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PREOPERATIVE DIAGNOSES: Nasal fracture and deviated nasal septum with obstruction.

POSTOPERATIVE DIAGNOSES: Nasal fracture and deviated nasal septum with obstruction.

OPERATION: Open reduction, nasal fracture with nasal septoplasty.

ANESTHESIA: General.

HISTORY: This 16-year-old male fractured his nose playing basketball. He has a left nasal obstruction and depressed left nasal bone.

DESCRIPTION OF PROCEDURE: The patient was given general endotracheal anesthesia and monitored with pulse oximetry, EKG, and CO2 monitors.

The face was prepped with Betadine soap and solution and draped in a sterile fashion. Nasal mucosa was decongested using Afrin pledgets as well as 1% Xylocaine, 1:100,000 epinephrine was injected into bilateral nasal septal mucoperichondrium and the nasal dorsum, lateral osteotomy sites.

Inspection revealed caudal portion of the cartilaginous septum lying crosswise across the nasal spine area and columella causing obstruction of the left nasal valve. Further up, the cartilaginous septum was displaced to the left of the maxillary crest. There was a large maxillary crest and supramaxillary crest had a large spur with the vomer bone touching the inferior turbinate.

There was a large deep groove horizontally on the right side corresponding to the left maxillary crest.

A left hemitransfixion incision was made. Mucoperichondrium was elevated from left side of the cartilaginous septum and mucoperiosteum was elevated from the ethmoid plate. Vomer and inferior tunnel was created at the floor of the left side of the nose to connect the anterior and inferior tunnels, which was rather difficult at the area of the vomerine spur, which was very sharp and touching the inferior turbinate.

The caudal cartilaginous septum, which was lying crosswise, was separated from the main cartilage leaving approximately 1 cm strut. The right side mucoperichondrium was released from the cartilaginous septum as well as ethmoid plate and the maxillary crest area.

The caudal cartilaginous strut was sutured to the columella with interrupted #4-0 chromic catgut suture to bring it into the midline.

Further back, the cartilaginous septum anterior to the ethmoid plate was deviated to the left side, so it was freed from the maxillary crest, nasal dorsum, from the ethmoid plate, and was sutured in the midline with a transfixion #4-0 plain catgut sutures.

Further posteriorly, the ethmoid plate was deviated to the left side and portion of it was removed with Jansen-Middleton punch forceps.

The main deviation was also caused by the vomerine crest and the maxillary crest and supramaxillary cartilaginous cartilage.

This area was freed from the perichondrium on both sides. The maxillary crest was removed with a gouge. Vomer was partially removed with a gouge and the rest of the vomer was displaced back into the midline.

Thus, the deviated septum was corrected. Left hemitransfixion incisions were closed with interrupted #4-0 chromic catgut sutures. The septum was also filtered with #4-0 plain catgut sutures.

By valve, septal splints were tied to the septum bilaterally with a transfixion #5-0 nylon suture.

Next, the nasal bone suture deviated to the left side were corrected. The right nasal bone was depressed and left nasal bone was wide. Therefore, the nasal bones were refractured back into the midline by compressing the left nasal bone and elevating the right nasal bone with the nasal bone elevator through the nasal cavities. The left intercartilaginous incision was made and the nasal bones were disimpacted subperiosteally and they were molded back into the midline.

Steri-Strips were applied to the nasal dorsal skin and a Denver type of splint was applied to the nasal dorsal to stabilize the nasal bones.

Nasal cavities were packed with Telfa gauze rolled on both sides with bacitracin ointment. Approximate blood loss was 10 to 20 mL.

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