2.2 Lateralising turbinates and raising septal mucosal flaps
We perform the transseptal approach using a 0 degree endoscope from the
start, although the initial steps could as well be performed using a
headlight akin to performing a septoplasty. Bilateral middle and
superior turbinates are pushed laterally using a Freer elevator to
create space for the flap in the nasal cavity (we do not routinely
resect the middle turbinates as some do). Incision is made on the nasal
septum using a no.15 scalpel blade in level with the anterior end of the
middle turbinate (Figure 1a), adjusting for any inherent septal
deflections; for example, if there is a sharp deviation that might
interfere with movement of instruments and endoscope further on and
needs removal upfront then the incision is made that bit further
anteriorly. Helpful modifications of this incision are detailed in the
discussion section. The incision starts approximately a centimetre below
the skull base superiorly (to avoid transecting the olfactory region and
down to the nasal septal floor inferiorly). The latter is important
because the septal flap would then be anchored at the floor rather than
the inferior part of the septum itself resulting in a) wider operative
field because the septal flap can be pushed more laterally into the
nasal cavity and b) reduced risk of inadvertently “dividing” the
flap’s inferior attachment whilst raising the mucoperichondrial flap. A
freer or suction elevator is used to raise a mucoperichondrial flap on
the ipsilateral side from skull base superiorly, up to nasal floor
inferiorly and on to the anterior surface of the sphenoid sinus (Figure
1b). Sphenoid sinus opening comes into view at the end of this step.