1030 - Septoplasty - Pawar8/6/2019 2 Septoplasty • Overall success rates vary from 43-85% • Thorough H&P is essential – Anterior rhinoscopy , nasal endoscopy, or both are sufficient

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SeptoplastyBest Practices and Perioperative Management

Sachin S. Pawar, MDAssociate Professor

Chief, Division of Facial Plastic & Reconstructive Surgery

August 8-11, 2019 | The American Club | Kohler, WI

Learner Objectives

• After this presentation you should:1. List reasons for failed septoplasty and common sites

of residual deviation.2. Describe strategies for safe perioperative analgesia,

including opioid best practices.3. Describe optimal management of the septum

following septoplasty.4. List indications for pediatric septoplasty and

describe general approach to surgery to minimize potential growth restriction


Clinical Consensus Statement


Han, J et al. (2015). Clinical Consensus Statement: Septoplasty with or without Inferior Turbinate Reduction. Otolaryngology‐‐head and neck surgery : official journal of American Academy of Otolaryngology‐Head and Neck Surgery 153(5), 708 720.

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Septoplasty• Overall success rates vary from 43-85%• Thorough H&P is essential

– Anterior rhinoscopy , nasal endoscopy, or both are sufficient to document septal deviation

– Nasal endoscopy is not necessary, but can be helpful in some situation

• Endonasal approaches most common, but external rhinoplasty approach may be needed for severe deviations


”Failed” Septoplasty• Potential reasons

– Alternative/missed diagnoses– Mucosal etiologies– Unrecognized nasal valve compromise– Initial surgery did not address critical areas of

stenosis or was too conservative– Post-operative recidivism of the septal

deviation or traumatic eventGillman GS, Egloff AM, Rivera‐Serrano CM. Revision septoplasty: a prospective disease‐specific outcome study. Laryngoscope. 2014;124(6):1290‐1295. doi:10.1002/lary.24356.


Revision Septoplasty

• Complicating factors– Surgically distorted anatomy– Disrupted tissue planes– Altered microcirculation– Post-surgical mucosal dysfunction

Gillman GS, Egloff AM, Rivera‐Serrano CM. Revision septoplasty: a prospective disease‐specific outcome study. Laryngoscope. 2014;124(6):1290‐1295. doi:10.1002/lary.24356.


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Dorsal Strut: 92%Caudal: 72%Midseptal: 56%Bone (PPE): 80%Inferior/Maxillary Crest: 13%

Gillman GS, Egloff AM, Rivera‐Serrano CM. Revision septoplasty: a prospective disease‐specific outcome study. Laryngoscope. 2014;124(6):1290‐1295. doi:10.1002/lary.24356.

LOCATION OF RESIDUAL DEVIATION


Caudal Septal Deviations

• Techniques to manage– Septal repositioning (”swinging door”)– Spreader grafts – extended– Suture techniques– Septal batten grafts– Extracorporal septoplasty


Lee JW, Baker SR. Correction of caudal septal deviation and deformity using nasal septal bone grafts. JAMA Facial Plast Surg. 2013;15(2):96‐100. doi:10.1001/2013.jamafacial.73.


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• Unrecognized/unmasked nasal valve collapse



Becker SS, Dobratz EJ, Stowell N, Barker D, Park SS. Revision septoplasty: review of sources of persistent nasal obstruction. Am J Rhinol. 2008;22(4):440-444. doi:10.2500/ajr.2008.22.3200.

Multivariate analysis:Significantly less likely to undergo revision septoplasty





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Significantly higher percentage of patients undergoing revision septoplasty had nasal valve addressed at time of revision (~40%) vs nasal valve addressed at time of primary (1%)




~50% had nasal valve surgery at time the time of revision septoplasty


Chambers KJ, Horstkotte KA, Shanley K, Lindsay RW. Evaluation of Improvement in Nasal Obstruction Following Nasal Valve Correction in Patients With a History of Failed Septoplasty. JAMA Facial Plast Surg. 2015;17(5):347‐350. doi:10.1001/jamafacial.2015.0978.


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SeptoplastyPerioperative Management




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Opioids

Opioids

• 90% of patients would have achieved adequate analgesia with as few as 11 opioid tablets


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Opioids

• 62 patients who underwent rhinoplasty• On average, only 40% of prescribed opioid

tablets were used• 74% of patients consumed 15 or fewer

hydrocodone-acetaminophen tablets• 5% required refills on pain medication



Nguyen, B., Yuhan, B., Folbe, E., Eloy, J., Zuliani, G., Hsueh, W., Paskhover, B., Folbe, A., Svider, P. (2019). Perioperative Analgesia for Patients Undergoing Septoplasty and Rhinoplasty: An Evidence‐Based Review The Laryngoscope 129(6), E200‐E212.


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• Six RCTs comparing outcomes of septal surgery with and without intranasal splints

• Splints associated w/ significantly increased post-op pain

• Insufficient evidence for decreasing rates of adhesions or other complications


• 279 studies -> 17 met inclusion criteria• Low level of evidence + high bias ->

unable to show clear benefit among any post-septoplasty treatment technique

• Septal sutures associated with less post-op pain vs other methods


Quinn, J., Bonaparte, J., Kilty, S. (2013). Postoperative management in the prevention of complications after septoplasty The Laryngoscope 123(6), 1328‐1333.

• Consensus:– Septal quilting sutures can obviate need for

nasal packing after septoplasty


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Septoplasty & Antibiotics

• ARS member survey showed 66% routinely use abx after septoplasty

• AAO-HNS consensus statement:– Abx have no benefit in routine septoplasty in

patients without nasal packing or splint placement


Pediatric Septoplasty


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Justicz, N., Choi, S. (2019). When Should Pediatric Septoplasty Be Performed for Nasal Airway Obstruction? The Laryngoscope 129(7), 1489‐1490.




Lawrence R. Pediatric septoplasy: a review of the literature. Int J Pediatr Otorhinolaryngol. 2012;76(8):1078-1081. doi:10.1016/j.ijporl.2012.04.020.


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Pediatric Septoplasty• May be safely performed without affecting future

nasal and facial growth• Nasal growth complete in females by 14 years and

15 years in males• In appropriate patients, septoplasty should not be

deferred until adolescence• Conservative management of septal deviations may

lead to increased facial asymmetry




Dispenza, F., Saraniti, C., Sciandra, D., Kulamarva, G., Dispenza, C. (2009). Management of naso‐septal deformity in childhood: long‐term results. Auris, nasus, larynx 36(6), 665 670.

Pediatric SeptoplastyDo:• Perform intervention on nasal septal

deformities to prevent facial deformities.

• Perform intervention on nasal septal deformities to prevent malocclusion.

• Preserve the mucoperichondriumduring septal surgery to avoid significant growth retardation.

• Perform septoplasty at age 6 or older, but earlier if necessary.

• Reconstruct defects in the cartilaginous septum to prevent septal perforation.

Do Not:• Elevate the nasal floor mucosa to avoid

damage to the incisive nerves. • Perform incisions or excisions through

the growing and supporting zones, especially the sphenoethmoid dorsal zone.

• Transect the septospinal ligament in order to prevent forward growth of the upper jaw.

• Separate the upper lateral cartilages from the septum without reconnecting in order to prevent deviations of the cartilaginous nasal dorsum.

• Implant alloplastic or biomaterials in the growing septum so that septal growth is not disturbed.

Gary CC. Pediatric nasal surgery: timing and technique. Curr Opin Otolaryngol Head Neck Surg. 2017;25(4):286‐290. doi:10.1097/MOO.0000000000000378.


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Summary

• Do– Perform a thorough nasal exam to determine all

potential causes of nasal obstruction to minimize risk of a “failed” septoplasty

– Utilize a combination of non-narcotic analgesics for post-operative pain control

– Consider transseptal suturing in lieu of nasal septal splints to improve patient comfort and decrease pain

– Consider performing septoplasty in select pediatrics patients to correct nasal airway obstruction


Summary

• Do not:– Neglect to address the nasal valve if indicated– Overprescribe narcotic pain medication– Routinely place nasal septal splints or packing– Routinely prescribe post-operative antibiotics for

septoplasty


Documents

1030 - Septoplasty - Pawar8/6/2019 2 Septoplasty • Overall success rates vary from 43-85% • Thorough H&P is essential – Anterior rhinoscopy , nasal endoscopy, or both are sufficient