5 deviated-nasal-septum
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Transcript of 5 deviated-nasal-septum
Deviated Nasal Septum
Dr. Vishal Sharma
Aetiology1. Trauma: blow on nose
2. Developmental:
Birth moulding High arched palate
Unequal growth b/w skull base & palate
3. Mass in opposite nasal cavity
4. Racial factors: common in Europeans
5. Hereditary: in posterior D.N.S.
Types1. Anterior / caudal dislocation
2. C-shaped deformity
3. S-shaped deformity
4. Septal Spur: shelf-like projection
5. Septal Thickening: organized hematoma
or over-riding of septal fragments
6. Impacted septum: despite decongestion
Anterior / caudal dislocation
C - shaped
S - shaped
Nasal septal spur
Thickened & impacted nasal septum
C-shaped DNS not touching lateral nasal wall
C-shaped DNS touching lateral nasal wall
Compensatory turbinate hypertrophy
Clinical features1. Nasal block: present on side of D.N.S.
C/L paradoxical nasal obstruction due to
compensatory inferior turbinate hypertrophy.
2. Recurrent cold: due to associated sinusitis
3. Headache: due to contact with lateral wall
(Sluder’s neuralgia), sinusitis
Clinical features4. Epistaxis: stretched mucosa on DNS dry
crusting & bleeding on removal; stretched
blood vessels over spur.
5. Hyposmia:
seen in high D.N.S.
6. External nasal deformity
Sequelae
• Sinusitis
• Mouth breathing snoring, pharyngitis
• Atrophic rhinitis & myiasis
• Otitis media
History of septal surgeries
• Edwin Smith Surgical Papyrus (dated 17th
century BC): world's oldest surgical
document & only surviving copy of a part of
an Ancient Egyptian textbook on trauma
surgery written in 3500 B.C. Listed are 48
traumatic injury cases, with description of
examination, diagnosis & treatment.
• Treatment of DNS: fracture reduction of DNS
with internal pack using grease coated linen
& external packing with stiff rolls of linen.
Edwin Smith Papyrus
• Bosworth operation (late 19th century): deviated part of septum amputated along with mucosa
• Asch (1899): full thickness cruciate incisions on septal cartilage
• Freer (1902): SMR of total septal cartilage • Killian (1904): SMR with preservation of dorsal &
caudal portion of septal cartilage • Metzenbaum (1929): Swinging door technique for
caudal septal dislocation• Peer (1937): Removal of caudal septum &
replacement after its alteration • Cottle (1948) : Maxilla-Premaxilla septoplasty
Gustav Killian
Maurice Cottle
Indications for septal surgery
1. D.N.S.: nasal obstruction / sinusitis /
headache / epistaxis
2. Along with rhinoplasty
3. Harvesting of septal cartilage graft
3. Trans-septal surgeries:
Hypophysectomy Vidian neurectomy
4. Hereditary telengiectasia
Septoplasty
Freer’s Incision
Cottle’s line
Drawn from frontal
spine to anterior nasal
spine. Deviations
anterior to it can be
treated by septoplasty
only. Posterior to it by
SMR or septoplasty.
Muco-perichondrial flap elevation on right side
Anterior + Inferior tunnels
Inferior cartilage strip removal
Dislocation of bony cartilaginous junction
Muco-periosteal flap elevation on both sides
Cartilage + Bone removed
Scoring & cross-hatching
Wedge excision & shaving
Anterior nasal packing
Outer nasal packing
Submucosal Resection
Killian’s incision
Muco-perichondrial flap elevation on right side
Cutting of cartilage & elevation of opposite flap
Excision of septal cartilage
Excision of septal cartilage
Cartilage + Bone removed
Anterior nasal packing
S.M.R. SeptoplastyRadical surgery Conservative
Not done below 17 yr Done after 4 yr
Killian’s incision Freer’s incision
Cannot correct anterior DNS Can correct
B/L mucoperichondrium elevated One side only
Radical removal of cartilage Only inferior strip
Rhinoplasty incision can’t combine Can
Revision surgery difficult Relatively easy
Cartilage graft can be harvested No
Complications common Rare
Complications of septal surgery
1. Haemorrhage 2. Septal haematoma
3. Septal abscess 4. Septal perforation
5. Saddle nose 6. Columellar retraction
7. Flapping septum 8. Persistent deviation
9. Nasal synechia 10. C.S.F. rhinorrhoea
11. Infection 12. Toxic shock syndrome
Septal haematoma Collection of blood under perichondrium
& periosteum of nasal septum.
Aetiology:
1. Nasal trauma
2. Septal surgery
3. Bleeding disorders
Clinical features• Bilateral nasal obstruction
• Sense of pressure over nasal bridge
• B/L smooth, rounded septal swelling
• On palpation mass is soft & fluctuant
• Absence of raised temperature, erythema,
swelling & tenderness of skin over nose.
Septal Haematoma
Treatment
1. Small: wide bore needle aspiration
2. Large:
a. incision & drainage
b. nasal packing (prevent recurrence)
c. systemic antibiotics (prevent abscess)
Complications
• Thickened nasal septum
• Septal abscess with cartilage necrosis
• Saddle nose
• Supra-tip deformity
• Septal perforation
Septal abscessCollection of pus under perichondrium
& periosteum of nasal septum.
Aetiology:
1. secondary infection of septal hematoma
2. following furuncle of nose or upper lip
3. following typhoid or measles
Clinical Features
• Bilateral nasal obstruction with fever
• Skin over nose shows raised temperature,
erythema, swelling & tenderness
• B/L smooth, soft, fluctuant septal swelling
• Septal mucosa congested
• Submandibular node enlarged & tender
Septal Abscess
Septal abscess
Treatment
• Abscess drained immediately
• Incision made on most dependent part
• Pus & necrosed cartilage removed
• Nasal packing done
• Systemic antibiotics for 10 days
Complications
• Necrosis of septal cartilage
• Saddle nose
• Supra-tip deformity
• Septal perforation
• Meningitis
• Cavernous sinus thrombosis
Saddle nose
Nasal synechia
Perforated nasal septum
Aetiology1. Trauma: septal surgery, nose picking,
septal cautery, ornamentation
2. Infection: septal abscess
3. Nasal Irritants: snuff, cocaine
4. Foreign body, Rhinolith, Nasal myiasis
5. Granuloma: TB, leprosy, syphilis, Wegener
6. Malignancy 7. Idiopathic
Clinical features
Small perforation: whistling sound
during respiration
Large perforation: nasal crusting
nasal obstruction
epistaxis on crust removal
Perforated nasal septum
Treatment
• Treat cause of septal perforation
• Alkaline nasal douche for crusting
• Small perforation: closed by mucosal
advancement flaps
• Large perforation: Silastic obturator,
Alloderm. Results of surgery are poor.
Nasal mucosal flaps
Nasal mucosal flaps
Sublabial flap
Silastic obturator
Thank You