Access osteotomy - Lateral Rhinotomy

The Lateral Rhinotomy approach is indicated for access for tumors involving the nasal cavity ethmoid sinus or anterior skull base. This allows exposure of the entire nasal cavity. Superiorly this extends to the skull base and inferiorly to the floor of the nose. All three turbinates are also exposed.

The patient is placed in a supine position with the entire face prepared and draped into the surgical field.

A 6.0 suture is passed through the skin of the upper eyelid and exits through the Gray line of the upper lid margin.

In the lower eyelid the needle is passed from the Gray line into the skin where it exits.

The suture is guided back picking up the same soft-tissue portions in the lower and upper eyelid to complete the mattress loop.

The tarsorrhaphy is not tightly secured and some space is left between the knot and the upper-eyelid skin. A hemostatic clamp is used to grasp the suture and apply traction to lower lid for full eyelid closure during the surgical procedure.

Since the suture was not fully tightened, when the hemostatic clamp is released, the lid may be opened for a forced duction test or evaluation of the pupil during the procedure.

The tissue is infiltrated with local anaesthetic containing vasoconstrictor (eg. 1 % Xylocaine with 1/100 000 epinephrine).

The incision is made around the base of the nose (or entering the nostril floor for a better esthetical result) and along the facial nasal groove (In the border of both esthetic units). The dissection goes deep to the subperiosteal plane of the frontal process of the maxilla.

Below the nasal bone the incision is deepened through the nasal mucosa.

The lateral aspect of the nasal bone is identified. A unilateral nasomaxillary osteotomy is made with a small osteotome, and the two osteotomy lines are joined at the level of the naso frontal junction.

The soft tissue and nasal skeleton are elevated and reflected to the contralateral side. This allows the exposure of the nasal cavity. The septum is cut and freed from the mobilized segment according to the resection plan.

This cut is usually part of the tumor resection. See the resection procedure.

The nasal skeleton is rotated back in place and no fixation is necessary, though a microplate fixation of the nasal bones may be used. The subcutaneous tissues are closed with an absorbable suture and the skin is closed with a permanent suture.