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.