NASAL SEPTUM AND ITS DISEASES
DEPT OF OTORHINOLARYNGOLOGYJ J M M CDAVANAGERE
Nasal septum and its diseases
Anatomy of nasal septum:Nasal septum consists of three parts:1. Columellar septum2. Membranous septum3. Septum proper: principle constituents of septum proper are a)perpendicular plate of ethmoid b)vomer c)septal(quadrilateral cartilage) minor contributions from crest of nasal bone,nasal spine of
frontal bone,rostrum of sphenoid,crest of palatine and maxilla and anterior nasal spine of maxilla.
Nasal septum and its diseases
o Septal cartilage forms a partition between right and left nasal cavities and provides support to tip and dorsum of cartilagenous part of nose.
o Septal destruction may occur in septal abscess, injuries, tuberculosis, excess removal during SMR leads to depression of lower part of nose and drooping of tip.
o Septal cartilage lies in a groove in the anterior edge of vomer and rests anteriorly on anterior nasal spine. during trauma, it may get dislocated from nasal spine or vomer causing caudal septal deviation and spur respectively.
BLOOD SUPPLY-NASAL SEPTUM
NERVE SUPPLY-NASAL SEPTUM
Fractures of nasal septum
Aetiopathogenisis: -Trauma inflicted from front, side or below.the septum
may buckle on itself, fracture vertically, horizontally or get crushed.
-fracture of septal cartilage or its dislocation can occur without nasal bones fracture in cases of trauma to lower nose.
-septal injuries with mucosal tears cause profuse epistaxis while with intact mucosa result in septal hematoma.
Fractures of nasal septum
Types :1}Jarjaway fracture: result from blow from front.
fracture line starts just above the anterior nasal spine and runs horizontally backwards just above the junction of septal cartilage with the vomer.
2}Chevallet fracture: results from blow from below. it runs vertically from anterior nasal spine upwards to the junction of bony and cartilaginous dorsum of nose.
Fractures of nasal septum
Fractures of nasal septum
Treatment: -early recognition and treatment of septal injuries is essential.
-dislocated or fractured fragments should be repositioned and supported between mucoperichondrial flaps.
-haematomas should be drained.Complications: a) deviation of cartilagenous nose. b) asymmetry of nasal
tip,columella,or nostril.
DEVIATED NASAL SEPTUM
AETIOLOGY:1) Trauma: lateral blow-displacement of septal cartilage from vomer. blow from front-buckling, fracture, duplication of septum with
telescoping of fragments.2) Developmental: the septum should grow at the same rate as
that of face. if septum grows at faster rate it becomes buckled. unequal growth between palate and base of skull may also cause buckling (high arched palate)
3) Congenital: abnormal intrauterine posture cause compressing forces acting on nose and upper jaw.
4) Hereditary5) Racial: Caucasians are more affected6) Secondary: to a tumour, mass or polyp.
DEVIATED NASAL SEPTUM
Types:1) Deviations: upper or lower, anterior or posterior, C
shaped, S shaped. nasal cavity on the concave side of the septum will be wider and may show compensatory hypertrophy of turbinates.
2) Anterior Dislocation: seen on tilting the patients head backwards.
3) Spurs: shelf like projection at the junction of bone and cartilage. may predispose for epistaxis and headache.
4) Thickening: it may be due to organized haematoma or over-riding of dislocated septal fragments
DEVIATED NASAL SEPTUM-types
Clinical features
Nasal obstruction: depending on the type it may be unilateral or bilateral. It is the most common symptom
headache Recurrent attacks of cold Epistaxis Anosmia External deformity Middle ear infection
Clinical features
Cottle’s test: used in nasal obstruction due to abnormality of nasal valve. In this test cheek is drawn laterally while the patient breathes quietly. If the nasal airway improves on test side the test is positive and indicates abnormality of nasal valve
Cottle’s test
Differential diagnosis
Polyps
Septal haematoma
Hypertrophied turbinates
Treatment- surgery
Submucous resection of nasal septum (SMR) It is generally done in adults It consists of elevating mucoperichondrial
and mucoperiosteal flap on either side of the septum, removing the deflected parts of bony and cartilagenous septum and then repositioning the flaps
SMR
Indications Deviated nasal septum causing nasal obstruction and
recurrent headaches Deviated nasal septum causing obstruction to
ventilation of paranasal sinuses and middle ear resulting in recurrent infections
Recurrent epistaxis from septal spur As a part of septorhinoplasty Harvesting cartilage graft for tympanoplasty and
rhinoplasty As an approach to surgeries of sphenoidal sinus,
vidian nerve and pituitary gland
SMR
Contraindications Acute URTI Patient below 17 yrs of age Bleeding disorders Uncontrolled hypertension and diabetes
mellitus
SMR
Anesthesia - Local anesthesia/ general anesthesia
Positioning: reclining position with head end of the table raised
SMR - STEPS
Infiltration: subperichondrial infiltration with 2% xylocaine with adrenaline
Incision: killian’s incision- curvilinear incision 2-3mm behind the anterior end of septal cartilage
Elevation of flaps: the mucoperichondrial and mucoperiosteal flap is elevated
Incision of the cartilage- cartilage is incised just posterior to the first incision
Elevation of opposite mucoperichondrial and mucoperiosteal flap
SMR – STEPS (cont…)
Removal of cartilage and bone - cartilage can be removed with Ballinger swivel knife or luc’s forceps. Bony spur is removed using gouge and hammer
Preserve a strip of 1cm wide cartilage along the dorsal and caudal borders (struts)
Nasal packing
SMR – STEPS
complications
Bleeding Septal haematoma Damage to surrounding structures Septal abscess Septal Perforation Depression of bridge Retraction of columella Synichae Flapping septum Infection- sinus and middle ear CSF rhinorrhoea
Cottle’s line
A vertical line between the nasal process of frontal bone and nasal spine of maxillary crest. it divides septum into anterior and posterior segments
Septoplasty
It is a conservative approach to septal surgery as much of the septal framework is retained
Indications: Deviated nasal septum causing nasal obstruction and
recurrent headaches Deviated nasal septum causing obstruction to ventilation
of paranasal sinuses and middle ear resulting in recurrent infections
Recurrent epistaxis from septal spur As a part of septorhinoplasty As an approach to surgeries of sphenoidal sinus, vidian
nerve and pituitary gland
Septoplasty (cont…)
Contraindications Acute URTI Bleeding disorders Uncontrolled hypertension and diabetes
mellitus
Septoplasty (cont…)
Anesthesia: local or general anesthesia Position: same as SMR Steps : Infiltration Incision: Freer’s incision– a unilateral
hemitransfixation incision at the caudal border of the septum
Exposure: the mucoperichondrial and mucoperiosteal flap is elevated on only one side
Septoplasty (cont…)
Separate septal cartilage from vomer and ethmoid plate
Inferior strip of cartilage is removed Correct the bony septum by removing deformed
parts Minor deviations of cartilage are corrected by
criss cross incision which breaks spring action of cartilage
Nasal packing
Post-operative complications
Bleeding Septal haematoma Damage to surrounding structures Septal abscess Septal Perforation Depression of bridge Retraction of columella Synechiae Infection- sinus and middle ear CSF rhinorrhoea
Differences between SMR and septoplasty
SMR1. Radical surgery2. Not done in children3. Killian’s incision4. Flaps elevated on both
sides5. Most of cartilage removed6. Caudal dislocation not
corrected7. Perforation chance higher8. Post operative saddling
may be present9. Revision surgery difficult
Septoplasty1. Conservative surgery2. Can be done in children3. Freer’s incision4. Flap elevated on concave
side only5. Most of cartilage preserved6. Caudal dislocation
corrected7. Perforation rare8. Post operative deformity
absent9. Revision surgery easier
Septal haematoma
It is collection of blood under the perichondrium or periosteum of nasal septum
Etiology: nasal trauma, post-operative, in bleeding disorder
Clinical features: Bilateral nasal obstruction Frontal headache Sense of pressure over nasal bridge Examination reveals smooth rounded swelling of the
septum in both the nasal cavity. Palpation may show the mass to be soft and fluctuant
Septal haematoma
Treatment: small haematomas can be aspirated with a wide bore needle, larger haematomas are incised and drained. Excision of small piece of mucosa from the edge of the incision gives better drainage. Nose is packed on both sides to prevent re-accumulation. Systemic antibiotics to prevent septal abscess
Septal haematoma
Complications If not drained may organize into fibrous
tissue leading to a permanently thickened septum
If secondary infection supervenes leads to septal abscess with necrosis of cartilage and saddling
Septal haematoma
Septal abscess
Etiology Secondary infection of septal haematoma Furuncle of the nasal vestibule Clinical features Severe bilateral nasal obstruction with pain and
tenderness over bridge of nose Fever with chills Frontal headache Skin over the nose may be red and swollen Smooth bilateral swelling of the nasal septum Congested septal mucosa Submandibular nodes may be enlarged and tender
Septal abscess
Treatment Abscess should be drained as early as
possible Pus and necrosed cartilage removed by
suction Incision may required to be re-opened daily
for 2-3 days to drain any pus or remove any necrosed piece of cartilage
Systemic antibiotics to be started as soon as possible and continued for two weeks
Septal abscess
Complications Depression of the cartilagenous dorsum Septal perforation Meningitis and cavernous sinus thrombosis
(rare)
Nasal septal perforation
Etiology Traumatic - post surgical, habitual nose picking, cauterization of
septum with chemicals or galvano-cautery for epistaxis Pathological perforationa) Septal abscessb) Nasal myasisc) Rhinolith or neglected foreign bodyd) Chronic granulomatous conditions like TB, lupus, leprosy, syphilis,
wegener’s Inhalant irritants- snuff and cocaine irritant, industrial toxins Malignancy idiopathic
Nasal septal perforation
Clinical features Whistling sound Irritation and crusting Epistaxis Nasal obstruction
Nasal septal perforation
Treatment Treat the root cause Inactive small perforation can be surgically
closed by plastic flaps or septal mucosal flaps
Larger perforations are difficult to close: their treatment is aimed to keep the nose crust free by alkaline nasal douch and application of lubricants, silastic obturator may also be used
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