Septoplasty Desti LR

SEPTOPLASTY, TURBINATE
REDUCTION AND CORRECTION OF

NASAL OBSTRUCTION
Desti Kusmardiani
Supervisor:
dr. Arif Dermawan, Mkes, Sp.T.H.T.K.L (K)
DEPARTMENT OF OTORHINOLARYNGOLOGY - HEAD&NECK

SURGERY
FACULTY OF MEDICINE UNIVERSITAS PADJADJARAN / Dr. HASAN
SADIKIN HOSPITAL
BANDUNG
1
INTRODUCTION
Nasal obstruction the most common
complaints in an otolaryngology practice.
Variety:
septal deviation,
turbinate hypertrophy,
nasal cartilage deformity,
sinus infections,
sinonasal neoplasms,
Mohamad R. Chaaban, Robert M. Naclerio, Septoplasty and Turbinate reduction, in Baileys ,
Byron J.; Head & Neck Surgery Otolaryngollogy, . 5th ed. 2014 p.613
ANATOMY
TURBINATES & TURBINATES LIKE STRUCTURES
Huizing EH, de Groot JAM. Functional Reconstructive Nasal Surgery, Georg Thieme Verlag,
2003
Neskey, D. Eloy, JA. Casiano, RR. 2009. Nasal, Septal, and Turbinate Anatomy and
ANATOMY
ANATOMY
Their bony skeleton may be lamellar, spongiotic, or
bullous.
a. Lamellar type most common, especially in
the inferior turbinate.
b. Spongiotic type frequently seen in the
inferior & middle turbinate.
c. Bullous type present in the middle turbinate
in 25% of the population, rare finding in the
inferior turbinate.
Huizing EH, de Groot JAM. Functional Reconstructive Nasal Surgery, Georg

Thieme Verlag, 2003
5
VASCULATURE OF THE LATERAL

NASAL WALL
The lateral nasal wall
and the turbinates are
supplied in a similar
way to the septum
Vascularization of the
lateral nasal wall.
Anastomoses
between
the internal (ethmoidal
arteries) and external
(sphenopalatine
artery) carotid system
Huizing EH, de Groot JAM. Functional Reconstructive Nasal Surgery, Georg Thieme
Verlag, 2003
Neskey, D. Eloy, JA. Casiano, RR. 2009. Nasal, Septal, and Turbinate Anatomy and
SENSORY INNERVATION
Nerve supply of the nasal cavity:

1. Posterior superior lateral nasal rami. 2. Posterior inferior lateral nasal rami. 3.
Posterior inferior lateral nasal rami. 4. Anterior alveolar nerve. 5. Nasopalatine
nerve. Huizing
6. Incisive
nerve.
EH, de Groot JAM. Functional Reconstructive Nasal Surgery, Georg Thieme Verlag, 2003
Neskey, D. Eloy, JA. Casiano, RR. 2009. Nasal, Septal, and Turbinate Anatomy and Embriology.
Otolaryngol Clin N Am 42 (2009). p193-205
ANATOMY
SEPTAL ANATOMY IN
SAGITAL VIEW
Mohamad R. Chaaban, Robert M. Naclerio, Septoplasty and Turbinate reduction, in Baileys ,11
DIAGNOSIS
History
Friedman M, Vidyasagar R. Surgical Management of Septal Deformity, Turbinates Hypertrophy, Nasal

Valve Collapse & Choanal Atresia . In : Bailey, Byron J.; Johnson, Jonas T.; Newlands, Shawn D. Head &
Neck Surgery - Otolaryngology, 4th Edition. p 320-34, 2006
13
DIFFERENTIAL
DIAGNOSIS OF NASAL
OBSTRUCTION

TREATMENT OPTIONS OF NASAL

OBSTRUCTION

DEVIATED NASAL
SEPTUM
Type of deviation:
Chapter20. disease of nasal septum in textbook of ear, nose & throat, 2 nd ed
DEVIATED NASAL
SEPTUM
DEVIATED NASAL
SEPTUM
Surgery for correction of a deviated
nasal septum has evolved aver the
course of the years
More recently, endoscopic
septoplasty was introduced as a
technique to address the deviated
nasal septum for enhanced
visualization during endoscopic sinus
surgery.
INDICATION OF
SEPTOPLASTY

Types of Septoplasty Incisions:

Killian Incision
Transfixion or Hemitransfixion
Incision
Cottle elevator
Although the procedure can be performed

under local or general anesthesia
The procedure is initiated with the
infiltration of a hemostatic agent. such as
1%
lidocaine
with
1
:
100,000
epinephrine, in the subperichondrial plane
to assist in raising submucosal flaps and
maintaining hemostasis throughout the
procedure.
Mohamad R.C, Robert M.N, Septoplasty and turbinate reduction, in Baileys , Byron J.; Head &
21
Neck Surgery Otolaryngollogy, . 5th ed. 2014 p.615
22
Video septoplasty
COMPLICATION
Septal hematoma
Epistaxis
CSF leak
Anosmia
Septal perforation
Sadlle nose
24
TURBINATE HYPERTROFI
25
MANAGEMENT
Medical
Friedman M, Vidyasagar R. Surgical Management of Septal Deformity, Turbinates Hypertrophy, Nasal Valve Collapse
& Choanal Atresia . In : Bailey, Byron J.; Johnson, Jonas T.; Newlands, Shawn D. Head & Neck Surgery Otolaryngology, 4th Edition. p 320-34, 2006
26
SURGICAL MANAGEMENT
The Goals of ideal turbinate reduction surgery
There is no single ideal procedure for all patients The surgeon has to
choose from the array of surgical options that are available and has to
select the best procedure to address the pathology in a given patient
Any technique destroying the turbinate mucosaloss of turbinate
function, crusting and adhesions
Huizing EH, de Groot JAM. Functional Reconstructive Nasal Surgery, Georg Thieme Verlag, 2003
Friedman M, Vidyasagar R. Surgical Management of Septal Deformity, Turbinates Hypertrophy, Nasal Valve Collapse & Choanal Atresia . In : Bailey, Byron J.; Johnson, Jonas T.;
27
Newlands, Shawn D. Head & Neck Surgery - Otolaryngology, 4th Edition. p 320-34, 2006
SURGICAL
MANAGEMENT

Thieme Verlag, 2003
28
Surgical management
INFERIOR TURBINATES
The current procedures that are most commonly used to treat bo
Most commonly used
Less
commonly
used
Friedman M, Vidyasagar R. Surgical Management of Septal Deformity, Turbinates Hypertrophy, Nasal Valve Collapse & Choanal Atresia . In : Bailey, Byron J.;
29
Johnson, Jonas T.; Newlands, Shawn D. Head & Neck Surgery - Otolaryngology, 4th Edition. p 320-34, 2006
Anesthesia
Mostperformed on an outpatient basis
The patient is placed in the sitting position.
The anterior nasal cavity topical local
anesthetic + epinephrinecotton pledgets with
the same solution are placed along the anterior
and middle aspects of the inferior turbinate.
30
ANESTHESIA
Transpalatal sphenopalatine ganglion blocks1%

lidocaine + 1/100,000 epinephrine ( 5 min)
Anterior aspect of the inferior turbinate is injected
with 3 - 5 mL of 1% or 2% lidocaine + epinephrine.
Anesthesia and enlarges the diameter of the

turbinate to prevent mucosal injury if
radiofrequency is used
Assists in hydrodissection and elevation of the
plane, in cases of submucosal turbinate reduction
31
Surgical Management of Inferior

Turbinates
1. SUBMUCOSAL TURBINATE
REDUCTION: CLASSICAL TECHNIQUE
Conservative submucous turbinate
resectioninferior turbinoplasty
Shown 3 to 5 years of relief from mucosal
and bony hypertrophy
This technique alone cannot be used to
manage nasal obstruction, because of
chronic hypertrophy of the nasal mucosa
32

Turbinates
1. SUBMUCOSAL TURBINATE REDUCTION: CLASSICAL
TECHNIQUE
A. Submucosal (anterior) turbinoplasty. An L-shaped incision is made in the mucosa of the anterior and
inferior margin with a No. 64
Beaver knife
B. A medially based mucosal flap is dissected
C. The anterior or the anteroinferior part of the turbinate bone is resected together with some of the
parenchyma as required
D. The mucosal flap is repositioned
E. The reduced turbinate is repositioned and fixed in its new position with gelfoam and an internal
dressing with ointment.
Thieme Verlag, 2003
33

Turbinates
2.
SUBMUCOSAL
MICRODEBRIDER-ASSISTED
TURBINATE REDUCTION
Powered instrumentation used in a functional
approach to inferior turbinates offers advantages
over traditional techniques with regard to
complications and mucosal preservation
This technique allows for incremental controlled
submucosal turbinate reduction
75% had complete resolution of their symptoms of
nasal obstruction, and the rest had some resolution
of their symptoms (complained of minimal nasal
obstruction postoperatively).
34

Turbinates

Turbinates
Video
Submucosal microdebriderassisted turbinate reduction
Inferior Turbinate Submucous Resection - YouTube[via torchbrowser.com].mp4
36

Turbinates
3. RADIOFREQUENCY-ASSISTED TURBINATE REDUCTION
It has given further advantage in the reduction of turbinate
hypertrophy.
Temperature-controlled
It is creating ionic agitationheats the tissue, and as the
temperature rises (47C)protein coagulation and tissue necrosis
Collagen deposition begins approximately 12 days after injury, and
at 3 weeks, chronic inflammation, fibrosis, and tissue volume
reduction from scar contracture occur.
This can be performed either by using unipolar or bipolar
radiofrequency probes
Some advocate a bipolar probe as better in terms of instant tissue
reduction, but no study has clearly shown that one technique is
superior.
37

Turbinates
Video RADIOFREQUENCYASSISTED TURBINATE
REDUCTION
turbinoplastica mediante radiofrequenza; radiofrequency reduction of inferior turbinates - YouTube[via torchbrowser.com].mp4
38

Turbinates
4. LASER REDUCTION
CO2 laser vaporization of the turbinate had
previously been accepted as a common treatment
for allergic rhinitisusually only a single procedure
is applied to minimize traumarepeated procedures
on separate days are often required to achieve an
adequate effect.
Holmium (Ho): Yttrium aluminum garnet (YAG)
laser efficacious, but has poor long-term efficacy
Potassium-titanyl-phosphate (KTP/532) laser
alternative useful tool in endoscopic intranasal
operations
Fox Diode Laser Turbinate Reduction - YouTube[via torchbrowser.com].mp4
39
Surgical Management of Inferior Turbinates
5. LATERALIZATION (OUTFRACTURE)
Lateralization (lateral displacement) of the inferior
turbinate by outfracturing the turbinate bone is the
most conservative method to address turbinate
obstruction.
It is mostly used in combination with another procedure
as lateralization alone is rarely effective enough.
Fffectively lateralize the IT for at least 6 monthssafe
and effective method to widen the nasal airway while
preserving the IT mucosa.
Lateralization of a protruding or hyperplastic
inferior turbinate is performed using the flat,
blunt end of a Cottle chisel.

Thieme Verlag, 2003
40
Surgical Management of Inferior Turbinates
6. (CRUSHING AND) TRIMMING

Provide the best compromise between reduction and
preservation of function when the inferior turbinate is
hypertrophic both anteriorly and posteriorly
The whole turbinate is first compressed using a special
forceps and then reduced by resecting a parallel or slightly
diagonal strip from its inferior margin.
The technique respects the functional capacity of the
remaining part of the turbinate.
A. The inferior turbinate is
crushed
and trimmed in cases with
hypertrophy of the whole
turbinate, including the tail.
The soft tissues are squeezed
using a modified Kressner
forceps.
B. The turbinate is trimmed
to size by resecting a strip
from its inferior margin with a
Heymann-type scissors.
C. The reduced turbinate
repositioned laterally
Huizing EH, de Groot JAM. Functional Reconstructive Nasal Surgery, Georg Thieme Verlag, 2003
41
COBLATION TURBINATE
REDUCTION
Submucosal turbinate reduction

Extramural turbinate reduction
42
Patient Post-op Instructions

Coblation Turbinate
Some patients may experience minor nasal
congestion and nasal drainage during the
first week following the procedure. Patients
should avoid blowing their nose during this
time.
After the procedure, it is normal for some
patients to experience minor bleeding.
Swelling is reduced within five to seven
days, and patients can return to normal
activity and diet immediately
43
Comparison Study
Comparison of the effects of radiofrequency
tissue ablation, CO2 laser ablation, and partial
turbinectomy applications on nasal mucociliary
functions was performed by Sapci et al.
The nasal mucociliary transport time were
counted at 12 weeks after surgery
They concluded :
Radiofrequency tissue ablation to the turbinate is
effective in improving nasal obstruction objectively
and in preserving nasal mucociliary functionsimilar
to partial turbinectomy technique
Laser ablation of the turbinate is effective in
improving the nasal obstruction disturbs the
mucociliary function significantly.
44
Surgical management of
Middle Turbinates
When indicated, the pathology and
abnormalities of the middle turbinate may be
corrected by resecting parts of the skeleton
and trimming the mucosa.
The surgical goal is to create a turbinate that
fits anatomically and physiologically.
Middle turbinate reduction may be carried out
as a single procedure.
More frequently, it is performed as a flanking
procedure in combination with septal or sinus
surgery.
Huizing EH, de Groot JAM. Functional Reconstructive Nasal Surgery, Georg Thieme
Verlag, 2003
45
Surgical management of
Middle Turbinates
A. The middle turbinate is
medialized with
the blunt end of a Cottle elevator
B. An L-shaped incision is made in
the
mucosa of the turbinate head
and
inferior margin with a No. 15
blade or a
No. 64 Beaver knife
C. The mucoperiosteum is
bilaterally
elevated; the bulla is exposed
D. The bulla is opened using the
sharp end
of a Cottle elevator
E.The mucosal lining of the inside
of the
bulla is removed together with
the medial
half of the bulla
F. The remaining bone and the soft
tissues
are compressed
G. The head and the inferior margin
of the
turbinate are trimmed to the
desired size
with Heymann scissors and
angulated
scissors
46
Thieme Verlag, 2003
Complication
Hemorrhage
Infection
Crusting
Empty nose syndrome
Nasolacrimal duct injury
47
NASAL VALVE OBSTRUCTION

The internal nasal valve is the narrowest
portion of the nasal airway and therefore may
contribute to obstruction
Deformities of the internal nasal valve include
inferiomedially displaced upper lateral
cartilage, septal deviation, inferior turbinate
hypertrophy, and pyriform aperture
stenosis,The external nasal valve is formed by
the septum, the medial and lateral crura of
the lower lateral cartilage, and the premaxilla
OPERATIVE PROSEDURE
HIGHLIGHT
Nasal obstruction is common and
caused by numerous etiologies,
some reversible with medical therapy
and
some
requiring
surgical
correction.
Patients should be optimized with
medical therapia even when a
surgical intervention is planned.
51
HIGHLIGHT
Causes of nasal obstruction amenable to
surgical correction include septal deviation,
turbinate hypertrophy, nasal valve collapse.
nasal polyps, choanal atresia. and sino-nasal
tumors.
The
most
common
complication
of
septoplasty is a septal perforation, howevet,
Other complications include nasal saddling,
anosmia, septal hematoma, failure to correct
deflection, and rarely CSF leak
52
HIGHLIGHT
The
operation
of
hypertrophied
inferior
turbinates is performed Only after a thorough
trial of medical treatment (including topical nasal
steroids, given over a protracted length of time
has failed
There is no single ideal procedure for all patients
in inferior turbinate hypertrophys surgery
The main goal of inferior turbinate hypertrophys
surgery should be the preservation of mucosal
surfaces, with reduction of the submucosal and
bony tissue
53
THANK YOU
54
OPERATIVE PROSEDURE
infiltration of a hemostatic agent.
such as 1% lidocaine with 1:100,000
epinephrine,
nasal cavities are then packed with
pledgets soaked with a decongesting
agent such as 4% cocaine,
axymetazoline, or neo-synephrine
incision on the side with the convex aspect of the

deviation to assist in raising an intact mucosal flap.
If a prominent septal spur is located anteriorly,
then dissection may be best achieved from that
side even if it is not the convex side.
A Freer's hemitransfixion incision (on the caudal
aspect of the cartilaginous sepblm) may be used
for caudal deviations (Fig. 42.2) or a Killian incision
(1 em posterior to the columella at the
mucocutaneous junction) may be used for more
posterior deviations.
Once the incision is made, a mucoperlchondrialmucoperiosteal flap is carefully raised on the

side of the incision over the cartilaginous
septum, posteriorly over the bony septum, and
inferiorly onto the maxillacy crest (Fig. 42.3).
An incision through the quadrangular cartilage
is then usually made 1 em posterior to the
dorsal and caudal portions of the cartilaginous
septum ("lrstrut"), and a
mucoperichondrialmucoperiosteal flap is then
raised on the contralateral side of the septum.
The cartilaginous septum is then

disarticulated from the bony septum
and the posterior cartilaginous
septum is removed and preserved for
reimplantation later.
The bony septum is then carefully
removal.

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SEPTOPLASTY, TURBINATE

REDUCTION AND CORRECTION OF

DEPARTMENT OF OTORHINOLARYNGOLOGY - HEAD&NECK

Huizing EH, de Groot JAM. Functional Reconstructive Nasal Surgery, Georg

VASCULATURE OF THE LATERAL

Nerve supply of the nasal cavity:

Friedman M, Vidyasagar R. Surgical Management of Septal Deformity, Turbinates Hypertrophy, Nasal

Mohamad R. Chaaban, Robert M. Naclerio, Septoplasty and Turbinate reduction, in Baileys ,

TREATMENT OPTIONS OF NASAL

Mohamad R. Chaaban, Robert M. Naclerio, Septoplasty and Turbinate reduction, in Baileys ,

Chapter20. disease of nasal septum in textbook of ear, nose & throat, 2 nd ed

Mohamad R. Chaaban, Robert M. Naclerio, Septoplasty and Turbinate reduction, in Baileys ,

Types of Septoplasty Incisions:

Although the procedure can be performed

The Goals of ideal turbinate reduction surgery

Huizing EH, de Groot JAM. Functional Reconstructive Nasal Surgery, Georg

The current procedures that are most commonly used to treat bo

Most commonly used

Transpalatal sphenopalatine ganglion blocks1%

Anesthesia and enlarges the diameter of the

Surgical Management of Inferior

Surgical Management of Inferior

Surgical Management of Inferior

Surgical Management of Inferior

Surgical Management of Inferior

Surgical Management of Inferior

Surgical Management of Inferior

Surgical Management of Inferior

Surgical Management of Inferior Turbinates

Huizing EH, de Groot JAM. Functional Reconstructive Nasal Surgery, Georg

Surgical Management of Inferior Turbinates

6. (CRUSHING AND) TRIMMING

Submucosal turbinate reduction

Patient Post-op Instructions

NASAL VALVE OBSTRUCTION

incision on the side with the convex aspect of the

Once the incision is made, a mucoperlchondrialmucoperiosteal flap is carefully raised on the

The cartilaginous septum is then

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