, complications acceptably low, and patient satisfaction rates very high—well beyond 70%—if the surgeon abandons the one-size-fits-all mentality and instead consistently employs a structured, systematic process that responds to the unique variables of each patient

as described herein.

PEARLS Rigorous preoperative evaluation applied routinely will allow the surgeon to better classify and describe each and every septal deformity in specific terms. Documenting a more detailed description of the anomaly will ultimately beget more targeted thinking of what is likely to be necessary to correct the problem surgically. Palpation of the caudal septum will often reveal subtle yet clinically relevant deformities as well as provide information about the integrity and strength of the underlying cartilage. Understanding the anatomy and evaluation of the nasal valve (internal and external) and examining inspiratory stability of the nasal sidewall are critical parts of the comprehensive evaluation of structural nasal airway issues. P.20 If the deformity in question is one in which more advanced reconstructive techniques are likely to be required (e.g., complex caudal septal deformity, severe septal angulations/deviations in regions critical to nasal support, deformities better served with reconstruction than resection), an external rhinoplasty approach may be required for optimal correction. In these cases, the surgeon should be comfortable using structural rhinoplasty techniques before undertaking such patients. Elevation of complete bilateral submucoperichondrial and submucoperiosteal flaps offers the distinct advantages of unparalleled exposure, full release, and uncompromised access to the underlying septal cartilage and bone. Obliging oneself to a mental checklist as surgery progresses—in all cases—will hold the surgeon more accountable and help the surgeon better identify areas within the nasal airway intraoperatively where attention might still be needed. With a checklist, areas of persistent deviation are less likely to remain unappreciated and unattended. This will improve outcomes. Commitment to proper postoperative care must be stressed to the patient as an important part of the process.

PITFALLS The most frequently seen areas of persistent deviation in revision septoplasty are in the residual dorsal strut (impinging on the internal nasal valve) or the residual caudal strut (impinging on either the internal or external nasal valve). Failure to identify properly these critical areas preoperatively or to address them intraoperatively will significantly increase the likelihood of failure and persistent nasal obstruction postoperatively. Treating the caudal septum as something sacred or untouchable will not only leave caudal septal deformities uncorrected but can complicate subsequent revision surgery. An approach to the simpler caudal septal deflections is described herein. More complex caudal septal reconstruction or complete replacement is indicated in some cases, and the surgeon should be comfortable with those or refer those cases to an otolaryngologist more skilled in complex nasal airway surgery. Injudicious elevation of the septal flaps, particularly over areas of high risk (severe angulation, spurs) will increase the risk of mucosal tears and septal perforations. The surgeon must refine the technical aspect of flap elevation and close incidental tears at the time of quilting the septal flaps as often as possible.

INSTRUMENTS TO HAVE AVAILABLE Standard Septoplasty Tray

1% lidocaine with 1:100,000 epinephrine Nasal decongestant spray (oxymetazoline or equivalent) Nasal specula (short, medium, long) Woodson and Cottle elevators Fraser tip suctions Bard-Parker no. 15 blade and scalpel Brown Adson forceps, toothed Adson forceps, bayonet forceps Double-action scissors Double-action rongeur 4 and 6 mm straight chisels Mallet Straight and curved small hemostats Needle drivers Small hooks (Guthries)—2 Wide double hook Ragnell retractors Small 4.5 inch iris scissors Suture scissors Sutures: 4-0 plain gut, 5-0 plain gut or chromic, 3-0 Prolene. possibly 4-0 polydiaxone, possibly Keith needles. Doyle splints Surgicel

SUGGESTED READING Gray LP. Deviated nasal septum: incidence and etiology. Ann Otol Rhinol Laryngol 1978;87:1-20. Stewart MG, Witsell DL, Smith TL, et al. Development and validation of the nasal obstruction symptom evaluation (NOSE) scale. Otolaryngol Head Neck Surg 2004;130:157-163. Dobratz EJ, Park SS. Septoplasty pearls. Otolaryngol Clin North Am 2009;42:527-537.

3 Endoscopic Septoplasty John M. Lee

INTRODUCTION Nasal septoplasty is one of the operations most frequently performed by otolaryngologists throughout the world. Whether it is done for the correction of septal deviations causing nasal obstruction or for improving access to the paranasal sinuses, this operation is one of the oldest procedures described in the surgical literature. Traditionally, this technique is performed with a headlight and nasal speculum and is considered a fundamental skill for junior trainees. However, with the advent of nasal endoscopy, the technique of endoscopic septoplasty was soon developed and first described in the early 1990s. Over the last 20 years, this modification of the traditional septoplasty has gained significant interest and popularity. Advantages of endoscopic septoplasty primarily rest on the improved illumination and visualization afforded by the endoscope, enabling the surgeon to more precisely evaluate and surgically correct the deviated nasal septum. This technique also offers a seamless transition when performing concurrent procedures such as endoscopic sinus surgery. Perhaps as importantly, this technique using better visualization has significantly improved the education of the surgical trainee. In the traditional headlight technique, it is very difficult for an observer to see and appreciate what the surgeon is actually doing, a limitation that also hinders appropriate surgical supervision. However, the endoscope provides an unparalleled view of the anatomy of the septum, allowing for a greater appreciation of this technique. In this chapter, specific indications for endoscopic septoplasty are reviewed and the practical steps for performing this procedure are discussed focusing on the key pearls for optimizing successful outcomes.

HISTORY A thorough rhinologic history is of fundamental importance when evaluating any patient with a suspected sinonasal problem. This is especially important in the context of a septal deviation, as symptoms may not always match the findings on physical examination. In fact, this may be the biggest pitfall in performing septoplasty: The presence of a septal deviation is not an absolute indication for surgical correction. Documenting the history carefully will allow the surgeon to identify the patient who will benefit from septal surgery. To this end, the first determination is whether patients are being evaluated for nasal airway symptoms or are there other concurrent sinonasal problems as well. If nasal obstruction is the primary concern, the side of obstruction, timing, and severity should be clearly elicited. The ideal candidate for septoplasty should have obstructive symptoms that parallel the side of the deviation. Issues of nasal congestion can be tricky, as this can reflect the dynamic and reactive nature of the nasal mucosa, something that is not addressed with surgery. In this regard, many patients will undergo a trial of conservative measures such as nasal steroid sprays prior to the consideration of septoplasty. Similarly, any suspected environmental allergies should be properly evaluated and treated. P.22 Many patients with a septal deviation may not have any significant obstructive symptoms. Instead, they may be under investigation for other rhinologic issues, including epistaxis, chronic rhinosinusitis, or a skull base tumor. While a deviated septum can be a contributing factor in the etiology of epistaxis or obstruction of the osteomeatal complex, this anatomical finding may be incidental on physical examination. Nonetheless, the septum may still need to be treated surgically as it may prevent adequate endonasal access to the

paranasal sinuses or the skull base. Finally, patients should also be asked if they are seeking a consultation for any external/cosmetic changes to the nose. If so, it is preferable to correct a deviated septum during a formal septorhinoplasty approach (not discussed in this chapter). It is also important to ascertain if there is any history of prior nasal surgery, recreational nasal drug use, or a history of autoimmune conditions.

PHYSICAL EXAMINATION In patients with a suspected septal deviation, a complete examination of the nasal cavity is required, and this begins with inspection of the external nose. While an exhaustive cosmetic analysis is not required, it is important to document the presence of a twisted nasal bridge, external valve stenosis, or collapse of the internal nasal valve (i.e., with a Cottle maneuver). All of these findings may contribute to the symptoms of nasal obstruction, which may not resolve with septoplasty alone. The examination of the nasal cavity is first performed with a nasal speculum and a headlight. This allows for a good assessment of the caudal septum. As I will discuss later, significant caudal deflections are a relative contraindication for endoscopic septoplasty. The headlight examination also allows for a general overview of the configuration of the nasal septum (e.g., midline, S-shaped, or C-shaped). A thorough nasal endoscopy should then be performed to carefully document the presence of a broad septal deviation or an isolated septal spur. This should be done after appropriate decongestion has been obtained and a topical anesthetic has been applied. Endoscopy allows for an appreciation of the nasal airway without any external manipulation (i.e., with a speculum). While there have been several classification systems proposed for documenting the type and degree of septal deviation, none are universally used. From a nasal airway perspective, the most important assessment is whether the extent of the septal deviation could account for symptoms of nasal obstruction. As a general rule, this may occur when a deviation or spur severely limits the inspection of the entire nasal anatomy. Anterior deviations may prevent adequate inspection of the middle turbinate and meatus while posterior deviations may prevent visualization of the nasopharynx. For revision cases, palpation of the septum with a cotton tip applicator may help with estimation of how much residual cartilage or bone is present. Endoscopy also allows for documentation of any concurrent sinonasal findings, including the presence of nasal polyps, hypertrophy of the inferior turbinate, and the presence of adenoid tissue or a neoplasm in the nasopharynx. All of these issues may contribute to problems of nasal obstruction and may need to be addressed. If endoscopic sinus surgery is being considered, the need for concurrent septoplasty should always be entertained if it appears that visualization or access to the middle meatus will be hindered both during surgery and in the postoperative period.

INDICATIONS Indications for endoscopic septoplasty can largely be classified into obstructive or access-related issues. The following is a list of the most common indications for endoscopic septoplasty: Broad septal deviation or isolated septal spur causing nasal obstruction (primary or revision) Septal perforation with concurrent symptomatic septal deviation Septal deviation/spur limiting endoscopic access for other endonasal procedures (e.g., endoscopic sinus or skull base surgery)

Septal deviation/spur contributing to refractory epistaxis

CONTRAINDICATIONS Endoscopic septoplasty should not be employed in isolation if there are anatomical abnormalities requiring an open septorhinoplasty approach. This includes a significant caudal septal deviation or a severely twisted nose. The endoscopic approach does not enable adequate manipulation of the caudal septum, and the advantages of visualization and illumination are obviated with external techniques. However, the endoscope can always be brought into the field as an adjunctive technique to evaluate the rest of the nasal airway. P.23

PREOPERATIVE PLANNING For a symptomatic septal deviation or spur, the only preoperative decision that must be made is whether the anatomical problem can be addressed with an endoscopic approach. As previously mentioned, caudal deflections often require an external technique to adequately reposition or reconstruct this area of the septum. If the decision is made to proceed with endoscopic septoplasty, there is little additional investigation that is required. Of course, this is dependent on the adequacy of the endoscopic examination preoperatively to thoroughly inspect the nasal cavity. If there is any suspicion of concurrent sinonasal conditions, such as chronic rhinosinusitis, a computed tomography scan of the paranasal sinuses is recommended for preoperative planning. This imaging modality can also be helpful in cases of revision septoplasty when it is not obvious how much bone remains in the septum. I strongly recommend that any suspected nasal mucosal inflammation be optimized prior to surgery. Addressing these problems can help with patient expectations and outcomes following surgical intervention. Adjunctive investigations such as acoustic rhinometry or rhinomanometry may be considered if it is still not entirely clear whether the obstruction is caused by mucosal inflammation or a fixed anatomical problem.

SURGICAL TECHNIQUE Broad Septal Deviation Both nasal cavities are decongested with pledgets soaked in either oxymetazoline or topical 1:1,000 epinephrine. A 0-degree endoscope is used to inspect the nasal cavity and confirm the previously documented septal deviation (Fig. 3.1). Under endoscopic guidance, both sides of the septum are injected with 1% xylocaine with 1:100,000 epinephrine in a submucoperichondrial plane in the area of anticipated flap elevation. A standard hemitransfixion or Killian incision is made for broad septal deviations. This is usually performed with a nasal speculum and a no. 15 blade with an overhead operating room light for illumination. As a righthanded surgeon, I prefer to try and make the incision on the left side of the nose to facilitate easier elevation of the flap regardless of the side of deviation. Conversely, the incision can be made opposite to the side of maximal septal convexity to minimize the risk of mucosal tears. Initial elevation of the flap is performed using a Freer elevator nonendoscopically to establish the correct submucoperichondrial plane. The depth (anterioposterior) of the flap does not need to be very long (approximately 1 cm), but it is important to establish the correct plane across a broad front.

Once the plane is established, the 0-degree endoscope is used to continue flap elevation under direct visualization. If available, a suction Freer elevator can facilitate this maneuver. Using the blunt end of the Freer, the technique involves sweeping the mucosal flap away from the septum in a superior-to-inferior direction (Fig. 3.2). The extent of flap elevation must be adequate enough to enable full access to the deviated portions of the quadrangular cartilage or the bony septum. In this regard, it is often advantageous to elevate the flap inferiorly down to the floor of the nose and the maxillary crest. The mucosal fibers in this region are particularly P.24 adherent to the underlying bone, and extra care is required to prevent tearing of the flap. It is important to note that it can be disorientating for junior trainees when elevating the septal mucosal flap superiorly, and caution must be taken when close to the skull base.

FIGURE 3.1 Endoscopic view demonstrating a broad right-sided septal deviations, obstructing the nasal airway and preventing visualization of the middle turbinate and meatus.

FIGURE 3.2 Elevation of a left submucoperichondrial septal flap with a Freer elevator. With one flap successfully elevated, I make a vertical incision in the septal cartilage anterior to the point of maximum septal deflection. This incision is stair stepped from the mucosal incision to minimize the chance of a through-and-through tear of the mucosa. Furthermore, it is important to maintain at least 1 cm of caudal septal cartilage to ensure adequate support of the tip. Using a no. 15 blade or a Freer elevator, the incision is carried through the full thickness of the cartilage, taking great care not to tear the mucosa of the contralateral side of the septum. The length of the cartilage incision should be broad enough to enable manipulation of the deviated portions of the septum (Fig. 3.3). A contralateral mucosal flap is then elevated under endoscopic guidance with the same technique as previously described (Fig. 3.4). With both flaps elevated, the deviated portions of the septal cartilage and bone can be removed in a targeted fashion (Fig. 3.5). A swivel knife is often helpful for removal of the inferior parts of the deviated P.25 cartilaginous septum. The septal bony-cartilaginous junction can then be disarticulated with a Freer elevator, allowing for the remaining cartilaginous septum to be swung back to midline. A Jansen-Middleton forceps can then be used to sharply remove the deviated portions of the bony septum. Great care must be taken to not twist the perpendicular plate of the ethmoid bone as theoretically this may result in a fracture of the skull base.

FIGURE 3.3 Using a no. 15 blade to make an incision in the septal cartilage, stair stepped with the hemitransfixion incision.

FIGURE 3.4 Elevating a contralateral submucoperichondrial septal flap on the right side. Throughout this entire process, the endoscope is routinely moved in and out of the septal flaps to inspect the nasal cavity and assess the adequacy of the septoplasty (Fig. 3.6). The Freer elevator is helpful for returning the flaps to midline and palpating any areas of residual deviation (cartilage, bone, or maxillary crest). These areas can be removed sharply piece by piece with a Jansen-Middleton forceps. It is always important to preserve at least 1 cm of caudal and dorsal cartilaginous strut to maintain adequate support of the nasal tip and dorsum.

FIGURE 3.5 Using a straight throughcutting forceps to remove the deviated septal cartilage. P.26

FIGURE 3.6 Using a Freer elevator to demonstrate adequate septoplasty. Note the improved airway on the right side with improved access to the right middle meatus region. Large fragments of normal (nondeviated) cartilage removed during the septoplasty can be replaced in between the septal mucosal flaps at the end of the procedure. Once the mucosal flaps are reapproximated in the midline, the hemitransfixion or Killian incision can be closed with an interrupted absorbable suture (i.e., 4-0 chromic). A quilting (transseptal mattress) stitch with a Keith needle and an absorbable suture is placed in cases where there are significant mucosal tears in order to ensure adequate reapproximation of the flaps. I prefer to place and suture oval-shaped Silastic stents on each side of the septum at the end of the surgery. This helps to approximate the mucosal flaps, prevent synechiae formation, and maintain a reasonable nasal airway during the postoperative period. The stents are removed approximately 5 to 7 days following surgery. Other options could include Doyle nasal splints or the placement of nasal packing.

Isolated Septal Spur For symptomatic septal spurs, a more direct approach can be employed, which minimizes the extent of mucosal flap elevation. As originally described by Lanza et al., this technique purposely creates a mucosal incision over the apex of a septal spur. These are the steps involved in this technique. Both nasal cavities are decongested with pledgets soaked in either oxymetazoline or topical 1:1,000 epinephrine. A 0-degree endoscope is used to inspect the nasal cavity and confirm the previously documented septal spur (Fig. 3.7).

FIGURE 3.7 Endoscopic view demonstrating an isolated right-sided septal spur.

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FIGURE 3.8 Using a no. 15 blade to make an incision over the apex of the spur. One percent xylocaine with 1:100,000 epinephrine is infiltrated into the submucoperichondrial plane only on the side of the septal spur. The injection is placed superior and inferior to the apex of the septal spur. Using a no. 15 blade under endoscopic guidance, a horizontal incision is made along the entire apex of the septal spur (Fig. 3.8). Superior and inferior septal mucosal flaps are then elevated using a Freer elevator (Fig. 3.9). The contralateral septal mucoperichondrium is dissected away from the superior aspect of the exposed cartilaginous or bony spur with a Freer elevator. The remaining inferior attachments are then divided, and the spur is removed from the nose. Alternatively, prominent bony spurs or the maxillary crest can be smoothed down using a powered burr. Once the spur has been removed, the superior and inferior mucosal flaps are replaced and held in place using a quilting suture with a Keith needle and an absorbable suture. Silastic splints can be used at the surgeon's discretion.

Septal Deviation in the Presence of a Septal Perforation The presence of an existing anterior septal perforation with a septal deviation posterior to it can make septoplasty challenging with the traditional headlight technique. However, endoscopic septoplasty allows the

surgeon to avoid the perforation entirely, minimizing the chance of enlarging it. Instead, the septal mucosal incision is P.28 made posterior to the perforation, and a targeted septoplasty is performed as previously described. For these posterior deviations, flap elevation can often be contained to just one side of the septum.

FIGURE 3.9 Elevating superior and inferior submucoperichondrial septal flaps with a Freer elevator.

Revision Septoplasty The endoscopic technique can be extremely useful in revision cases where there has been previous resection of the septal cartilage or bone. Finding the correct surgical plane between both sides of the septal mucosa is significantly enhanced with the improved magnification and illumination provided by the endoscope. Once the flaps are elevated, the residual deviated cartilage or bone can be safely removed.

POSTOPERATIVE MANAGEMENT Endoscopic septoplasty is routinely performed as an outpatient procedure. Following surgery, patients are instructed to irrigate their nasal cavity with saline on a daily basis to remove any residual blood and to prevent formation of crusts. Postoperative antibiotics are not routinely recommended and are left to the discretion of the surgeon. If silastic stents are placed, they are usually removed 5 to 7 days following surgery. During this postoperative visit, a thorough endoscopic examination is performed to ensure that the septum is healing appropriately and any synechiae are divided.

COMPLICATIONS Complications following endoscopic septoplasty are rare but can include the following: Bleeding Dental pain and numbness Persistent septal deviation Postoperative infection Reduced nasal tip support Septal hematoma Septal perforation Synechiae In the original series (n = 111) of endoscopic septoplasty reported by Hwang et al., the incidence of complications was low and included only synechiae formation (4.5%), perforation (0.9%), and septal hematoma (0.9%). Subsequent studies have continued to demonstrate that this technique can be performed safely with a low complication rate.

RESULTS Endoscopic septoplasty in the patient appropriately selected can provide excellent clinical outcomes. From a nasal obstruction standpoint, Chung et al., reported that 70% of patients had a complete resolution of their nasal obstruction while 20% had a partial improvement over a 13-month follow-up. The key in achieving good subjective outcomes begins with a good preoperative assessment and ensuring that the patient is a good candidate for endoscopic septoplasty. Furthermore, it is important to counsel patients regarding appropriate expectations following surgery. If there are concurrent conditions such as allergic/nonallergic rhinitis, these conditions may mitigate any objective improvements in nasal airway and patients may require continued medical or topical nasal therapy for their nasal congestion. If endoscopic septoplasty is performed to facilitate endoscopic sinus surgery, the benefits of improved access to the middle meatus are immediately seen in the postoperative period. During surgery, the ability to manipulate the middle turbinate and access the paranasal sinuses is often greater than what can be accomplished in the clinic with topical anesthesia. If required, concurrent septoplasty can significantly improve the ability to provide adequate postoperative sinus care. Finally, while transitioning to endoscopic septoplasty from the traditional headlight technique may initially seem more time consuming, the operative time quickly becomes similar after gaining familiarity with this procedure. In fact, for isolated septal spurs, endoscopic septoplasty can be done significantly faster than any traditional approach. Ultimately, the improved visualization is what makes this technique so appealing for treating deviations of the nasal septum. P.29

PEARLS Ensure appropriate candidacy for endoscopic septoplasty. Finding the correct submucoperichondrial plane during endoscopic flap elevation will minimize bleeding in the

surgical field and facilitate easier dissection with a Freer elevator. Broad flap elevation around the area of the septal deviation will minimize the risk of mucosal tears (especially near the maxillary crest or floor of the nose). Use the endoscope to routinely reinspect the nasal cavity to ensure that the septal deviation has been adequately treated.

PITFALLS Surgically treating an asymptomatic septal deviation (unless it is impairing access for a concurrent endonasal procedure) Inadequate management of allergic/nonallergic rhinitis Not addressing concurrent issues of external/internal nasal valve collapse or a severely twisted nose Applying endoscopic septoplasty techniques for significant caudal deflections Overly aggressive resection of caudal or dorsal septal cartilage

INSTRUMENTS TO HAVE AVAILABLE Freer elevator (suction Freer if available) Jansen-Middleton forceps 0-degree endoscope Irrigating sheath for endoscope (if available)

SUGGESTED READING Lanza DC, Farb Rosin D, Kennedy DW. Endoscopic septal spur resection. Am J Rhinol 1993;7:213-216. Giles WC, Gross CW, Abram AC, et al. Endoscopic septoplasty. Laryngoscope 1994;104:1507-1509. Hwang PH, McLaughlin RB, Lanza DC, et al. Endoscopic septoplasty: indications, technique and results. Otolaryngol Head Neck Surg 1999;120:678-682. Chung BJ, Batra PS, Citardi MJ, et al. Endoscopic septoplasty: revisitation of the technique, indications and outcomes. Am J Rhinol 2007;21:307-311. Sautter NB, Smith TL. Endoscopic septoplasty. Otolaryngol Clin North Am 2009;42:253-260.

4 Technique for Closure of Nasal Septal Perforation Edmund deAzevedo Pribitkin

INTRODUCTION Conditions causing bilateral disruption of the opposing nasal septal mucoperichondrium frequently result in necrosis of the underlying septal cartilage resulting in the creation of a nasal septal perforation. Successful treatment of such perforations remains a surgical challenge, including closure of the perforation and restoration of normal nasal function. No single standardized technique exists for closure of all perforations, but successful repairs generally include mucoperichondrial advancement flaps and interpositional grafts of cartilage or connective tissue. I combine either an endonasal or an open rhinoplasty approach with bilateral advancement flaps of the mucoperiosteum of the floor of the nose and an interpositional porcine intestinal submucosa graft (SurgiSIS ES Cook Surgical, Bloomington, Indiana) to achieve a 90% success rate in closing septal perforations.

HISTORY Symptoms are generally related to the size and location of the perforation. Patients may complain of nasal congestion and obstruction, nasal crusting and drainage, recurrent epistaxis, a whistling sound on inspiration, and pain. Smaller, posterior perforations tend to be asymptomatic, whereas large, anterior perforations may result in loss of dorsal support resulting in a deformity of the external nose. As perforations increase in size, laminar airflow is increasingly disrupted, resulting in turbulence and a sensation of nasal obstruction. Increased turbulent flow causes drying of the nasal mucosa with a compensatory increase in the production of mucous and complaints of rhinorrhea. Eventually, crusting and bleeding result from an inability of the mucosa to heal overexposed cartilage at the edge of the perforation. Pain often accompanies crusting and bleeding as a result of a chronic, low-grade chondritis.

ETIOLOGY The etiology of nasal septal perforations can be divided into four categories.

Traumatic Causes Prior septal surgery is the most common cause of septal perforations. Perforation rates of 17% to 25% have been reported following submucous resection and 1% to 5% following septoplasty in which cartilage is preserved. When a tear in the mucoperichondrium occurs on one side, the intervening cartilage can usually get its blood supply from the opposite, intact membrane. However, when opposing mucoperichondrial flaps have been injured during surgery to remove intervening cartilage, a through-and-through perforation is likely to develop. P.32 Immediate repair of any injured opposing flaps during surgery followed by placement of interposition grafts of cartilage, crushed cartilage, fascia, acellular human dermal allograft (AlloDerm LifeCell, Branchburg, NJ), or porcine intestinal submucosa (SurgiSIS ES Cook Surgical, Bloomington, Indiana) is recommended. Other forms of iatrogenic trauma resulting in perforations include prior nasal cauterization or packing for epistaxis, nasogastric tube placement, nasal endotracheal intubation, and chronic use of a nasal cannula.

Traumatic perforations may also arise from nose picking, blunt trauma with an untreated septal hematoma, nasal foreign bodies (especially batteries), and nasal fractures with exposed septal cartilage.

Inflammatory/Infectious Inflammatory and infectious etiologies should always be considered and are often elicited during history taking. Infectious diseases include syphilis, human immunodeficiency virus infection, mucormycosis, and diphtheria. Granulomatous diseases causing perforations include sarcoidosis, Wegener granulomatosis, and tuberculosis. Septal perforations may be present in inflammatory conditions such as systemic lupus erythematosus, Crohn disease, dermatomyositis, and rheumatoid arthritis.

Neoplastic Carcinomas, T-cell lymphomas, and cryoglobulinemias have been described as presenting with septal perforations. Many patients present with associated pain and tenderness. Biopsy of suspicious mucosal surfaces is indicated.

Inhaled Substances/Toxic Exposures Inhaling cocaine may lead to septal perforation through the direct actions of adulterants whose toxic effects are heightened by the vasoconstrictive effects of the cocaine. This vasoconstriction decreases normal blood flow to injured areas of the septal mucoperichondrium. Chronic abuse may permanently damage the nasal mucosa and lead to chronic obstruction despite successful repair of perforations. Physiologic changes in the mucosa may also be seen in perforations resulting from chronic use of oxymetazoline, phenylephrine, or menthol inhalers. Topical corticosteroids have also been implicated in the etiology of septal perforations, especially if applied incorrectly or used extensively following septal surgery. Individuals who are continuously exposed to chemicals or aerosolized dust in the workplace may develop a septal perforation. Cited exposures include fumes from chromic and sulfuric acid, glass dust, mercurials, and phosphorus. Workers should wear a filter during exposure to irritants to prevent perforation and other toxic respiratory effects.

PHYSICAL EXAMINATION Physical examination should focus on determining the dimensions and position of the perforation as well as the proportion of the septum involved by the defect. Nasal decongestion and removal of all crusts should enable complete visualization of the septum with rigid or flexible nasal endoscopy. The quality and quantity of the remaining intact mucosa should be assessed along with the amount of persistent cartilage and its relationship to the borders of the perforation. The amount of healthy available donor tissue from the floor of the nose and the mucoperichondrium surrounding the perforation must be determined. The extent of deviation of the remaining nasal septum and the presence of septal spurs must be evaluated. Suspicious areas of mucosa must be biopsied. Nasal cultures for fungal and bacterial species may be necessary in the presence of an inflammatory process. Evaluation of the external nose includes palpation to assess the integrity of the nasal dorsum and mechanisms of the tip support. The surgeon must assess the potential for a saddle nose deformity as well as the need for reduction of a dorsal hump to acquire additional mucoperichondrium to help close the perforation.

INDICATIONS Nasal septal perforations that are symptomatic and have failed conservative medical therapy should be closed. Patients with a nasal septal perforation will generally benefit from a regimen of nasal douching with saline lavages and humidification of their home and work environments. Emollients such as Vaseline or muciprocin 2% may further reduce nasal crusting. Some authors have suggested the use of nasal topical estrogens to reduce mucosal squamous metaplasia and strengthen the vascular supply of the septal mucosa.

CONTRAINDICATIONS Successful closure of a nasal septal perforation depends largely upon the size of the perforation and the availability of native nasal mucosa for repair. The lack of available, healthy nasal mucosa may make closure of large defects impossible without “borrowing” tissue from outside of the nose. The anterior-to-posterior length of P.33 the perforation is not critical in closure because the greatest degree of tension of the wound is typically from the floor of the nose to the dorsum. However, a perforation that extends to the dorsum or the floor of the nose is almost impossible to repair unless there is some small cuff of membrane to which one can sew an inferiorly based advancement flap. Patients with a chronic or recurrent disease process, those with persistent intranasal drug (cocaine) usage, and those without adequate donor site mucoperichondrium should be considered candidates for placement of a nasal septal obturator rather than attempting to repair the perforation. A nasal septal obturator can be placed as an office procedure under local anesthesia if there is a straight septum surrounding the perforation. Prostheses are made of a variety of materials including silastic, silicone, and acrylic. The prosthesis may virtually eliminate symptoms of epistaxis, whistling, and nasal obstruction, but crusting, unfortunately, continues and may even increase despite continued local irrigation.

PREOPERATIVE PLANNING Serologic and Urine Testing In patients without a definitive cause for the perforation or in patients with rheumatologic complaints, the clinician should place a Purified Protein Derivative (PPD) test for tuberculosis and should obtain the following serologic evaluations: erythrocyte sedimentation rate, rheumatoid factor, antineutrophil cytoplasmic autoantibodies (Wegener granulomatosis), angiotensin-converting enzyme (sarcoidosis), and fluorescent treponemal antibody absorption (syphilis). A urine drug screen is performed on all patients with a suspected history of intranasal drug use.

Imaging Computerized tomography (CT) of the paranasal sinuses is recommended for all patients to determine the presence or absence of concomitant paranasal sinusitis and to assist in preoperative planning. Acute exacerbations of chronic sinusitis can jeopardize the success of the SurgiSIS ES grafts. In my experience, approximately one out of ten patients will require functional endoscopic sinus surgery. Typically, this is performed 6 to 8 weeks prior to the repair of the septal perforation to permit complete healing. Imaging also

permits more detailed measurements of the available mucoperichondrium in the donor site. Specifically, the width of the mucoperichondrium of the floor of the nose must be 1.5 times the height of the perforation on the coronal view CT to insure success (Fig. 4.1).

Stabilization of Systemic Illnesses Successful control of diabetes, vasculitides, Wegener granulomatosis, sarcoid, syphilis, and chronic rhinosinusitis must precede surgical intervention. Cessation of intranasal drug use must be confirmed by urine drug screen.

Classification of Perforations and Determination of Operative Approach All perforations may be successfully approached through an open rhinoplasty. The following characteristics permit an endonasal repair: Small perforation (