Septoplasty 210523

Endoscopic
Septoplasty :
Pearls and Pi+alls
Kartika Dwiyani
Persahabatan Hospital, Jakarta
Rhinology Academic Health System Universitas Indonesia
The nasal septum is a complex osseocar7laginous
structure that divides the nose into two nasal passages
Generally, it is rare to have a symmetrical nasal cavity,

à some degree of devia-on is considered a normal
anatomical varia-on
Anatomy of the Septum
Becker DG. Septoplasty and Turbinate Surgery. Aesthe7c surgery Journal.2003

Vasculariza7on
Kyun Kim T, et al. Deviated nose: Physiological and pathological changes of the nasal cavity. Arch Plast Surg. 2020
Studies of human skulls have revealed that septal
devia7on can be found in 75-‐80% of the popula7on
Nasal septal devia0ons play a

cri0cal role in nasal obstruc0on
symptoms, nasal resistance,
e p i s t a x i s , r h i n o s i n u s i 0 s ,
rhinogenic headache and
snoring/ sleep disturbace
Septoplasty
Note is a surgical
that a deviated septum aplone
rocedure
(without that is used to
symptoma7c
obstruc7on)
correct is naot an indica-on
deviated for
nasal septoplasty
septum
Althobai7 KH, et al.Common Causes of Failed Septoplasty: A Systema7c Review.2022
Teixeria J. Nasal Septal Devia7ons: A Systema7c Review of Classifica7on Systems.2016
Septoplasty
1.Infiltra-on :
Subperchondrial infiltra7on of the nasal septum was
done bilaterally using 1: 200.000 adrenaline in saline
solu7on
Shehata A. ENDOSCOPIC VERSUS TRADITIONAL SEPTOPLASTY. AAMJ. 2012

A study showed that injec7on of 10 ml of diluted
adrenaline (1:100000 or 1:200000) in the sub-‐
mucoperichondrial plane for pa7ents undergoing
septoplasty is safe

No sta7s7cally significant increase in the heart rate,
systolic and diastolic blood pressure and mean arterial
pressure
Alfabani NA, et al. Effect of using diluted adrenaline injec7on on hemodynamical parameters during septoplasty. Pan Arab J Rhinol. 2021
Reported Complica-on
A case of ventricular tachycardia (> 200x/min) – cardiac
arrest, around 7 minutes ager infiltra7on of 6 ml
lidocain 2% and adrenalin 1:200.000

Absolute Contra Indica2on :

Pheochromocytoma and thyrotoxicosis

Extra Cau2on
The pa7ents with cardiovascular disease
à more prone to cardiac arrhythmias
à Consider risks vs benefit
Pawar SC, et al. Cardiac arrest ager submucosal infiltra7on with lignocaine 2%—epinephrine in nasal surgery: A case report. SAJAA. 2009
Preven2on
• Careful aspira7on of the needle each 7me we inject
drugs
• Injec-ng a small test dose is the safest method
• The principal is using the lowest possible dose of

vasoconstrictor to produce the desired ac7on,
while minimally affec7ng physiology of the pa7ent
Pawar SC, et al. Cardiac arrest ager submucosal infiltra7on with lignocaine 2%—epinephrine in nasal surgery: A case report. SAJAA. 2009
Infiltra7on of septal mucoperichondrium with
lidocain and adrenaline instead of normal saline
was not advantageous in parameters tested
including bleeding amount, dura7on of surgery, and total
mucosal injury
Gungor V et al. Infiltra7on with lidocain and adrenaline instead of normal saline does not improve the septoplasty proceduret. 2016
2. Hydrodissec-on :
Pressure insuffla7on of fluid into a space that separates
car7lage and bones with mucoperichondrium and
mucoperiosteum

The amount of Nasal Saline used for flap eleva7on was
ranged from 8ml to 22ml, based on the extent and
loca7on of the devia7on.
The advantages of this method include

less mucosal tears, less opera7ng 7me,
less post opera7ve adhesions and crus7ng

3.Septoplasty Incision
(using No. 15 knife blade)
Hemitransfixion Incision

à about 2 mm above
and parallel to the
c a u d a l m a r g i n o f
car7laginous septum

Killian Incision

à p o s t e r i o r t o
m u c o c u t a n e o u s
junc7on

4. Flap eleva-on and dissec-on
How to be sure you are working

subperichondrially ?
• The color of septal car7lage is bluish gray

• Using knife produce a scratching sound
• No bleeding à No vessels between perichondrium and car7lage
• Eleva7ng mucoperichondrium proceeds easily


The convex side of the deviated septum shows mucosal
thinning due to mechanical pressure of the crooked
car7lage, or spurred bone
Preven7on of mucosal tears
à an especially cau7ous approach is required when
eleva7ng the mucoperichondrium on the convex side of
the septum
Kyun Kim T, et al. Deviated nose: Physiological and pathological changes of the nasal cavity. Arch Plast Surg. 2020
5. Septal car-lage incision
just posterior to the mucosal incision

à To perform the contralateral mucoperichondrial flap
eleva7on
mucoperichondrium

6. Posterior chondrotomy
Separate the car7lage from the ethmoid perpendicular
lamina and vomer

7.Inferior chondrotomy “Swinging door maneuver”
Excise a wedge of car7lage along the maxillary crest to
release the caudal septal abachments and allow the
septum to “swing” to the midline

8. Removal of deviated part
• The deviated bony septum could be removed

precisely using turbinate scissors or through-‐cupng
instruments

• The car7laginous septal devia7on, may be incised
anterior to the deviated part
Tsen Lin Y. Septoplasty: Endoscopic and Open Techniques, 2020

The septal car7lage should be preserved at least
1–1.5 cm in width dorsally and caudally
For the stability and maintain the structure of the nose and nasal 7p
Keystone area
Simon PE, et al. The Nasal Keystone Region: An Anatomical Study. JAMA FACIAL PLAST SURG. 2013
Tsen Lin Y. Septoplasty: Endoscopic and Open Techniques. 2020
9. Wound closure

• Reassessment of the nasal airway
• The septal flap is reapproximated
• The hemitransfixion or Kilian incision is closed with
through-‐and-‐through interrupted sutures
Common Complica7on
Bleeding
à Result from fracturing septal bone by force
Dąbrowska‑Bień J, et al. Complica7ons in septoplasty based on a large group of 5639 pa7ents . European Archives of Oto-‐Rhino-‐Laryngology .
2018
Common Complica7on
Septal perfora-on result from
• Trauma7c eleva7on of mucosal flaps with opposing
tears in the flap on the other side
• The Suture is 7ght enough to cause ischemia and
necrosis of surrounding area
• Healing complica7ons due to infec7on
Preven-on
• Careful eleva7on of mucosal flap
• Make an effort to close any mucosal tears at the end
of surgery
• Adequate suture
2018
Common Complica7on
Adhesions or sinechia between septum and inferior
turbinate
àif a tear in the septal mucosa is opposite to a
mucosal defect of the turbinate, especially ager
simultaneous interven7ons at the turbinate
2018
Other Complica7ons
• Infec7on
• Anosmia/ hiposmia
• CSF leak
• Visual loss

2018
Deviated nasal septum in children
Deviated nasal septum in children should be corrected to

avoid unnecessary facial deformity, morbidity nasal
symptoms and provide harmonious growth of the nose
and face.

Swain SK. Deviated nasal septum in children: a review.Interna7onal Journal of Contemporary Pediatrics .2022.
à An important cause of nasal obstruc7on

Other than nasal symptoms, it may result in headache,
nasal bleeding, nasal discharge, postnasal drip, and
hyposmia or anosmia

The main target of the treatment of the deviated nasal
septum in children is to restore the patency of the
nasal cavity

…Notes
The growth of the quadrangular car7lage of the nasal
septum ends at 5 to 6 years of age

The bony component such as vomer and perpendicular
lamina grow un7l adolescence

In pa7ents with the age of 5 to 16 years,

The bony part of the nasal septum should not be
removed for avoiding any deple7on of ac7ve facial
growth and altera7ons of the nasofacial development.
…Notes
On the contrary, the car7laginous por7on of the nasal

septum can be resected, even though the resec7on
should be conserva7ve

َ‫ إِلَيْك‬ ُ‫ وَأَتُوب‬ َ‫ أَسْتَغْفِرُك‬ َ‫ أَنْت‬ َّ‫ إِال‬ َ‫ إِلَه‬ َ‫ ال‬ ْ‫ أَن‬ ُ‫ أَشْهَد‬ َ‫ وَبِحَمْدِك‬ َّ‫ اللَّهُم‬ َ‫سُبْحَانَك‬
Purity belongs to You, Allah and all praise be to You
I bear witness that there is none worthy of worship but You
I seek Your forgiveness and repent to You

Septoplasty 210523

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Septoplasty 210523

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Endoscopic

Generally, it is rare to have a symmetrical nasal cavity,

Becker DG. Septoplasty and Turbinate Surgery. Aesthe7c surgery Journal.2003

Nasal septal devia0ons play a

Shehata A. ENDOSCOPIC VERSUS TRADITIONAL SEPTOPLASTY. AAMJ. 2012

Absolute Contra Indica2on :

• Injec-ng a small test dose is the safest method

• The principal is using the lowest possible dose of

The advantages of this method include

Shehata A. ENDOSCOPIC VERSUS TRADITIONAL SEPTOPLASTY. AAMJ. 2012

Becker DG. Septoplasty and Turbinate Surgery. Aesthe7c surgery Journal.2003

Shehata A. ENDOSCOPIC VERSUS TRADITIONAL SEPTOPLASTY. AAMJ. 2012

How to be sure you are working

• The color of septal car7lage is bluish gray

Shehata A. ENDOSCOPIC VERSUS TRADITIONAL SEPTOPLASTY. AAMJ. 2012

Shehata A. ENDOSCOPIC VERSUS TRADITIONAL SEPTOPLASTY. AAMJ. 2012

Becker DG. Septoplasty and Turbinate Surgery. Aesthe7c surgery Journal.2003

Becker DG. Septoplasty and Turbinate Surgery. Aesthe7c surgery Journal.2003

• The deviated bony septum could be removed

Tsen Lin Y. Septoplasty: Endoscopic and Open Techniques, 2020

Deviated nasal septum in children should be corrected to

à An important cause of nasal obstruc7on

In pa7ents with the age of 5 to 16 years,

On the contrary, the car7laginous por7on of the nasal

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