LESSON 1: Eye, Ear, Nose, and Throat (EENT) Surgery

Section IIi: nose SURGERY

1-30

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1-30. SEPTECTOMY, OR SUBMUCOUS RESECTION

a. General. Septectomy, or submucous resection (SMR) deviations of the nasal septum may result from faulty development of the septum or from injury to the nose. The patient's symptoms include inadequate or difficult nasal breathing or obstruction of nasal drainage. Septal deviations tend to cause sinus disease and the formation of polyps. The operation consists of removing the bent parts of the nasal septum that lie between the flaps of mocous membane to establish a straight partition.

b. Preparation of the Operating Room.

(1) The setup of sterile instruments and other equipment is done as prescribed locally. Gauze packing is included for use as a pressure dressing.

 

(2) The room is darkened before the patient arrives. The surgeon usually uses an electrical head lamp that will focus a beam into the nostrils. The circulator is to connect and carefully check all special lighting equipment prior to the start of the procedure.

 

(3) This operation is generally done with the patient under local and/or topical anesthesia. Before the patient arrives, the operating table is made into a reclining chair by use of a foot-piece and pillows placed for protection of feet from pressure and relief of strain on vessels and tendons of the lower extremities. The reclining chair is adjusted to meet the physical characteristics and comfort of the patient. The table is raised or lowered to accommodate the surgeon.

c. Preparation of the Patient.

(1) In some cases, the hair of the nostrils may be clipped with fine, curved scissors. Sterile mineral oil drops or an antibiotic ointment may be put in the eyes of the patient to protect them from prepping solutions. The face is scrubbed with a mild soap and water. The face prep and draping of the patient is done prior to anesthetizing. The circulating nurse should observe changes in the vital signs of the patient. When cocaine or some similar narcotic agent is used, a thiopental (Pentothal®) sodium setup and oxygen equipment should be in the room. Topical medications that have changed color should not be used. The amount of the topical agent dispensed for the operation must be recorded on the anesthesia record and on the pharmacy's narcotic form.

 

(2) The patient is draped with sterile towels and sheets as follows:

(a) Place the small sheet with two towels on top of it over the head of the table and under the head of the patient.

 

(b) Bring the uppermost towel around the head, including the hairline.

 

(c) Secure the ends of the uppermost towel with a towel forceps and tuck the free ends under the patient's head.

 

(d) Drape a large sheet over the patient, bringing its upper end up to the chin.

 

(e) Place the tray with the instruments in position for the surgeon.

 

(f) Adjust the lighting system.

 

(g) Record the vital signs of the patient.

 

(h) Reassure the patient if awake.

d. Operative Procedure. The operative procedure will vary with the individual surgeon. A general review of most procedures is as follows:

(1) The nostril is opened with a speculum. An incision is made through the mucoperichondrium and mucoperiosteum of the septum with a knife, blade number 15. The tissues are separated and elevated, using a Freer knife.

 

(2) The cartilage is incised with a knife, and the mucous membrane is elevated with a septal elevator; part of the septal cartilage is excised with a Ballenger knife; deviated cartilage and bony, thickened structures are removed with a septum punch and a nasal cutting forceps.

 

(3) The mucous membrane is freed from the bony septal base by means of a chisel, gouge and mallet, or punch forceps. Bleeding is controlled by cotton sponges; suctioning is used to expose the field.

 

(4) The perpendicular plate of the ethmoid may be removed, as well as the vomer, by means of the S-retractor, chisel and mallet, and a suitable septum-cutting forceps.

 

(5) The incision may or may not be sutured with silk #3-0 fused to a small 1/2-circle taper-point needle on a Crile needle holder.

 

(6) Nostrils are packed with petrolatum gauze in order to keep the septal flaps in a midline position. The face is cleansed with both moist and dry compresses.

e. Specimens. Excised tissue is processed as a specimen.

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