Step 4 Submucosal Dissection of Nasal Cavity

If it is necessary to strip the nasal mucosa from the lateral wall, floor, or septum of the nose, this maneuver is done carefully with periosteal or Freer elevators. A forked right-angle retractor is placed over the anterior nasal spine and subperiosteal dissection superiorly allows the retractor to retract the septum and nasal mucosa above the level of the anterior nasal spine. A scalpel is used to make a horizontal incision on top of the anterior nasal spine, freeing the cartilaginous septum from the top of the spine and thus the attachment of the nasal mucosa from the anterior nasal spine. The rim of the piriform aperture is thin and sharp, and the nasal mucosa is adherent. Periosteal elevators are used to strip the mucosa from the entire circumference of the piriform rim.

Nasal Floor Dissector Elevator
Figure 7- 6 Submucosal dissection of the nasal cavity. Note the tip of the periosteal elevators inside the piriform aperture.

Dissection into the nasal cavity is easiest to perform along the lateral wall and floor. The anteroinferior margin of the piriform rim is usually located above the nasal floor. Thus, after freeing the nasal mucosa from the piriform rim, the elevators should be inserted inferiorly before advancing posteriorly (Fig. 7-6). Dissection of the lateral wall of the nose is performed by gently inserting a periosteal elevator between the nasal mucosa and the lateral wall of the nasal cavity. It is not advanced deeply until the entire circumference of the lower one half of the piriform has been dissected. The previously taut nasal mucosa can then relax somewhat so that the elevator can be advanced more deeply along the lateral wall. The elevator is advanced in a sweeping motion to free the entire lateral wall and floor of its mucosa to the level of the inferior turbinate. The posterior edge of the nasal floor is approximately 45 mm posterior to the piriform aperture and can be felt when the elevator steps off the posterior edge.

Once the lateral wall and floor of the nose are stripped of mucosa, the elevator is placed at the junction of the floor of the nose and the nasal septum. A tenacious attachment of the mucosa to the septal crest of the maxilla must be carefully elevated to prevent perforation. A simple maneuver for stripping the septal mucosa from this approach is to place a Freer elevator along the junction of the septum and the floor of the nose and twist it so that the edge against the septum is twisted superiorly, freeing the mucosa on the septum.

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