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Nasal septum and its diseases
1. NASAL SEPTUM AND ITS DISEASES
DEPT OF
OTORHINOLARYNGOLOG
Y
JJM M C
DAVANAGERE
2. Nasal septum and its diseases
Anatomy of nasal septum:
Nasal septum consists of three parts:
1. Columellar septum
2. Membranous septum
3. 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.
3. 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.
6. 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.
7. 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.
9. 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.
10. 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) Hereditary
5) Racial: Caucasians are more affected
6) Secondary: to a tumour, mass or polyp.
11. 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
13. 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
14. 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
17. 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
18. 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
19. SMR
Contraindications
Acute URTI
Patient below 17 yrs of age
Bleeding disorders
Uncontrolled hypertension and diabetes
mellitus
20. SMR
Anesthesia - Local anesthesia/ general
anesthesia
Positioning: reclining position with head end
of the table raised
21. 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
22. 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
24. 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
25. 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
26. 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
28. 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
29. 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
30.
31. 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
32. Differences between SMR and
septoplasty
SMR Septoplasty
1. Radical surgery 1. Conservative surgery
2. Not done in children 2. Can be done in children
3. Killian’s incision 3. Freer’s incision
4. Flaps elevated on both 4. Flap elevated on concave
sides side only
5. Most of cartilage removed 5. Most of cartilage preserved
6. Caudal dislocation not 6. Caudal dislocation
corrected corrected
7. Perforation chance higher 7. Perforation rare
8. Post operative saddling 8. Post operative deformity
may be present absent
9. Revision surgery difficult 9. Revision surgery easier
33. 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
34. 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
35. 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
37. 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
38. 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
39. Septal abscess
Complications
Depression of the cartilagenous dorsum
Septal perforation
Meningitis and cavernous sinus thrombosis
(rare)
40. Nasal septal perforation
Etiology
Traumatic - post surgical, habitual nose picking, cauterization of
septum with chemicals or galvano-cautery for epistaxis
Pathological perforation
a) Septal abscess
b) Nasal myasis
c) Rhinolith or neglected foreign body
d) Chronic granulomatous conditions like TB, lupus, leprosy, syphilis,
wegener’s
Inhalant irritants- snuff and cocaine irritant, industrial toxins
Malignancy
idiopathic
41. Nasal septal perforation
Clinical features
Whistling sound
Irritation and crusting
Epistaxis
Nasal obstruction
42. 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