Indications for Endoscopic Septoplasty

Endoscopic septoplastyEndoscopic septoplasty

Claudiu Manea, MD, PhDClaudiu Manea, MD, PhD

University of Medicine and Pharmacy University of Medicine and Pharmacy ““Carol DavilaCarol Davila””, ,

Bucharest, RomaniaBucharest, Romania

�� Septal deviation is a common Septal deviation is a common clinical finding in patients clinical finding in patients reporting reporting nasal obstructionnasal obstruction. .

�� Septal deviation has also Septal deviation has also been implicated as a been implicated as a contributing factor in contributing factor in �� the the development of development of

rhinosinusitisrhinosinusitis, ,

�� contact point headachescontact point headaches, ,

�� May May impair visualization impair visualization during endoscopic sinus during endoscopic sinus surgery (ESS). surgery (ESS).

Septoplasty remains one of the most common rhinologic surgical procedures (340,000 procedures in the US/year)

IntroductionIntroduction

�� Until the 1960s, submucous septal resection as Until the 1960s, submucous septal resection as

promoted by Freer and Killian was standard promoted by Freer and Killian was standard

practice in Western Europe practice in Western Europe

�� With this a more or less straight septum was obtained With this a more or less straight septum was obtained

in the areas where the septal skeleton was resected.in the areas where the septal skeleton was resected.

�� Two strips of cartilage were left behind, one to Two strips of cartilage were left behind, one to

maintain the dorsum and the other to keep the tip maintain the dorsum and the other to keep the tip

and columella in place.and columella in place.

�� Complications: Complications:

�� Scar formation Scar formation –– saddling and retraction of the saddling and retraction of the

columellacolumella

�� Septal perforationsSeptal perforations

�� Limitations:Limitations:

�� Correction of patology in the dorsal, caudal, inferior Correction of patology in the dorsal, caudal, inferior

and posterior parts of the septum was not possibleand posterior parts of the septum was not possible

IntroductionIntroduction

�� 1991 Stammberger[1]1991 Stammberger[1]�� the application of endoscopic techniques for the correction of sthe application of endoscopic techniques for the correction of septal eptal

deformities.deformities.

�� Giles et al. [2]Giles et al. [2]�� evaluated the role of endoscopic septoplasty as an adjunct to evaluated the role of endoscopic septoplasty as an adjunct to

functional endoscopic sinus surgery.functional endoscopic sinus surgery.

�� Park et al. [3]Park et al. [3]�� concluded that they could visualize the nasal septum under concluded that they could visualize the nasal septum under

magnimagnifification on a video monitor and operate with precisioncation on a video monitor and operate with precision

�� Hwang et al. [4] stated that endoscopic septoplasty is helpful iHwang et al. [4] stated that endoscopic septoplasty is helpful in: n: �� correction of posterior septal deformities, correction of posterior septal deformities,

�� revision cases revision cases

�� as an effective teaching tool.as an effective teaching tool.

1. Stammberger H (1991) Functional endoscopic sinus surgery. The Messerklinger Technique, Decker BC. Philadelphia: pp 430–434

2. Giles WC, Gross CW, Abram AC, Greene WM, Avner TG (1994) Endoscopic septoplasty. Laryngoscope 104(12): 1507–1509

3. Park DH, Kim TM, Han DG, Ahn KY (1998) Endoscopic assisted correction of the deviated nose. Aesthetic Plast Surg 22(8):190–195

4. Hwang PH, McLaughlin RB, Lanza DC, Kennedy DW (1999) Endoscopic septoplasty: indication, technique, and results. Otolaryngol Head Neck

Surg 120(5):678–682

DefinitionDefinition

�� Endoscopic septoplasty is a fast Endoscopic septoplasty is a fast developing concept and gaining developing concept and gaining popularity as it: popularity as it:

�� provides a provides a direct direct –– targeted approach targeted approach to the septal anatomic deformity, to the septal anatomic deformity,

�� allowing a allowing a minimally invasive minimally invasive procedureprocedure

�� limited septal mucosal limited septal mucosal flflap dissection ap dissection and removal of a small cartilaginous and removal of a small cartilaginous and/or bony deformityand/or bony deformity

Indications for Endoscopic SeptoplastyIndications for Endoscopic Septoplasty

�� To improve surgical access to the middle/superior To improve surgical access to the middle/superior

meatus meatus

�� as an adjunct to endoscopic DCR & endoscopic sinus surgeryas an adjunct to endoscopic DCR & endoscopic sinus surgery


�� To remove To remove isolated septal spurs. isolated septal spurs.


�� To remove To remove isolated septal spurs. isolated septal spurs.

�� In a study by Sindhwani & Wright, [1] In a study by Sindhwani & Wright, [1]

�� 54% patients with complaints of nasal obstruction and facial 54% patients with complaints of nasal obstruction and facial

pain were cured pain were cured

�� 38% showed improvement 38% showed improvement

�� 8% patients were notbene8% patients were notbenefifited. ted.

�� In a study by Harley et al. [2]In a study by Harley et al. [2]

�� patients with nasal obstruction and headache were selected patients with nasal obstruction and headache were selected

and signiand signifificant improvement was observed in endoscopic cant improvement was observed in endoscopic

group as compared to conventional group. group as compared to conventional group.

1. Sindhwani R, Wright DE (2003) Role of endoscopic septoplasty in the treatment of atypical facial pain. The Journal of Otolaryngology 32(2):77–79 2.

Harley DH, Powitzky ES, Duncavage J (2003) Clinical outcomes for the surgical treatment of sinonasal headache. Otolaryngol Head Neck Surg 129:217–221


�� Septoplasty during Endoscopic Sinus Surgery for Chronic Septoplasty during Endoscopic Sinus Surgery for Chronic RhinosinusitisRhinosinusitis

�� Septal deviation is known to be the most common reason for Septal deviation is known to be the most common reason for �� OMC dysfunction, OMC dysfunction,

�� nasal obstruction, nasal obstruction,

�� nasal mucocilliary clearance alterationnasal mucocilliary clearance alteration


�� Septoplasty during Endoscopic Sinus Surgery for Chronic RhinosinSeptoplasty during Endoscopic Sinus Surgery for Chronic Rhinosinusitisusitis

�� Septoplasty only Septoplasty only in the treatment of patients with CRS and septal in the treatment of patients with CRS and septal

deviation revealed deviation revealed similar results similar results subjectively with subjectively with septoplasty and ESSseptoplasty and ESS

=> => septoplasty aloneseptoplasty alone can be can be adequate for treatment of CRS adequate for treatment of CRS with septal with septal

deviation. [1]deviation. [1]

�� Sun et al. [2] found that 47% of the patients with septal deviatSun et al. [2] found that 47% of the patients with septal deviation had ion had

ipsilateral or bilateral OMCipsilateral or bilateral OMC disease with disease with severity correlated to the severity correlated to the

angle of deviangle of deviation. ation.

1. Osama G. Abdel-Naby Awad, Abd El-Rehim A. Abd El-Karim, Mostafa S. Hamad Role of surgical septal correction in subjective improvement of chronic rhinosinusitis. 2014. Egypt J Otolaryngol 30:196–200

2. Sun Z, W ang R, Yang W. CT study of the ostiomeatal complex in patients with deviated nasal septum. Zhonghua Er Bi Yan Hou Ke Za Zhi 1996; 31:294–296.


�� Revision septoplastyRevision septoplasty�� The ability to The ability to reduce mucosal elevation reduce mucosal elevation by placing the incision in the by placing the incision in the

immediate vicinity of an isolated septal deflection immediate vicinity of an isolated septal deflection -- a a very important very important advantage in revision septoplastiesadvantage in revision septoplasties

�� In this situation In this situation the flaps are frequently adherent the flaps are frequently adherent form extensive form extensive prior submucosal dissection & cartilage resection. prior submucosal dissection & cartilage resection.

�� Elevation in these areas is difficult Elevation in these areas is difficult & may compromise flaps & may compromise flaps viability. viability.

�� Thus Thus the need to elevate flaps the need to elevate flaps in an in an area with no underlying area with no underlying cartilagecartilage is is minimized or eliminatedminimized or eliminated. .

�� This becomes a This becomes a crucial advantage crucial advantage in patient with in patient with preexisting preexisting septal perforationseptal perforation..


�� To solve nasal obstructionTo solve nasal obstruction

�� Limited indicationLimited indication

�� Usually, for complex septal Usually, for complex septal

deformities deformities –– CottleCottle’’s approaches s approaches

are used are used

�� Resection of the posterior part of nasal septum Resection of the posterior part of nasal septum

�� Pathway for transPathway for trans--sphenoidal access of sphenoidal access of

clival/pituitary surgeryclival/pituitary surgery


Endoscopic Septoplasty: The Open Book

Method


Method


Method

�� Creasta filmCreasta film

Advantages of Endoscopic vs. Standard Advantages of Endoscopic vs. Standard

Headlight TechniqueHeadlight Technique

�� It facilitates accurate identiIt facilitates accurate identifification of the pathology due to cation of the pathology due to �� better illuminationbetter illumination, ,

�� improved accessibility improved accessibility to remote areas and to remote areas and

�� magnimagnifificationcation. .

�� Endoscopic septoplasty is associated with Endoscopic septoplasty is associated with signisignifificant reduction in cant reduction in patients morbiditypatients morbidity in both peroperative and post operative period in both peroperative and post operative period (with pack and after pack re(with pack and after pack re--moval) due to: moval) due to: �� limited extent of limited extent of flflap dissectionap dissection, ,

�� not using Killian nasal speculum not using Killian nasal speculum which by pressure can cause perwhich by pressure can cause per--operative operative discomfort, discomfort,

�� limited manipulation and resection of septal framework limited manipulation and resection of septal framework thus obviating the need thus obviating the need for a tight pack and requiring packing for a lesser duration. for a tight pack and requiring packing for a lesser duration.

�� Use of light pack after endoscopic septoplasty leads to Use of light pack after endoscopic septoplasty leads to lesser incidence of lesser incidence of pressure headache, vacuum headache and watering of eyespressure headache, vacuum headache and watering of eyes..



�� It allows It allows better understanding of the lateral wall pathology better understanding of the lateral wall pathology associated with the septal associated with the septal

deformity. deformity.

�� It allows It allows limited incision and elevation limited incision and elevation of the of the flflaps. aps.

�� It It facilitates realignment facilitates realignment by limited and precise resection of the pathological by limited and precise resection of the pathological

areas and/or by precise repair, by strategically placed wedge reareas and/or by precise repair, by strategically placed wedge resections/ sections/

shaving of cartilage. shaving of cartilage.

�� It effectively It effectively relieves the contact areas relieves the contact areas and thus the and thus the contact headache contact headache by allowing by allowing

intraoperative assessment. intraoperative assessment.



�� ENT surgeons ENT surgeons have always been have always been

notoriously known as notoriously known as selfish surgeons selfish surgeons

because the because the assistant is not able to watch assistant is not able to watch

the surgical stepsthe surgical steps. .

�� Endoscopic septoplasty Endoscopic septoplasty can be a can be a

valuable teaching toolvaluable teaching tool

�� with help of video monitors the learning with help of video monitors the learning

opportunities have increased.opportunities have increased.

ComplicationsComplications

�� HematomasHematomas

�� SinechiaSinechia

�� Septal perforationsSeptal perforations

1. Park DH, Kim TM, Han DG, Ahn KY (1998) Endoscopic assisted correction of the deviated nose. Aesthetic Plast Surg 22(8):190–195

2. Hwang PH, McLaughlin RB, Lanza DC, Kennedy DW (1999) Endoscopic septoplasty: indication, technique, and results. Otolaryngol Head

Neck Surg 120(5):678–682

Significant lower rate Significant lower rate

in endoscopic in endoscopic

septoplasy [1, 2]septoplasy [1, 2]

ConclusionsConclusions

�� Endoscopic septoplasty is increasingly becoming Endoscopic septoplasty is increasingly becoming more common as an adjunct to ESS, more common as an adjunct to ESS,

�� Endoscopic septoplasty offers an alternative to Endoscopic septoplasty offers an alternative to traditional headlight technique with superior traditional headlight technique with superior visualization. visualization.

�� Also endoscopic septoplasty is an excellent teaching Also endoscopic septoplasty is an excellent teaching tool when used in conjunction with video monitors.tool when used in conjunction with video monitors.

Documents

Indications for Endoscopic Septoplasty