Endoscopic Septoplasty

Overview

Indications

• Limited or focal septal deviations (not complex multi-level deformities)
• Isolated septal spurs, especially posterior spurs
• Concurrent endoscopic sinus surgery (ESS) - when a septal deviation obstructs access to the middle meatus or makes postoperative debridement difficult
• Patients where minimal mucosal dissection is preferred

• Caudal end deflections
• Nasal spine prominence or maxillary crest irregularities
• High dorsal deflections
• Septal fractures
• Complex deviations requiring wide mucoperichondrial flap elevation
• Cummings Otolaryngology Head and Neck Surgery

Preoperative Preparation & Anesthesia

1. A dry operative field enabling careful dissection
2. Analgesic effect

• 4% cocaine solution on cotton pledgets (2-4 mL in adults), or
• Oxymetazoline

• Cummings Otolaryngology Head and Neck Surgery, p. 572

Surgical Technique

1. "Direct" Endoscopic Septoplasty (Fully Endoscopic)

2. "Assisted" Endoscopic Septoplasty

• A conventional hemitransfixion incision (made with headlamp guidance)
• Once a ~1 cm submucoperichondrial flap has been elevated, the 0-degree endoscope is inserted to guide further dissection

Key Surgical Principles

• Mucosal preservation is the primary goal - a submucous approach protects the mucoperichondrial envelope
• Avoid contiguous bilateral mucosal tears (opposite sides of the septum) - these lead to septal perforation
• Any mucosal fenestrations, even unilateral ones, should be closed with 5-0 plain suture at the time of surgery
• If mucosal flaps are weakened, crushed cartilage grafts are interposed within the envelope to prevent perforation, support the membrane, and facilitate re-entry if revision is needed
• The septum is re-quilted with a continuous 5-0 plain mattress suture (using a curved needle, not a straight Keith needle, to avoid turbinate injury and synechiae)

Endoscopic Septoplasty vs. Conventional Septoplasty

Combined with Endoscopic Sinus Surgery (ESS)

• Cause lateral displacement of the middle turbinate, obstructing the ostiomeatal complex (OMC)
• Make ESS technically difficult or impossible
• Impede postoperative endoscopic debridement

Postoperative Care

• Nasal packs (if used) are removed early; after removal, saline nasal flushing 4x/day is started
• Antibiotic ointment instilled into each vestibule beginning 24 hours postoperatively
• Gentle suctioning on postoperative days 5-10
• Gentle nose blowing permitted after week 3
• Strenuous exercise avoided for 6 weeks
• Internal nasal splints are used selectively (septal perforation repair, excoriated membrane) - soft silastic splints (0.02-inch) are preferred over hard commercial splints

Complications

• Cummings Otolaryngology Head and Neck Surgery, p. 582

Summary

Vocal Cord (Vocal Fold) Polyps

Definition

Anatomy Recap

1. Epithelium (squamous)
2. Reinke's space (superficial lamina propria) - where polyps arise
3. Intermediate lamina propria
4. Deep lamina propria
5. Vocalis muscle

Etiology & Pathophysiology

Types of VC Polyps

1. Hemorrhagic (Vascular) Polyp

• Arises from rupture of a deeper capillary - blood accumulates focally like a blood blister
• Appears dark red/purple in early stages
• Alters vocal fold margin contour and stiffens mucosa (seen stroboscopically)
• Classic history: abrupt onset hoarseness during extreme vocal effort (shouting at a party, sporting event, loud sneeze)
• May re-bleed intermittently; discoloration evolves through bruise stages

2. Pedunculated (End-Stage) Polyp

• Long-standing hemorrhagic polyp loses its vascular appearance and becomes pale, gelatinous, pedunculated
• May move in and out of the glottis with respiration
• During phonation, may be displaced upward onto the fold's superior surface
• Large pedunculated polyps can cause dyspnea and airway obstruction (ball-valve effect)

3. Sessile (Broad-Based) Polyp

• Attached to the fold by a broad base rather than a narrow pedicle
• Contains unorganized gelatinous debris in the subepithelial space

Clinical Features

• Chronic vocal huskiness
• Intermittent aberrant vocal sounds
• Impaired or absent falsetto register
• Large polyps may cause dyspnea, respiratory stridor, or ball-valve airway obstruction
• Sudden enlargement if bleeding occurs into the polyp

Diagnosis

• Voice abuse history, smoking, reflux, abrupt onset of hoarseness with exertion

• Subepithelial mass, broad-based or pedunculated
• Normal overlying epithelium (distinguishes from malignancy)
• Can be translucent (pale/gelatinous) or hemorrhagic (dark/blood-filled)

• Preserved mucosal wave (key finding distinguishing polyp from scar or sulcus)
• Stiffness of the fold at the polyp site
• Size, turgidity, and pedunculation affect vocal capabilities

Treatment Overview

Unlike nodules, vocal fold polyps do not resolve with voice therapy alone and typically require surgical removal. - K.J. Lee's Essential Otolaryngology

Microlaryngoscopy Surgery (MLS) for Vocal Cord Polyp

What is MLS?

• Binocular magnification via the operating microscope
• Direct bimanual access to both vocal folds
• A hands-free operative field

Setup and Positioning

Instruments Used

• Microlaryngoscopy forceps - various angles (right-turning, left-turning, heart-shaped, alligator) for grasping and mobilizing the polyp
• Microsurgical scissors - for cold-instrument excision
• Suction Freer elevator - for submucosal dissection
• Microsurgical cup forceps - to remove tissue fragments
• Cocaine-soaked pledgets - for hemostasis
• Laryngeal telescope (0° or 30°, 5 mm) with digital video - for telescopic visualization; provides better depth assessment than microscope alone

Step-by-Step MLS Technique for Vocal Fold Polyp

Step 1 - Laryngoscope Insertion and Suspension

Step 2 - Arytenoid Palpation

Step 3 - Polyp Identification and Assessment

• Size and extent
• Pedunculation vs. broad base
• Location on the fold
• Vascularity (hemorrhagic vs. pale)

Step 4 - Mucosal Incision (Cold Technique - Microflap)

• A small incision is made in the overlying mucosa at the superior surface or free edge of the fold, just at the base of the polyp
• Using microsurgical elevators or suction instruments, the mucosa is gently elevated off the polyp

Step 5 - Polyp Excision

• For pedunculated polyps: The polyp is grasped with heart-shaped or right-turning forceps to reveal its pedunculation and confirm mucosal flexibility; microsurgical scissors then cut the pedicle
• For broad-based / sessile polyps: Submucosal dissection separates the polyp from the underlying vocal ligament, then forceps and scissors excise the lesion
• The goal is to remove the polyp at the level of Reinke's space while preserving the vocal ligament and as much overlying epithelium as possible

"A long-standing polyp, whether hemorrhagic or at end stage and pale, should be trimmed away superficially at the time spot coagulations take place." - Cummings Otolaryngology

Step 6 - Hemostasis

• Spot coagulation of large capillaries identified in Reinke's space
• Cocaine-soaked pledgets applied for vasoconstriction and hemostasis
• For hemorrhagic polyps: the large feeding capillaries must be interrupted (slightly deeper coagulation may be needed to reach the capillary level)

Step 7 - Wound Check

• Inspect the residual wound - ideally a "tiny residual wound" is all that remains
• Ensure no contralateral mucosal injury (which could cause adhesions/web)
• Confirm no residual polyp tissue at the pedicle

Hemorrhagic Polyp: Special Surgical Considerations

• Evacuation through a tiny incision may be preferred over waiting, as spontaneous resorption is unlikely and progression to chronic polyp is expected
• After hematoma evacuation, detect and interrupt the large capillaries within Reinke's space using spot coagulation

Difficult Airway Considerations

• A ball-valve pedunculated polyp can block the airway on expiration and may be dislodged into the trachea during intubation
• In such cases, awake fiberoptic nasotracheal intubation in the sitting position is the preferred approach
• A small cuffed ETT (5.0-6.0 mm microlaryngoscopy tube) is requested
• Hollinger laryngoscope (with narrow neck and distal anterior flare) provides better glottic exposure than the Dedo laryngoscope in difficult cases

Postoperative Care

• Voice rest for 5-7 days after surgery
• Voice therapy (short course) for vocal hygiene and to prevent recurrence
• Treat underlying GERD with PPIs
• Prognosis for full return of vocal functioning after precision microsurgery is excellent

Comparison: MLS vs. KTP Laser