Partial inferior turbinate resection for correction of nasal septum deviation under nasal endoscopy
Zhang Liqiang, Department of Otolaryngology, Qilu Hospital, Shandong University
Anatomy of application
The nasal septum is composed of bony and cartilaginous parts. The bony part consists of the median plate of the sieve bone, the pear bone, the nasal crest of the maxilla and palate bone, and the pterygoid crest of the butterfly bone. The cartilaginous part consists of the septal plate of the dorsal cartilage and the medial pedicle of the greater pterygoid cartilage. Deviation of the nasal septum refers to the change in the morphology of the nasal septum. It can occur in the bony part, cartilaginous part, or in a mixed type. C-shaped, S-shaped, sphenoid, and bony crest are common.
The inferior turbinate is a separate piece of sparse bone with longitudinal thin grooves on the medial side for vascular penetration, and the edges lend irregular protrusions to each bone plate of the lateral wall of the nasal cavity. From anterior to posterior, the turbinate crest of the maxilla, the descending process of the lacrimal bone, the hooked process of the sieve bone, and the turbinate crest of the palatine bone. The attachment of the inferior turbinate to the lateral wall of the nasal cavity is linear and arcs from front to back, with the highest point at the junction of the anterior middle 1/3, where the bone is thinnest. The anterior end of the inferior turbinate is about 2 cm from the anterior nostril and the posterior end is about 1 cm from the pharyngeal opening of the eustachian tube.
The inferior nasal canal is the space between the inferior turbinate and the nasal floor is about 3-3.5cm long, and its front side wall has the mucous membrane of the nasolacrimal duct in a crepuscular opening, called the tear duct, which reaches the tear sac upward through the nasolacrimal duct.
Overview
Nasal endoscopic septal correction is the main method for treating deviated nasal septum. The main advantages are as follows: 1. the operation under direct vision, clear vision, accurate operation and light injury; 2. the ability to complete some more complex nasal septal surgery, easy to retain more nasal septal stent structure, flexible operation style and good postoperative results. At present, septal correction mainly includes submucosal resection and septoplasty of the nasal septum.
Successful sinus surgery can mostly restore the mucosa of the inferior turbinate to normal, and only a few patients with chronic rhinitis have the need for inferior turbinate resection. In a small number of patients with persistent inferior turbinate hypertrophy (unresponsive to treatment), volume reduction surgery can improve nasal ventilation and enhance the patient’s quality of life. Since most patients with deviated septum have compensatory hypertrophy of the inferior or middle turbinate on the spacious side of the nose, treatment of the inferior turbinate is sometimes required after correction of deviated septum, mainly including partial inferior turbinate resection or inferior turbinoplasty.
Indications and contraindications for surgery
Indications: partial inferior turbinate resection or inferior turbinoplasty is required for deviated septum that causes nasal congestion or headache, obstructs the drainage of the middle nasal passage or affects the operation of endoscopic sinus surgery; bony hypertrophy of inferior turbinate or soft tissue hyperplasia that is insensitive to drug treatment.
Contraindications: Surgery should be postponed for those who are less than 18 years old.
Pre-surgical preparation
Detailed anterior rhinoscopy or nasal endoscopy, coronal CT of the sinuses.
Patient position and anesthesia
The patient is placed in a supine position with the head slightly elevated, routinely disinfected, and sterile towels are laid. Local or general anesthesia can be chosen.
Key points of surgery
The incision site should be selected according to the deviation of the nasal septum. A killian incision should be made on the left side of the septum or at the skin-mucosal junction on the lateral side of the deviated septum. The starting point of the incision should be as high as possible, starting from the top of the anterior septum and ending at the bottom of the septum, and extending appropriately toward the base of the nose. For simple nasal septal spine, bony crest or local deviation, the incision can be made in front of the local deviation or on the surface of the crest from anterior to posterior.
It is usually not easy to separate the nasal septal cartilage from the nasal crest of the maxilla, so the septal cartilage can be separated backward to the median plate of the sieve bone and the pear bone first, and here it is easy to separate downward to reach the nasal floor. The extent of detachment depends on the degree and extent of the deviation, as well as the principle of facilitating adequate exposure of the surgical field and continued detachment. The separation should be at least 1 cm beyond the area of deviation to avoid tearing of the mucosa when removing cartilage and bone. The mucosal knife cuts through the cartilage obliquely from top to bottom at a depth of 1/3-1/2 mm approximately 1 to 2 mm after the original incision, then cuts through the cartilage from one place, and the stripper picks through to confirm that it is located under the contralateral mucous cartilage membrane, then enters the contralateral side and the cartilage can be separated along the incision. To separate the contralateral mucous cartilage membrane and mucous periosteum, the stripper is pressed against the cartilage and bone surface of the nasal septum, and the separation is carried out gradually and deeply backward by using the up and down strokes of the two edges of the stripper. When separating the nasal septal cartilage from the nasal crest of the maxilla and the pear bone, it is not easy to separate and easily tear the mucosa because the periosteal fibers at the junction are reflexed to the opposite side and connected with the contralateral periosteum. When separating the spine or crest, the spine or crest can be separated from all around to the most prominent part of the spine or crest. The curvature is obvious and the area around the spine or crest should be fully de-tensioned. If it is still difficult to separate, the concave mucoperiosteum of the spine or crest is separated and the free cartilage is excised to widen the gap between the mucoperiosteum on both sides, and then the sharpest part of the spine or crest is separated.
For limited spine or crest, an arcuate incision can be made with a sickle knife in front of the spine or crest under 0 degree endoscopy to dissect the mucoperiosteal and mucoperiosteal membranes. If necessary, another transverse incision can be made posteriorly at the midpoint of the arcuate incision along the tip of the spinous process or osseous crest. The mucosal cartilage and mucosal periosteum are separated with a small striker. If there is a second incision, it can be separated upward and downward along the second incision to fully expose the protruding spinous process or bony crest. The nasal septal spine or crest is removed with straight biting forceps, or with a small flat chisel. The mucoperiosteal and mucoperiosteal membranes are repositioned.
If the septal cartilage is to be preserved, after separating the mucoperiosteum on one side, the osteochondral junction is punctured with a striker and the bony septum and contralateral mucosal flap are separated. The bony deviation is removed and the cartilage deviation can be partially excised or incised or the deviated septal cartilage can be cut into “field” shape or several small pieces accordingly. The cartilage strip of 2-4mm wide between each small piece is removed and the septal cartilage, which is still attached to the mucosal cartilage membrane on the opposite side, is pushed to the midline so that the nasal septum is straightened. If the septal cartilage is more deviated, the cartilage should be removed in large part and the deviated septal cartilage should be removed with a septal gyrator or septal sinus bite forceps.
Under direct endoscopic view, the deviated septal vertical plate and plow bone are removed with septal multi-joint biting forceps. If the junction of maxillary nasal crest and cartilage is much inflated or there is nasal crest, the inflated bone crest on both sides can be flattened with flat chisel and chiseled out or the deviated maxillary bone and palatine nasal crest are removed with septal multi-joint biting forceps.
Carefully check whether there are small cotton balls left between the two layers of nasal septal mucosa and periosteum, and carefully aspirate the clot. The mucosa of the nasal septum was repositioned and the septum was observed to be rectified. Depending on the situation, the incision was closed with or without sutures. Bilateral nasal caulking is performed to prevent the formation of a nasal septal hematoma. To ensure that the patient is able to ventilate through the nasal cavity after surgery, a nasal ventilation tube can be placed at the time of tamponade.
If the inferior turbinate is to be treated at the same time, the inferior turbinate surgery is performed after the septal surgery. Depending on the lesion of the inferior turbinate, the following treatments are available.
If the nasal stenosis is mainly due to inferior turbinate adduction and the inferior nasal tract is spacious, an inferior turbinate fracture extrapolation is feasible. After the inferior turbinate bone is completely fractured, the inferior turbinate can be pushed outward with a striker on the inner side of the inferior turbinate.
If the inferior turbinate is mainly soft tissue hypertrophy, partial inferior turbinate resection is feasible. This can be combined with fracture outgrowth if necessary.
In case of bony hypertrophy of the inferior turbinate, submucosal partial excision of the inferior turbinate is required. At the inferior edge of the inferior turbinate, a small circular knife is used to cut the mucosa from posterior to anterior to the bone, and the mucosa is separated against the bone, first separating the mucosa of the medial inferior turbinate, then separating the inferior edge, and then separating the mucosa of the lateral inferior turbinate to form a mucosal flap that reaches the root of the inferior turbinate and then reaches the posterior end of the inferior turbinate.
If both the bony and soft tissues of the inferior turbinate are significantly enlarged, inferior turbinoplasty is feasible. The inferior turbinate bone is first moved inward to provide room for the 0 degree nasal endoscope and cutting suction device to operate. The soft tissues of the lateral wall of the vertical part of the inferior turbinate are removed using the straight tip of the cutting suction device. The medial aspect of the inferior turbinate bone is then separated with a striker or septal cartilage knife to remove the posterior portion of the inferior turbinate bone, which becomes harder as it is removed forward and can be removed with a small antitension clamp. Since this is the narrowest part of the nasal cavity, removal of this part of the bone is critical. After all of the lateral mucosa and bone is removed, the remaining mucosa is rolled upward to cover the wound. The mucosa is rolled over with a striker and the horizontal portion of the residual inferior turbinate bone is externally folded if necessary.
Postoperative treatment
1. Apply anti-business systemically to prevent infection.
2. Remove the nasal stuffing after 24-48 hours.
Complication control
Nasal septal hematoma Incomplete hemostasis, too loose stuffing, or hypertension are the main causes of septal hematoma after surgery. The following points should be noted to prevent postoperative bleeding: preoperative auxiliary examinations should be comprehensive, detailed medical history should be taken, consultation of relevant departments should be requested if necessary, and perioperative treatment should be done. Hemostasis should be complete during surgery. In addition to applying epinephrine gauze to stop bleeding, electrocoagulation can also be used to stop bleeding. When stuffing the nasal cavity, the force should be uniform and avoid too loose.
Nasal septum perforation The damage of peeling the mucous cartilage membrane during surgery is heavy, and the site of the torn mucous cartilage membrane is in the same position on both sides, which is not detected during surgery and not treated in time, and the infection of nasal septum after surgery can form perforation.
Adhesions between the nasal septum and the lateral wall of the nasal cavity The damage to the mucous membrane of the nasal septum during surgery is heavy and adhesions can be formed with the inferior turbinate.
Bleeding from the inferior turbinate Bleeding during extraction of the filling after inferior turbinate surgery is a common complication after inferior turbinate surgery. The gauze strips can be extracted in small amounts at 48 hours after inferior turbinate surgery, and the removal is stopped if there is bleeding, and the removal is delayed until 72 hours, then the bleeding can be significantly reduced.
Nasal atrophy The inferior turbinate should be removed moderately, and the extent and size of removal should be determined by the degree of inferior turbinate hypertrophy and the patient’s condition. Breathing ventilation should not be pursued unilaterally at the expense of other functions.
Once the mucous cartilage membrane is ruptured on one side, the integrity of the mucous cartilage membrane on the opposite side must be ensured. Once the same part is ruptured on both sides, the cartilage can be used to fill in the perforation, or free tissue flaps can be cut to repair it. The filling of the nasal cavity must not be too tight to avoid compression necrosis and perforation. Appropriate antibiotics should be applied after surgery to prevent infection.
Evaluation
The nasal endoscopic submucosal resection of the nasal septum is operated under direct vision from beginning to end, and the stubble intersection and fibrous adhesion zone existing at the junction of the plough bone, the vertical plate of the sieve bone and the nasal septal cartilage can be clearly seen, which ensures accurate operation without complications. When making the anterior mucosal incision of the nasal septum and starting to separate the mucosal cartilage membrane a 30 degree or 70 degree endoscope can be used, using the angle of the endoscope, the separated mucosal cartilage membrane and white cartilage can be clearly seen, which helps to find the correct level. When separating the mucosal cartilage membrane and mucoperiosteum, a small suction head with a bevel can be used instead of a stripper or a stripper with a suction, which can be clearly operated by separating while suctioning. In order to facilitate the surgical operation and reduce the damage to the mucosa of the septum, sinus surgery on the wide side of the nasal cavity can be performed endoscopically first, followed by septal correction. After the septum has been corrected, sinus surgery on the narrow side of the nasal cavity is then performed.
Inferior turbinate surgery to improve nasal ventilation should in most cases preserve as much of the inferior turbinate mucosa as possible to avoid dry crusting and hyperventilation of the nasal cavity due to the absence of the inferior turbinate mucosa. Inferior turbinoplasty is a method that can improve nasal ventilation while preserving most of the soft tissues of the inferior turbinate and is a method worth promoting.