Chapter 185 - Septoplasty, Turbinate surgery Flashcards Preview

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Flashcards in Chapter 185 - Septoplasty, Turbinate surgery Deck (42)
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1
Q

Strut - what it is, why its important

A

1.cm dorsocaudal

Avoid loss of tip support, saddle nose

2
Q

What to do with excised cartilage

A

May replace into mucoperichondrial pocket to decrease septal perf risk

3
Q

Blood supply to IT

A

br of posterior lateral nasal artery

4
Q

Tip support maj/min

A

Major: septum, lower lateral cart, upper lat (attachments between these)

Minor: interdomal lig, dorsal septum, membranous septum, sesamoid, skin, SQ tissue of tip, maxillary spine

5
Q

Nose in cleft lip/palate

A

I/L LLC displaced I/P/L
Nasal tip, caudal septum, columella toward non-cleft side
Bony septum toward cleft side

6
Q

Common complications of untreated septal hematoma

A

Septal perf, Saddle nose

7
Q

What to do if afrin is injected into vessels

A

phentolamine (a blocker)

Oxymetazoline will cause HTN, vasoconstriction, tachycardia

8
Q

Sx of TSS

A

high fever, vomiting, hypotension, diarrhea, rash, multiorgan failure
Due to TSST-1 toxin

9
Q

How many people have a deviated septum?

A

50%

most asymptomatic

10
Q

Killian vs Hemitransfixion vs Transfixion

A

Killian - past mucocutaneous junction, less risk of tip support loss?

Hemi- at mucocutaneous junction, better access to caudal septum, allows bilateral flap elevation

Transfixion - bilateral hemi, allows access to caudal, columella, medial crura

11
Q

Steps to septoplasty

A
  • afrin spray, inject epi:lido bilateral in subperichondrial space
  • incision near caudal septum, subperichondrial flap
  • disarticulate septal cart, remove bony septum if necessary
  • resect septal cart (leave strut)
  • repair tears in flaps
  • consider replacing excised septum into mucoperichond pocket
  • close mucosal incision, quilt septum, splints
12
Q

Postop care and instructions after septoplasty

A

May have congestion, pain, bloody drainage mild intermitt, fatigue. Also may have nausea, dry mouth, difficulty sleeping
ABX, analgesics, antiemetics
Moisten nasal cavities with saline, keep head elevated
Take a week off work/school
Light activity first week
Full activity 1-2 weeks
F/u in 1-2 weeks
Complete mucosal healing within 3-4 weeks

13
Q

Risks of septoturbinoplasty

A

infection, bleed, dry/crust, persist congestion, hematoma/abscess, perf, scar, alter smell/taste, numb, CSF leak, cosmesis

14
Q

Anatomy of IT

A

medial submucosal tissue - vein, erectile
lateral- glandular
Hasner’s valve (flap at NLD orifice) opens into inf meatus

15
Q

Max dose of lidocaine, bupivacaine, cocaine

A

Lido: 5 (without epi) 7 (with epi) mg/kg (some say 4/7.5)
Bupiv: 3mg/kg
Cocaine: 2-3 mg/kg or 200mg

16
Q

Amides vs Esters

A

Amide- metaolized in liver. Lidocaine, Bupivacaine. Almost never have allergic rxn (if so, likely to preservative)

Ester- met in liver and plasma, may have allergic rxn, ut still likely due to preservative. Cocaine.

17
Q

Sx of local anesthetic toxicity

A
  • Sense of doom, HA, anxiety, palp, respiratory distress, HTN, restless, disorient, rambling speech, seizures, vomiting, tachy, sweat
  • THEN: LOC, apnea, bradycardia, hypotension, CV collapse
18
Q

prilocaine, banzocaine toxicities, how to treat the major one

A

Benzo 200mg, Prilo 7mg/kg
Methemoglobinemia - hypoxia, SOB, cyanosis, AMS, HA
arrythmia, seizure, coma, death
Pulse ox inaccurate
Tx- supp O2, slow IV influsion of 1-2 mg/kg 1% methylene blue

19
Q

Improving hemostasis in nasal surgery

A

Stop anti-coagulant meds 1-2 weeks before and after surgery
HOB elevated 30 deg during surg
Decongestants
Minimize mucosal trauma

20
Q

When congestion due to turbinate hypertrophy is better during the day

A

upright
exposure to steam
exercise

21
Q

When to do surgery on turbintes

A

Persistent sx affecting QOL

Despite steroids, a-histamine, saline, decong

22
Q

Treatment of ozena

A

(Empty Nose Syndrome)

Saline, topical ointments, augment inferolateral nasal wall

23
Q

When to consider middle turbinate surgery

A

Avoid if unnecessary because it helps with humidification, airflow, proper sinus drainage, olfaction

May reduce if polypoid degeneration or concha bullosa

24
Q

Internal nasal valve

A

Septum, head of inf turb, upper lateral cartilage

25
Q

External nasal valve

A

columella, lateral crus of LLC, nasal ala

26
Q

Congestion with nasal valve collapse: worse or better with exercise?

A

Worse

Better with breathe right strips or cottle maneuver

27
Q

Treatment of nasal valve collapse

A

Intranasal stent, Breathe Right
Spreader graft, flaring sutures, butterfly graft, batten graft, lateral crural strut graft, alar rim graft, bone anchored suture
Cartilage from septum, ear or rib

28
Q

Septal hematoma/abscess presentation

A

Acute congestion, pain, swelling, fever

Fluctuance of septum occluding nose

29
Q

Septal hematoma/abscess treatment

A

Immediate I&D (local or general)

nasal splints 1 wk (prevent recurrence)

30
Q

Presentation of septal perforation

A

whistling sound, dryness, crust, bleeding, pain, congestion, drain, ASx

31
Q

DDx septal perforation

A
surgery
trauma
drug use
vasculitis
infxn
granulomatous disease
malignancy
32
Q

Treatment of septal perf

A

Cons: saline, ointment
Surg: silastic septal button or repair
If 5mm or less, primary repair with interpositional graft
If 0.5-2cm, open approach, local mucosal flaps
If >2cm, tough to repair

33
Q

Contraindications to septal perf repair

A

active cocaine abuse

active infection, inflammatory, malignant disease

34
Q

Causes of saddle nose

A

nasal trauma
aggressive surgery during hump reduction
inadequate dorsal strut in septoplasty

35
Q

Treatment of saddle nose deformity

A

Open

Augment area with conchal or rib cartilage (onlay technique)

36
Q

How old a child should be prior to septoplasty

A

16 (by then, nose development usually complete)

Can do turbinoplasty when younger, but be conservative

37
Q

When you may need to go from endonasal septoplasty to open

A

Deviation from midline in dorsal septum, septal angle, caudal septum, nasal spine

38
Q

How to correct deviation of dorsal septum, septal angle

A

shave, extended spreader grafts

39
Q

How to correct deviation of posterior septal angle

A

shave, reposition cartilage on nasal spine

40
Q

How to correct deviation of caudal septum

A

septal batten graft, reposition, tongue-in-groove technique, caudal septal extension graft

41
Q

Pros and cons to nasal splints after nasal surgery

A

Pros: eliminate dead space between flaps, prevent hematoma, enhance mucosal healing, prevent synechiae, stabilize remaining septal cartilage
Remove 1 wk after
Cons: discomfort, infection, studies don’t show major differences between splint and non-splint, so may not be necessary

42
Q

How nasal surgery impacts sleep disordered breathing

A

Improved CPAP compliance, subjective sleep sx, QOL

More likely to help if breathe right strips or topical decongestants help decrease snoring or improve sleep quality

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