Introduction
Nasal obstruction is a common presenting complaint for patients in an otolaryngology office. Up to one-third of the population complains of nasal obstruction severe enough to seek treatment from a physician. The three primary anatomic causes of nasal airway obstruction include nasal septal deviation (NSD), inferior turbinate hypertrophy, and lateral nasal valve collapse. The nasal septum is composed predominantly of the quadrangular cartilage anteriorly, the bony perpendicular plate of the ethmoid superiorly and posteriorly, and the bony vomer inferiorly and posteriorly on the maxillary crest. Any deviation of the nasal septum can restrict nasal airflow, which is worsened by inflammation of the nasal mucosa. This often manifests as venous engorgement, increased nasal secretions, and tissue edema/swelling that further impair nasal airflow and contribute to the sensation of nasal blockage.
Corda et al. demonstrated a significant difference in nasal airflow patterns and velocity in a nasal cavity with a deviated septum compared to a healthy nasal cavity. The most constricted area was found in the mid-nasal region in patients with an NSD and in the nasal valve region in a healthy nasal cavity. The NSD cavity projected higher nasal resistance by 38% to 55% in comparison to the healthy nasal cavity, indicating an increased degree of nasal obstruction during breathing.
The nasal cavity is lined by stratified squamous and respiratory-type pseudostratified columnar epithelium. Respiratory mucosa (also called Schneiderian membrane) may contain goblet cells and undergo squamous metaplasia. Septal deviation predisposes the mucosa to chronic inflammation and squamous metaplasia, both of which may render patients susceptible to chronic rhinosinusitis. Increased lymphocytic infiltration and squamous metaplasia are observed on both sides of the nasal mucosa; however, they are more severe on the side opposite the deviation.
Indications
The main indication for performing a septoplasty is an NSD causing symptomatic obstruction that has not responded to medical management, though recurrent epistaxis related to a septal deformity is often approved as medically necessary. There is usually a deviation of the cartilaginous and/or bony parts of the septum into one or both nasal passages, reducing the cross-sectional area of the nasal passages, hindering airflow, and causing a sensation of nasal blockage. The goal of septoplasty is the correction of septal deviation while simultaneously preserving as much of the septum anatomy as possible.
With improvements in anesthesia protocols, improved reimbursement for office-based procedures such as balloon sinuplasty and balloon dilation of the Eustachian tubes (BDET), and the advent of new technology and tools such as the Relieva Tract Nasal Dilation System (Acclarent Inc., Irvine, CA) and VivAer radiofrequency ablation (Aerin Medical Inc., Mountain View, CA), many surgeons are performing septoplasty successfully in the office. There are distinct advantages of office septoplasty, including improved access to the middle meatus and nasopharynx for other endonasal or transnasal procedures and increased treatment options for patients who cannot or do not wish to have general anesthesia. Patients with significant caudal septal deflections, dorsal septal deviations contributing to external nasal deformity, and septal deformities with excessively thickened cartilage or bone are not good candidates for office septoplasty. ,
Technique
With appropriate patient selection and counseling, the procedure may be done under local anesthesia or intravenous sedation. Patients who do not tolerate examination of the nasal cavity with flexible endoscopy are not ideal candidates for septoplasty in the office under local anesthesia.
Patient Positioning and Anesthesia
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Position the patient in the supine position with the head elevated 45 degrees.
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Decongest the nose with oxymetazoline sprayed into the nose.
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Place cottonoids moistened with topical anesthetic (4% lidocaine or 4% tetracaine) along the nasal floor for approximately 10 minutes.
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Inject 1% lidocaine with epinephrine (1:100,000) bilaterally in the septum in the submucoperichondrial/mucoperiosteal plane and the inferior turbinates. This assists in the hydrodissection of the planes, analgesia, and hemostasis.
Equipment and Supplies
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Use a rigid zero-degree endoscope with a monitor and endoscopic camera to maximize visualization of the nasal cavity.
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Have suction available to evacuate any fluids.
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Use instrumentation such as the Relieva Tract Nasal Dilation System to provide increased intranasal space by displacing the inferior turbinate and lower nasal septum. Typically, the 16 × 40-mm noncompliant balloon is used.
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Hemostasis is often improved due to balloon compression of the capillaries. However, it is important to have therapies to address bleeding, such as oxymetazoline, topical epinephrine, silver nitrate, bipolar, or unipolar cautery.
Technical Procedure
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Under endoscopic visualization, insert the balloon along the floor of the nose and lower septum, beneath any prominent septal spur ( Fig. 15.1, A , B ). The proximal end of the balloon should be evenly positioned with the head of the inferior turbinate.
Fig. 15.1 (A) Preoperative left septal spur. (B) Balloon inserted beneath spur on the floor of the nose. (C) Persistent bony spur after balloon dilation. (D) Septum after spur excision.
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Slowly inflate the balloon (approximately 1 atm per second) to the desired pressure and hold it inflated in position for 2 minutes. If the balloon moves proximally, distally, or superiorly from the floor of the nose during the procedure, deflate the balloon, reposition it, and reinflate and hold for up to 2 minutes total inflation time.
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Deflate the balloon completely and remove it from the nose. Repeat the procedure on the opposite side of the nose.
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Reposition the septum in the midline bluntly with an elevator.
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Excise persistent cartilaginous or bony spurs or deviations through a keyhole, hemitransfixion, or Killian incision as required ( Fig. 15.1C ). Elevate a mucoperichondrial and/or mucoperiosteal flap over the deviated cartilage or bone and remove as needed until the septum is straight ( Fig. 15.1D ).
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Use nasal splints or absorbable packing if the septum is unstable, or if there is concern about possible septal perforation or adhesions.
Outcomes
With proper patient selection, counseling, and anesthesia, patients tolerate septoplasty in the office under local anesthesia well. In a retrospective study by the authors of 113 patients treated in the office with septoplasty and outfracture of the inferior turbinates using a balloon in multicenter private practices, 97% (110/113) of patients were able to complete bilateral full-pressure dilation for 2 minutes. Three patients did not tolerate either full dilation to 12 atm of pressure, 2 minutes of dilation on each side, or both due to significant discomfort, so the procedure was stopped.
The use of the balloon as a tool in septoplasty appears to have effects both mechanically in directly widening the nasal airway by alteration and movement of cartilaginous and bony tissue and histologic changes to the soft tissue that lead to decreased submucosal inflammation while preserving the overlying mucosa and regenerating damaged epithelium.
From various models of nasal fracture, the nasal septum absorbs a significant amount of energy and functions as a crumple zone with impact loading. The bony cartilaginous junction and the anterior nasal spine experience relatively high stress, and tissues of the vomer–ethmoidal region posterior to the septal cartilage are also common fracture sites in nasal trauma. It can be extrapolated that applying significant and persistent force to the lower part of the septum with a balloon will cause fractures in those same areas, separating the quadrangular cartilage from the bony perpendicular plate and vomer, and separating the vomer from the nasal crest. In effect, performing a closed reduction of the septal fractures with intact overlying mucosa will function to straighten the septum. Computed tomography scan of a cadaver sinus ( Fig. 15.2 ) demonstrates the mechanical straightening of the bony septum and uniform lateralization of the inferior turbinates along the entire length.
(A) Cadaver CT with left septal deviation. (B) Balloon fully inflated coronal view. (C) Balloon fully dilated axial view. (D) CT after balloon dilation. (Permission granted by Acclarent, Inc, an Integra LifeSciences Company, Princeton, New Jersey, USA.)
