The “three stages and nine levels” of septal surgery
Stage 1: Focus on septal surgery operation
At this stage, many people are only interested in how septal surgery is done, or rather, they just notice the deviated septum. This is a big improvement compared to some “doctors” who only know the inferior turbinate and ignore the deviated septum. Those who diagnose inferior turbinate hypertrophy and hypertrophic rhinitis as long as there is nasal congestion, without paying any attention to the state of inflammation of the nasal mucosa, whether it is in the acute phase or chronic phase, whether it is in the acute attack of chronic inflammation or in the improvement of chronic inflammation, or even misrepresenting inferior turbinate as nasal polyp, just to be able to, and only to earn a little income by damaging inferior turbinate. Compared to “doctors”, these people are already considered good. The “doctor” who said the inferior turbinate is a nasal polyp, whether intentionally or unintentionally, the author can hardly consider them as peers, that is to say, these people are not doctors at all, and certainly not in the author’s “three religions and nine classes” and The “three levels and nine classes” are included. Although Confucius declared: “There is no class in teaching. But I have no words to say to such “doctors”.
Although, since Quelmalz first published his article on deviated septum in 1750, septal surgery has gone through four periods: subtotal septal resection, typical submucosal resection (including modified submucosal resection), septal correction, and septoplasty. However, the most widely used in clinical practice to date is still submucosal resection (including modified submucosal resection) and septoplasty. The general guiding principles for the various surgical approaches are as follows.
1. submucosal resection of the nasal septum: also called Killian method, it is a method of removing the cartilage and bone bulk of the nasal septum.
2. Modified submucosal resection: Based on the submucosal resection of nasal septum, the cartilage or bone removed will be repositioned after trimming.
3. Septal correction: Only the deviated part is removed, and the cartilage and bone that are not deviated are preserved as much as possible, which is another modification of submucosal resection.
4. Septoplasty: It is based on complete correction of the deviated nasal septum by cutting and reducing the cartilage and displacing the fracture of the bony part to preserve as much cartilage and bony structures in the septum as possible.
One stage one: frontoscopic submucosal resection or correction of the nasal septum
Although some doctors just notice the deviated septum and are just content to perform septal surgery, at least such a person is still considered a doctor. Of course, the same septal surgery differs greatly because of various subjective and objective conditions.
First of all, in terms of illumination equipment, there are currently two ways to perform nasal septal surgery: frontoscopic and endoscopic. In the former, due to the limitations of the illumination range, often only the anterior and inferior deviations of the nasal septum can be better treated, and the high and posterior deviations are often treated with unsatisfactory results. In this case, the surgical approach taken is mostly submucosal resection and correction, and if you want to implement a shaping procedure, it is not only difficult to operate, but also difficult to handle in place. Therefore, no matter how experienced, how dexterous, how dedicated and how self-improving the doctor is, due to the objective conditions, nasal septal surgery under frontal mirror illumination is always only in a most basic technical stage.
Surgical steps: conventional anterior incision of the left side of the nasal septum, separating the mucous cartilage membrane and mucous periosteum of the left septum, cutting through the cartilage, entering the opposite side, similarly separating the mucous cartilage membrane and mucous periosteum of the opposite side, putting in a fixed long nasal mirror, exposing the deviated part of the nasal septum, removing part of the nasal septal cartilage with a circumferential knife, then removing part of the vertical plate of the sieve bone with a biting clamp, and using a bone chisel to remove the deviated part of the lower plow bone. Sometimes, some doctors will also trim the excised flatter cartilage and reincorporate it into the septum.
Problems: 1. High septal deviation: Due to the fear of nasal collapse and the treatment philosophy of satisfying ventilation, most high septal deviations are retained to varying degrees, and only the lower and middle deviations are treated more completely. 2. Posterior septal deviation: Due to the fear of excessive resection potentially leading to pat-like septum and septal perforation, and the limitations of frontal mirror illumination, for inexperienced 3.Vesicular middle turbinate: Patients with “C” type high deviation are often accompanied by vesicular middle turbinate on one side, due to the limitation of frontoscopic illumination and the lag of treatment concept, not only the high deviation will be preserved to different degrees, but also the vesicular middle turbinate will be ignored. 4. Inferior turbinate lesions: whether hypertrophic or inflammatory, partial excision of the inferior turbinate is the most common treatment under frontoscopic illumination, and if the inflammatory state of the nasal mucosa is not noted, excessive excision occurs during the acute phase of inflammation. The resulting late problems are often difficult to remedy and are one of the most important reasons for unsatisfactory patient treatment.
One-stage secondary: nasal endoscopic submucosal resection or correction of the nasal septum
As with most rhinological procedures, endoscopic septal surgery, is rapidly replacing frontoscopic surgical operations. However, submucosal resection and correction of the nasal septum are still the most used endoscopic septal surgical procedures. However, the management of posterior and high deviations has been significantly improved due to the expansion of illumination. The refinement of the entire surgical operation has been improved to some extent. At the same time, the use of surgical instruments, too, is quietly changing. In any case, the operation level of nasal septal surgery has still made great progress.
Surgical steps: under 0 degree nasal endoscopy, an incision is made on the left side of the anterior part of the septum, or on the right side, and the mucous cartilage and mucoperiosteum of the septum are separated with a stripper, mostly with a suction stripper, or with the help of an assistant. The stripper with suction is often used, or an assistant can help. The incision is continued by cutting through the cartilage and into the contralateral side, and the mucous cartilage and mucoperiosteum on the contralateral side are separated in the same way. Using scissors or vascular forceps, the septal cartilage is first removed, while, later, the posterior bony deviation is removed with biting forceps. Again, the more straight septal cartilage can be retracted into the nasal septum after trimming.
Advantages: 1. Since the nasal endoscope can enter the nasal septum, the posterior deviation of the nasal septum can be dealt with more easily compared with the anterior deviation. 2. Not only can sinus lesions be dealt with simultaneously under the nasal endoscope, but also, there is a newer understanding and more attention to the high deviation that affects the opening of the sinuses. Thus, the first step in the comprehensive treatment of deviated nasal septum was taken, and the treatment concept of simultaneous and coordinated treatment of multiple structures was gradually formed as a result. Of course, all these are still afterthoughts. At this stage of treatment, these concepts have not yet been fully formed.
Problems: 1. As the number of cases of high deviations requiring correction has increased and posterior deviations are more easily treated, the risk of nasal collapse, slapping-like septum, and nasal septal perforation associated with submucosal resection has increased. 2. With the widespread development of sinus opening, the number of cases of septal deviations requiring concurrent treatment under the age of 18 has likewise increased substantially. The limitation of submucosal resection in terms of age has become an important factor limiting the operation.3. The limitation of one-handed operation, without simultaneous suction, the endoscope is easily stained by blood. Even with simultaneous suction, the chances of endoscopic blood staining are still high. The continuous improvement and effective use of the lancet has also become an important factor limiting the success of the operation in one go.
Surgical instruments: 1. 0 degree nasal endoscope and cold light source system, equipped with TV surveillance system is very necessary. 2. suction stripper. 3. biting bone forceps, needle holder, straight and curved vascular forceps, No. 7 handle. Instruments no longer needed include: cricothyrotomy knife, bone hammer, bone chisel, fixed long nasoscope.
A segment of tertiary: nasal endoscopic septoplasty
Since the creation of nasal endoscopic surgical techniques in the 1980s, nasal endoscopic septal surgery has been widely performed for its many advantages such as clear vision, flexibility of operation, and applicability. However, due to the limitations of the technical level, submucosal resection or/and correction is still used in more cases. In the case of deviated septum under 18 years of age, septoplasty should be routinely chosen over submucosal resection and correction with extensive excision. Even for adults over 18 years of age, septoplasty is effective in reducing the risk of nasal collapse, septal perforation, and septum flapping.
However, for high, posterior, complex deviations, for deviations with abnormal bone thickening, etc., the original septoplasty, it is difficult to be widely applied. Therefore, even if the same septoplasty is performed, there are great differences in the specific operation and guideline. That is to say the same segment of three levels, the level of operation is also different, but at present, doctors who can carry out nasal endoscopic septoplasty are already considered to be the best in septal surgery.
Surgical steps
1.Traditional way of septoplasty: incision at the front of the nasal septum, separation of mucous cartilage membrane and mucous periosteum on one side of the incision, down to the bottom of the nose and up to the top of the nose. Separate the septal cartilage from the vertical plate of the sieve bone and the interplumb bone connection, and enter the opposite side. Separate the periosteum of the vertical plate of the sieve bone and the plough bone on the opposite side, down to the base of the nose. The upper part of the septum retains the triangular cartilage attached to the vertical plate of the sieve bone to prevent septal collapse. Push the cartilage to the contralateral side and preserve the connection between the contralateral mucous cartilage membrane and the cartilage. Cartilage treatment: The cartilage is cut and reduced according to the type of deviation and then pushed to the center. Bone management: For the septal vertical plate and plow bone, fracture displacement or lamellar chiseling is performed from inside the nasal septum.
Key points of operation: 1) separate the mucous cartilage membrane on one side only, not both sides; 2) separate the cartilage-bone junction, enter the opposite side, and separate the mucous membrane bilaterally; 3) correct the deviation mainly by: cartilage “cutting and reduction” and bone “fracture displacement”.
Problems: In theory, cartilage can be corrected by “cutting and reducing” and bone by “fracture displacement”, but in fact, in case of deviation with thick bone, fracture displacement is only a beautiful fairy tale, and bony deviation can only be In fact, in the case of thick bony deviation, the fracture displacement is only a fairy tale and the bony deviation can only be removed, and the so-called shaping is only the shaping of cartilage, not the real sense of septum bone and cartilage shaping. In case of high septal deviation, it is either left untreated or operated at risk. In the case of complex and severe deviation, it is either partially treated or reluctantly treated.
In the past, the reports on septoplasty in the literature have either changed the concept, which is not the real meaning of septoplasty, or they have not been reported in a factual way, or they have been lightly described, avoiding the important points, only reporting the number of cases of septoplasty without describing the specific operation steps of septoplasty in detail. Or to generalize the whole picture, just based on the successful operation of a few cases of septoplasty, derived into a report, making people wrongly believe that this operation can be applied to all types of nasal septal deviation.
2. Modified septoplasty type 1: A conventional septal anterior recess side incision is made to separate the ipsilateral septal cartilage from the cartilaginous membrane connection, down to the base of the nose and up to the top of the nose. From the incision, cut through the cartilage into the contralateral side, and similarly separate the contralateral cartilage from the cartilaginous membrane. Continue posteriorly to separate the vertical plate of the septum on both sides and the connection between the plastron and the periosteum. The septal cartilage was separated from the vertical plate of the sieve bone and the connection between the plough bone to form the apical connection of the septal cartilage, and the left and right sides were separated, and the anterior, posterior and inferior sides were free. The upper part of the nasal septum retains the triangular cartilage connected to the vertical plate of the sieve bone to prevent septal collapse. Treatment of the cartilage part: the cartilage is deviated as a whole and does not bend by itself, and the cartilage is pushed to the center with the tip as the axis. If the cartilage is curved, the cartilage will be pushed into the center after uninterrupted cutting and reduction according to the type of curvature. Bone treatment: Using the Xomed XPS 2000 ENT power cutting system with a cutting bit with a striker at the front end, the thicker vertical plate of the septum and the deviation of the plow bone were thinned and the fracture was displaced from both the inner and outer nasal septum.
Key points: 1) The incision and stripping are exactly the same as that of submucosal resection, except that the incision is chosen on the depressed side instead of the left side of the septum as a rule. 2) As in the traditional molding, the cartilage is still loosely separated from the sieve bone vertical plate and the plough bone interconnection, and the cartilage and bony deviation are treated separately. 3) The difference is that the cartilage is connected through the upper part instead of preserving one side of the mucous The cartilage membrane is kept in place to ensure that it does not detach. Bony deviation is corrected by grinding away the deviated part or by grinding thin and then fracture displacement.
3.Modified septoplasty type 2: A conventional septal anterior recessed lateral incision is made to separate the ipsilateral septal cartilage from the cartilaginous interconnections, down to the base of the nose and up to the top of the nose. From the incision, cut through the cartilage into the contralateral side, and similarly separate the contralateral cartilage from the cartilaginous membrane. The vertical plate of the septum on both sides and the connection between the plastron and the periosteum were continued posteriorly to fully expose the deviated part of the septum. Using the Xomed XPS 2000 ENT power cutting system with a cutting drill with a striker at the front end, the treatment is started from the side of the deviated projection. For the bowed deviation, the cartilage and bone plate can be directly ground thin so that it can achieve cartilage reduction and fracture displacement of the bone plate and nudge centering, and for the limited projection, it can be directly ground away. The connection between the septal cartilage and the vertical plate of the posterior superior septum is maintained as much as possible, and only partial excision or grinding of the deviation of the connection between the septal cartilage and the plastron is performed. This operation can preserve more bone and cartilage and prevent septal collapse while simplifying the surgical operation and completely correcting the high deviation.
Key points: 1) The incision and stripping are exactly the same as modified septoplasty type 1, except that the connection between the cartilage and the vertical plate of the sieve bone is preserved, and only the connection between the cartilage and the plow bone is separated, and the bony deviation of the cartilage and the vertical plate of the sieve bone is treated in one piece. Both cartilage and bony deviations are removed or/and thinned using a power system. This not only preserves as much bone and cartilage as possible, the cartilage is less likely to fall out and does not lead to collapse and softening of the nasal bridge.
Disadvantages: special instruments are required, skillful handling is needed, and inadequate treatment can easily cause re-deviation.