Deviated septum is a common and frequent disease in our ENT department, which can cause symptoms such as nasal congestion, nasal bleeding, headache and tinnitus, and even trigger and aggravate diseases such as allergic rhinitis and chronic sinusitis. In adolescent patients with deviated septum, there are also manifestations such as poor concentration and memory loss.
According to the shape of deviation, nasal septal deviation can be divided into “C” deviation, “S” deviation, crestal and sphenoid (talipes), high, low, anterior and posterior deviation according to the site of deviation, and mixed deviation.
Each type of septal deviation has different effects on the normal physiological functions of the nasal cavity: high septal deviation is highly associated with the occurrence of sinusitis; nasal septal deviation can interfere with the transport of intranasal media and is associated with the development of allergic rhinitis; posterior septal and low crestal deviations lead to refractory rhinorrhea; severe septal deviation is also an important cause of the development of obstructive apnea syndrome. Therefore, nasal septal curvature surgery should be performed on the basis of preserving the normal physiological structure of nasal septum as much as possible, correcting structural abnormalities and minimizing trauma.
For nasal septal deviation, the surgical approach can be simply divided into traditional septal deviation surgery (including subtotal nasal septal resection, typical submucosal resection, septal correction and septoplasty, and modified septoplasty under nasal endoscopy, which preserves the original hardness and thickness of the nasal septum, avoids the flapping-like septum formed by the septum swinging with respiratory activity, minimizes the extent of septal cartilage and bone removal , and The septal cartilage and bone are minimally removed, and the septal scaffold is preserved, which reduces the adverse effects of nasal collapse, septal perforation, septal hematoma and postoperative swelling, and is in line with the minimally invasive theory. It has become the main method of surgical treatment for nasal septum deviation.
According to the biomechanical rules of nasal septal deviation proposed by Han Demin, the tension caused by the unbalanced development of the skull and septal cartilage and the unbalanced growth and development of each part of the nasal septum mainly acts on the three tension lines at the connection of the septal cartilage, i.e. anterior, posterior and inferior. One or more septal cartilages of 3-5mm wide are removed to eliminate the surface tension of the deviated septal cartilage and to reshape the septal cartilage scaffold.
Basic method: Different incisions are chosen without stripping the septal cartilage corresponding to the mucosa of the right septum. The septal perpendicular plate and the spinous projection were removed, the plow bone was removed, and the septal perpendicular plate and the slightly deviated part of the plow bone were fractured so that they were in a neutral position. The cartilage below the nasal septum and the junction of the maxillary nasal crest was removed in a forward strip with a width of about 3 mm, and the enlarged and deviated part of the maxillary nasal crest was dissected downward through this incision.
1. C- or S-type deviation: Make a transverse incision at 3-5 mm from the top of the nose at the septum cartilage, cut off only the cartilage, and then make a transverse incision at the most obvious point of deviation. If the deviation of the septal cartilage is still not corrected, a longitudinal incision can be made behind the mucosal incision of the septum to cut the septal cartilage and then make a longitudinal incision at the obvious place of deviation, so that the septal cartilage is free in the shape of a “field”, and make one or more cartilage scratches parallel to the base of the nose according to the deviation (must be in the concave surface, push the cartilage attached to the opposite mucous cartilage membrane to the median For simple cartilage deviation, especially anterior median deviation, the traditional Killian incision is used; for posterior septum and high C- or S-shaped deviation, the Morched incision is used, i.e., a curved incision is made. For simple bony deviation of the posterior septum, choose a longitudinal mucosal incision at the junction of the septal bone and cartilage, the length should be greater than the deviation, cut the mucoperiosteal membrane, separate the ipsilateral mucoperiosteal membrane, lightly press the four-sided cartilage, disconnect the bone from the cartilage, separate the contralateral mucoperiosteal membrane, bite off the deviated bone, reset the mucoperiosteal membrane, the incision does not need to be sutured; 4. For mixed deviation and those with crestal prominence at the base of the nose, perform L-shaped incision, and after separating the bilateral mucous and periosteal membranes, dissociate the septal cartilage from the vertical plate of the sieve bone, the plough bone, the nasal crest of the maxilla and the nasal crest of the palate, bite off the deviated bone, and then implant the cartilage after correction; 5. No suture is needed; 6. For adolescent nasal endoscopic septoplasty, it is not necessary to pursue absolute anatomical uprightness of the nasal septum in order to achieve nasal patency and release sinus drainage obstruction. The scope of surgery should be reduced as much as possible to avoid the possibility of affecting facial development. The septal cartilage and bone take should also be preserved as much as possible. For the treatment of deviated septal cartilage, only the cartilage below the septal cartilage or (and, posteriorly, about 3 mm wide at the junction with the hard bone) should be removed in strips.
1.3, postoperative treatment: local application of erythromycin eye ointment to the nasal cavity. If there is stuffing, remove it 48 h after surgery. If there are stitches, remove the incision sutures in about 5 days. Regular outpatient review.
The mechanism is that the nasal septum and the anterior septal nerve of the turbinates are both nasal sensory nerves and contain more parasympathetic nerve fibers, and the nasal septal neuropeptides play an important role in the development of allergic rhinitis and the persistence of symptoms. The level of nasal septal neuropeptide is higher in patients with persistent allergic rhinitis than in normal individuals. This area is a high density area of nasal mucosal gland distribution, and the surgery destroys the parasympathetic fibers distributed in this area by the sieve anterior nerve, causing it to form scars, blocking nerve reflexes, decreasing nerve sensory function, decreasing sensitivity to external adverse stimuli, reducing vasodilation, decreasing nasal septal neuropeptide content, decreasing gland secretion, and reducing or eliminating sneezing and runny nose symptoms; the unique ablation technology of low temperature plasma system The nerve endings distributed in the nasal colliculus, upper anterior part of the nasal septum, middle turbinate and anterior part of the inferior turbinate are denatured, which destroys the cholinergic microganglia in the mucosa of the turbinate, reduces the release of acetylcholine, reduces vasodilation and permeability, and reduces glandular secretion, thus improving the symptoms of runny nose and congestion.
2.The nasal cavity can be not filled after septum correction surgery, or suture can be used instead of filling. When the mucosa is intact on both sides, the mucous membrane of one side can be cut at the nasal septum near the nasal floor from back to front, and the incision is about 1~2 cm long and parallel to the nasal floor.
3, septum correction surgery complications (perforation, legacy, collapsed nose, hematoma, the reasons for: 1, perforation reasons or mainly the reasons for the operator, inexperience, lack of knowledge of the anatomical structure, surgical skills are not familiar, incorrect concept, rough surgical operation, inadequate prevention of complications in surgery, the degree of deviation or multiple parts of the deviation of the partial correction of omission, congenital enlightenment, etc.. The integrity of the mucosa on one side should be ensured as much as possible during surgery, and in case the breakage on both sides cannot be avoided, it is necessary to try to prevent the appearance of a pair of penetrations, and if there is a pair of penetrations, remedial measures should be used immediately for repair. The next consideration is poor local blood supply, such as improper filling, too tight filling. There are also infection factors and patients’ own repair factors.
2, intraoperative mucosal injury of the nasal septum, fear of continuing the operation causing greater perforation, and hastily terminate the operation, resulting in legacy. In local anesthesia surgery, the patient cannot tolerate the surgery and cause perforation or is forced to discontinue the surgery, or is worried about correcting high deviation to form collapsed nose without correction, and the omission leads to unremarkable postoperative efficacy resulting in legacy.
3. The suture is too dead, the hemostasis is not complete, the caulking is pulled out prematurely, or the patient’s own problem, resulting in hematoma.
4. Insufficient awareness of the hazards of high deviation of the nasal septum, resulting in collapsed nose.