Endoscopic nasal surgery encompasses a variety of procedures, including submucous septoplasty, nasal cavity hemostasis, submucous resection of the inferior turbinate bone, dacryocystorhinostomy, and removal of nasal cavity masses. The patient is positioned supine, and the skin around the mouth and nose is routinely disinfected before sterile drapes are applied. General or local anesthesia is administered depending on the case.
Submucous Septoplasty
Indications
Indications include:
- Persistent nasal obstruction caused by nasal septal deviation.
- Drainage obstruction of the paranasal sinuses due to septal deviation.
- Headaches caused by nasal septal deviation.
- Epistaxis associated with nasal septal deviation.
- A preparatory procedure for certain nasal cavity or sinus tumors and chronic rhinosinusitis (CRS) surgeries.
Preoperative Assessment
This includes nasal endoscopy and sinus CT imaging. The purposes are:
- Assessing the relationship between septal deviation and sinusitis.
- Detecting lesions that may complicate endoscopic surgery.
- Identifying the areas and extent requiring correction.
- Identifying lesions that may affect postoperative nasal and sinus ventilation and drainage.
- Detecting potential lesions that could lead to postoperative nasal adhesions.
Surgical Steps
An incision is made along the junction of the skin and mucosa of the nasal septum, extending from top to bottom. The septal mucosa and mucoperiosteum are dissected on the side of the incision, and approximately 1–2 mm posterior to the incision, the cartilage is incised down to the contralateral mucoperiosteum. Dissection continues in the submucoperichondrial space on the contralateral side. The tension in the quadrilateral cartilage is relieved by making a vertical strip resection 2–3 mm anterior to the incision, representing the first tension-relieving zone, while preserving as much cartilage as possible. The second tension-relieving zone occurs at the junction of the quadrilateral cartilage and the perpendicular plate of the ethmoid bone. A portion of the thickened perpendicular plate is excised to align it with the quadrilateral cartilage. The third tension-relieving zone is located at the junction of the quadrilateral cartilage with the nasal crest of the maxilla and palatine bone and the vomer, where bone spurs or deviations are common. By freeing these three tension zones, the nasal septum is restored to a central position. To prevent subsequent nasal bridge or dorsum collapse postoperatively, care is taken to preserve the supportive midline structures of the septal cartilage and bone.
For cases of isolated septal spurs or localized deviations, tension-relieving procedures may be performed exclusively at affected areas. Incisions are made anterior to the localized deviation or along the surface of the spur. Submucoperiosteal dissection is performed to remove the deviated bone. The extent of dissection depends on the severity of the deviation and aims to ensure adequate exposure of the surgical field and removal of deviated bone.
Nasal Cavity Hemostasis
Basic Principles
The bleeding site is identified and hemostasis is achieved quickly and effectively, suitable for arterial or venous bleeding from clearly localized sites within the nasal cavity. Common sites of nasal bleeding include the Little’s area on the nasal septum, the posterior part of the inferior meatus, the posteroinferior nasal septum, the anterior wall of the sphenoid sinus (near the choanal margin), and the nasal roof (olfactory cleft).
Surgical Methods
Endoscopy provides direct visualization with clear illumination and precise localization of the bleeding site. Techniques such as high-frequency electrocoagulation, low-temperature plasma radiofrequency, laser coagulation, microwave coagulation, or nasal packing are used to achieve hemostasis.
Points of Note
In cases of severe bleeding where the bleeding site is difficult to locate or hemostasis cannot be immediately achieved using electrocoagulation, laser, or microwave methods, adrenaline-soaked cotton strips are utilized to control active bleeding and clear nasal cavity clots. If no active bleeding is observed after applying adrenaline, arterial bleeding might appear as a slight mucosal bulge, identified through suction-induced rebleeding that confirms the source.
Output power selection for plasma, laser, and microwave equipment is carefully managed to avoid deep tissue burns, and coagulation is performed in multiple sessions. Special attention is paid when operating near the upper nasal septum to prevent septal perforation.
Advantages of Endoscopic Nasal Hemostasis
These include:
- Facilitating precise identification of bleeding points in all regions of the nasal cavity, particularly the posterior nasal cavity.
- Enabling accurate, efficient hemostasis under direct visualization with minimal difficulty and trauma.
- Reducing unnecessary use of anterior or posterior nasal packing and being suitable for treating epistaxis in patients with hypertension, cardiovascular diseases, or blood disorders.
Submucous Resection of the Inferior Turbinate Bone
This is primarily used for nasal obstruction caused by hypertrophy of the inferior turbinate secondary to osseous hyperplasia. A longitudinal incision is made along the lower edge of the inferior turbinate, reaching the turbinate bone. Tissue is bluntly dissected to expose the bone, and parts of the middle or lower sections of the bone are excised. After proper alignment of the mucosa, hemostasis is achieved, and the area is packed to stabilize and control bleeding.
Dacryocystorhinostomy
This is indicated for lacrimal sac obstruction of various causes. The posterior boundary for this procedure is the attachment of the uncinate process, with the anterior limit being the attachment of the anterior part of the middle turbinate. A U-shaped mucoperiosteal flap is created to expose the frontal process of the maxilla. Bone is drilled away to expose the lacrimal sac. A lacrimal probe is inserted through the punctum and lacrimal canaliculus to locate the sac. The sac is incised, and its flap is reflected posteriorly to cover the exposed bone. A wedge-shaped expanding sponge is placed at the sac opening for dilation. Postoperatively, daily lacrimal duct irrigation is performed to maintain patency.