Download Nasal Valve Stenosis

CPT Code 30465 with 20912 – Repair of Nasal Valve Stenosis with Septal Cartilage
Grafting - AGOSTINO
Equipment:
Supplies:
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Headlight; Suction; Nasal Set including: Nasal Speculae 25 mm, 45 mm,
and 70 mm; Adson –Brown Forceps; Adson – single tooth pick-ups;
two mosquito hemostat forceps; Boies butter knife; Swivel knife; Freer
elevator; Cottle elevator; Cottle knife; Woodson elevator; 15 blade
handle; Ferris-Smith Forceps; Takahashi Forceps; #7, #10 Frazier Suction;
Bayonet Forceps; Gorney Turbinate Scissors, Jansen-Middleton Forceps;
Hammer; Chisel; and, Separate Mayo-Stand
1. Sutures – 5.0 Monocryl 493G; 4.0 Monocryl Y315 dyed purple;
4.0 Vicryl on RB-1 – J214; 4.0 Black Nylon - cutter
2. Drapes – 4 towels; Standard Split Sheet or Body drape; Drape of Head
3. Prep: Ivory Soap
4. Fluids: 1 Liter Saline for Irrigation and for cartilage support
1 Liter of Water for Cleaning Instruments
5. Medications: 1% Xylocaine and 1:100,000 epinephrine solution;
Topical oxymetazoline
5. Gloves: 8 ½ Latex-Free and Powder-Free (2Pairs)
6. Dressing: ½”Steri – Strips; mastisol; Reuter bi-valve splints (0.25mm)
7. Misc. - Yankauer Suction; Orogastric Tube, Ray-tec; ½” x 3”
cottonoids; 10 cc control syringe and 27 Gauge Needle;
small basins ( 3 round and one rectangular)
Mayo Set-up:
#1 Initial Mayo is to the right of the patient and has local anesthetic; topical afrin; and
bayonet forceps and small 25 mm nasal speculum for nasal decongestion
prior to prep.
#2 Mayo Stand: L to R – and closest to pt.: Nasal Speculae 25 mm, 45 mm, and 70 mm;
Adson –Brown Forceps; Adson – single tooth pick-ups;
two mosquito hemostat forceps; Boies butter knife; Swivel knife; Freer
elevator; Cottle elevator; Cottle knife; Woodson elevator; 15 blade
handle;
Second Row, away from patient: Ferris-Smith Forceps; Takahashi
Forceps; #7, #10 Frazier Suction;Bayonet Forceps
Sequencing
1. The patient is taken to the operating room and placed under general endotracheal
anesthesia with the tube taped in the midline of the mandible. The patient is rotated
90 degrees so that the left arm of the patient usually goes toward the anesthesiologist.
2. Four of the 1/2” x 3” cottonoids are soaked in topical Afrin and two are placed in
each nostril.
3. The oral cavity is injected at the greater palatine foramina with 1% Xylocaine with
1:100,000 epinephrine solution using a 10 mL control syringe and a 27-gauge needle.
4. The nose will be injected with attention to the septum and front part of the nose as
well as the collumela, the upper lateral cartilages and as well as the lateral side walls
in both sides of the nasal septum.
5. The face will then be cleansed with the preparatory solution of Ivory soap on 4” x 4”
gauze.
6. The head will be draped with 2 towels underneath the head and a towel clip to hold
the towels out of the way as well as placing the towel across the oral cavity. The split
sheet across the body is used to cover up the area around your head.
7. An hemi-transfixion incision is made on the left side nose at the caudal end of the
septum with a 15-blade knife while retracting the collumela with a 25-mm nasal
speculum for exposure.
8. The Cottle knife is used to better define the planes in the right and left side of the
mucoperichondrium of the cartilage.
9. To elevate the right-sided submucoperichondrial plane up to the space just behind the
upper lateral cartilage, a Woodson Elevator and a 45-mm long Cottle speculum are
used.
10. The inferior one-half of the attachmment of the upper lateral cartilage to the septum
on the right side is divided.
11. The left side of the nose is exposed with the 45 mm speculum and the
submucoperichondrium of the left side of the septum is elevated extending to the
bony cartilaginous junction.
12. The Freer elevator is used to expose the inferior strip of septal cartilage on the left
side of the nose.
13. The submucoperiosteal plane over the vomer and perpendicular plate of the ethmoid
is elevated with a Cottle elevator posteriorily to the sphenoid sinus region.
14. The Anterior portion of the septal cartilage is cut vertically, at least 15 mm
posteriorly to the caudal end of the septum, with a Cottle knife, leaving an anterior
L-shaped cartilaginous strut.
15. A separate transverse cut is made posteriorly with the Cottle knife over the superior
aspect of the inferior cartilage strip.
16. The Swivel knife is used to make a posterior and inferior cut along the bony
cartilaginous junction after using the Cottle elevator to elevate the right sided
sub- mucoperichondrial flap.
17. The superior portion of the septal cartilage is removed from the mid portion of the
nose using Ferris-Smith forceps and this cartilage is set aside in a bowl of saline in
the middle of the Mayo stand.
18. The inferior strip of cartilage is then elevated off of the vomer with a Freer elevator
and the cartilage grasped with the Ferris-Smith forceps and placed in the saline.
19. We then elevate a right sided sub-mucoperiosteal flap on the right side of the bone.
20. The bone that is deviated off of the mid-line is then cut with the Gorney Turbinate
scissors and Jansen-Middleton forceps while retracting the septal mucosal flaps with
a 70 mm long speculum. The bone is removed with Takahashi forceps and set aside
in saline.
21. The cartilage that was harvested from the nose is then fashioned into the spreader
grafts. The spreader graft for the right side is fashioned by taking 2 pieces of
cartilage from the superior portion of the resected quadrangular cartilage and scoring
the middle area between these cartilage pieces that measure approximately 2 x 1
mm thick x 18 mm long. The left sided cartilage spreader graft is fashioned by
trimming the inferior strip cartilage that is removed from the lower portion of the
septum.
22. If there is a large spur to be present, this could be removed with a chisel and a mallet
or possibly using a Boies elevator in the appropriate nasal vault to push the spur and
residual cartilage in a medial direction. With the spur removed, we would redirect
attention to insertion of cartilage into the upper cartilage wall.
23. Prior to inserting this cartilage, I would detach the inferior half of the upper lateral
cartilage on the left side from the left side of the septum.
24. To insert the grafts, I place the cartilage grafts by taking 2 pieces of cartilage on the
right, passing a 4-0 Monocryl suture or Y315 suture through the skin at the bony
cartilaginous junction on the right after tagging the end of the suture with a hemostat.
The suture will be passed out through the left hemi-transfixion incision after passing
the suture through and through the septal grafts that need to be sewn together. After
these grafts are sewn together, I would then pass the suture between the upper lateral
cartilage and lower lateral cartilage junction on the right of the midline and I would
use a stay suture of Y315 Monocryl to pull the cartilage graft into the position
between the septum and the ipsilateral upper lateral cartilage. Then, I would repeat
this procedure on the left side of the midline with the 4-0 Monocryl (Y315) suture
after tagging the end of the suture with a hemostat. The suture would go
through the spreader graft on the left fashioned from the inferior strip of cartilage and
then back up to the upper cartilage and lower cartilage junction on the left of the
midline.
25. After correcting the nasal valve position, the incisions are closed with multiple
interrupted sutures of 5-0 Monocryl suture.
26. I pull the hemostats holding the 4-0 Monocryl sutures in the anterior direction and
close the septal flaps with a mattress suture of a 4-0 Vicryl (J214) suture in a left to
right and right to left alternating fashion, starting just posterior to the spreader grafts.
This prevents posterior migration of the grafts along the residual septal cartilage.
27. Thereafter, I evaluate the septum and place Reuter Bivalve splints (standard thin 0.25
mm thick) on either side of the septum and secure them with a 4-0 nylon suture.
28. The external dressing of ½” Steri-Strips and Mastisol would be applied to nose.
29. The patient has an NG tube passed to the stomach to evacuate contents.
30. The patient is allowed to awaken and extubated after placing a nasal drip pad.
© Michael A. Agostino, MD, FACS
January 13, 2010
Modified from notes from March 1, 1998.