Endoscopic septoplasty

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1 Endoscopic septoplasty Claudiu Manea, MD, PhD University of Medicine and Pharmacy Carol Davila, Bucharest, Romania

2 Septal deviation is a common clinical finding in patients reporting nasal obstruction. Septal deviation has also been implicated as a contributing factor in the development of rhinosinusitis, contact point headaches, Septoplasty remains one of the most common rhinologic surgical procedures (340,000 procedures in the US/year) May impair visualization during endoscopic sinus surgery (ESS).

3 Introduction Until the 1960s, submucous septal resection as promoted by Freer and Killian was standard practice in Western Europe With this a more or less straight septum was obtained in the areas where the septal skeleton was resected. Two strips of cartilage were left behind, one to maintain the dorsum and the other to keep the tip and columella in place. Complications: Scar formation saddling and retraction of the columella Septal perforations Limitations: Correction of patology in the dorsal, caudal, inferior and posterior parts of the septum was not possible

4 Introduction 1991 Stammberger[1] the application of endoscopic techniques for the correction of septal s deformities. Giles et al. [2] evaluated the role of endoscopic septoplasty as an adjunct to functional endoscopic sinus surgery. Park et al. [3] concluded that they could visualize the nasal septum under magnification on a video monitor and operate with precision Hwang et al. [4] stated that endoscopic septoplasty is helpful in: i correction of posterior septal deformities, revision cases as an effective teaching tool. 1. Stammberger H (1991) Functional endoscopic sinus surgery. The Messerklinger Technique, Decker BC. Philadelphia: pp Giles WC, Gross CW, Abram AC, Greene WM, Avner TG (1994) Endoscopic septoplasty. Laryngoscope 104(12): Park DH, Kim TM, Han DG, Ahn KY (1998) Endoscopic assisted correction of the deviated nose. Aesthetic Plast Surg 22(8): Hwang PH, McLaughlin RB, Lanza DC, Kennedy DW (1999) Endoscopic septoplasty: indication, technique, and results. Otolaryngol Head Neck Surg 120(5):

5 Definition Endoscopic septoplasty is a fast developing concept and gaining popularity as it: provides a direct targeted approach to the septal anatomic deformity, allowing a minimally invasive procedure limited septal mucosal flap dissection and removal of a small cartilaginous and/or bony deformity

6 Indications for Endoscopic Septoplasty To improve surgical access to the middle/superior meatus as an adjunct to endoscopic DCR & endoscopic sinus surgery

7 Indications for Endoscopic Septoplasty To remove isolated septal spurs.

8 Indications for Endoscopic Septoplasty To remove isolated septal spurs. In a study by Sindhwani & Wright, [1] 54% patients with complaints of nasal obstruction and facial pain were cured 38% showed improvement 8% patients were notbenefited. ted. In a study by Harley et al. [2] patients with nasal obstruction and headache were selected and significant improvement was observed in endoscopic 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): Harley DH, Powitzky ES, Duncavage J (2003) Clinical outcomes for the surgical treatment of sinonasal headache. Otolaryngol Head Neck Surg 129:

9 Indications for Endoscopic Septoplasty Septoplasty during Endoscopic Sinus Surgery for Chronic Rhinosinusitis Septal deviation is known to be the most common reason for OMC dysfunction, nasal obstruction, nasal mucocilliary clearance alteration

10 Indications for Endoscopic Septoplasty Septoplasty during Endoscopic Sinus Surgery for Chronic Rhinosinusitis Septoplasty only in the treatment of patients with CRS and septal deviation revealed similar results subjectively with septoplasty and ESS => septoplasty alone can be adequate for treatment of CRS with septal deviation. [1] Sun et al. [2] found that 47% of the patients with septal deviation ion had ipsilateral or bilateral OMC disease with severity correlated to the angle of deviation. 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 Egypt J Otolaryngol 30: 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:

11 Indications for Endoscopic Septoplasty Revision septoplasty The ability to reduce mucosal elevation by placing the incision in the immediate vicinity of an isolated septal deflection - a very important advantage in revision septoplasties In this situation the flaps are frequently adherent form extensive prior submucosal dissection & cartilage resection. Elevation in these areas is difficult & may compromise flaps viability. Thus the need to elevate flaps in an area with no underlying cartilage is minimized or eliminated. This becomes a crucial advantage in patient with preexisting septal perforation.

12 Indications for Endoscopic Septoplasty To solve nasal obstruction Limited indication Usually, for complex septal deformities Cottle s s approaches are used

13 Indications for Endoscopic Septoplasty Resection of the posterior part of nasal septum Pathway for trans-sphenoidal sphenoidal access of clival/pituitary surgery

14 Endoscopic Septoplasty: The Open Book Method

15 Endoscopic Septoplasty: The Open Book Method

16 Endoscopic Septoplasty: The Open Book Method

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19 Creasta film

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21 Advantages of Endoscopic vs. Standard Headlight Technique It facilitates accurate identification of the pathology due to better illumination, improved accessibility to remote areas and magnification cation. Endoscopic septoplasty is associated with significant reduction in patients morbidity in both peroperative and post operative period (with pack and after pack re-moval) due to: limited extent of flap dissection, not using Killian nasal speculum which by pressure can cause per-operative discomfort, limited manipulation and resection of septal framework thus obviating the need for a tight pack and requiring packing for a lesser duration. Use of light pack after endoscopic septoplasty leads to lesser incidence of pressure headache, vacuum headache and watering of eyes.

22 Advantages of Endoscopic vs. Standard Headlight Technique It allows better understanding of the lateral wall pathology associated with the septal deformity. It allows limited incision and elevation of the flaps. It facilitates realignment by limited and precise resection of the pathological areas and/or by precise repair, by strategically placed wedge resections/ shaving of cartilage. It effectively relieves the contact areas and thus the contact headache by allowing intraoperative assessment.

23 Advantages of Endoscopic vs. Standard Headlight Technique ENT surgeons have always been notoriously known as selfish surgeons because the assistant is not able to watch the surgical steps. Endoscopic septoplasty can be a valuable teaching tool with help of video monitors the learning opportunities have increased.

24 Complications Hematomas Sinechia Significant lower rate in endoscopic septoplasy [1, 2] Septal perforations 1. Park DH, Kim TM, Han DG, Ahn KY (1998) Endoscopic assisted correction of the deviated nose. Aesthetic Plast Surg 22(8): Hwang PH, McLaughlin RB, Lanza DC, Kennedy DW (1999) Endoscopic septoplasty: indication, technique, and results. Otolaryngol Head Neck Surg 120(5):

25 Conclusions Endoscopic septoplasty is increasingly becoming more common as an adjunct to ESS, Endoscopic septoplasty offers an alternative to traditional headlight technique with superior visualization. Also endoscopic septoplasty is an excellent teaching tool when used in conjunction with video monitors.

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