Nasal septum and its diseases[1]

DR PRIYANKA

Development Anatomy Septal diseases : deviated septum septal perforation septal fractures involvement in

systemic diseases

DEVELOPMENT Developin brain and pericardium forms two

prominent bulgings on the ventral aspect of embryo separated by stomatodaeum

Mesoderm covering the forebrain forms a downward projection : frontonasal process

Mandibular arch forms the lateral wall of the stomatodaeum which gives off a bud nd grows to form maxillary and mandibular process

Ectoderm in frontonasal process forms b/l localized thickenings to form nasal placodes.

These sink below the surface to form nasal pits.

Edges of the pit are raised to form the medial and lateral nasal process

Maxillary process grows medially fuses with the lateral nasal process and then with the medial nasal process

Medial and the lateral nasal process fuse

Nasal septum develops with the fusion of maxillary process and frontonasal process.

Initially its entirely cartilagenous, together with triangular cartilages forms a cartilagenous structure that supports the nose from the crista galli to the lower third of nose

A midline ridge develops from the posterior edge of frontonasal process in the roof of oral cavity and extends posteriorly to the opening of the rathkes pouch

This becomes the nasal septum which is continuous with the partition anteriorly between the primitive nasal cavities

On either side of the anterior septum, an invagination of ectoderm forms the vomeronasal organ : rudimentary in humans

Longitudinal strips of cartilage 7-15mm in length may be identified in embryos lyin adjacent to the vomeronasal organ on either side of the septal cartilage

Cephalic part of septum ossifies from the perpendicular plate of ethmoid bone.

Vomer develops in the tissues covering the posteroinferior part of septal cartilage

Two ossification centres appear for vomer at 8th week on eithr side of cartilage uniting to form a deep groove in which the cartilage sits

Nasal bones arise during 10th and 11th weeks

ANATOMY NASAL SEPTUM HAS 3 PARTS : COLUMELLAR :  Columellar septum. It is

formed of columellaContaining the medial crura of alar cartilages united together by fibrous tissue and covered on either side by skin.

Membranous septum. It consists of double layer of skin with no bony or cartilaginous support. It lies between the columella and the caudal border of septal Cartilage. Both columellar and membranous parts are freely movable from side to side.

Septum proper. It consists of osteocartilaginousframework, covered with nasal mucous membrane.

Cartilagenous portion composed of quadrilateral cartliage, contributions from lower and upper lateral cartilages.

Quadrilatral cartilage(Septal cartilage) not only forms a partition between the right and left nasal cavities but also provides support to the tip and dorsum of cartilaginous part of nose.

Septal cartilage lies in a groove in the anterior edge ofvomer and rests anteriorly on anterior nasal spine

Its destruction leads to drooping of nasal tip and depression of nose

is 3-4 mm thick in its centre and increases to 4-8 mm anteroinferiorly, this is called the footplate

Similar expansion of cartilage can be seen posteriorly known as lateral posterior process at the junction of lateral nasal cartilage

Anteroinferior edge lies free in the columellar septum

It sits inferiorly in the nasal crest of the palatine process of maxilla

Its anterosuperior margin is connected to the posterior border of the internasal suture

Distal end of superior margin is connected by fibrous tissue on each side to the medial crurae of the major alar cartilage

Posterosuperior border is continuous with the perpendicular plate of ethmoid

Posterior septal angle formed where septum articulates with the nasal spine anteroinferiorly

A : Anterior septal angle

B mid septal angle C : posterior septal

angle

Bony septum : mainly by perpendicular plate of ethmoid and vomer

Minor contributions : crest of nasal bone

nasal spine of frontal bone

rostrum of sphenoid

crest of palatine bone

crest of maxilla

anterior nasal spine of maxilla

Bony septum: perpendicular plate of ethmoid forms the superior and anterior bony septum, which is continuous above with the cribriform plate and crista galli.

Vomer defined as keel shaped bone, extends anteriorly from spenoid and superiorly from nasal crest of maxilla and palatine bone.

forms the posterior and inferior nasal septum and articulates by its two alae with the rostrum of sphenoid creating vomerinovaginal canals which transmit pharyngeal branches of maxillary artery.

Inferior border of vomer articulates with nasal crest formed by maxillae and palatine bones.

Anterior border articulates with perpendicular plate of ethmoid and septal cartilage inferiorly.

Posterior border forms the free edge

ARTERIAL SUPPLY Internal and external carotid system Sphenopalatine artery : posteroinferior septum Greater palatine artery anteroinferior part of

septum Superior labial artery branch of facial artery anterior and posterior ethmoid arteries

Sphenopalatine artery : enters through the sphenopalatine foramen and immediately divides into posterior septal and posterior lateral rami

Posterior septal branch runs medially across the sphenoid to the posterior part of septum

Takes course anteroinferiorly in mucoperichondrium

Terminal branches anastomose in littles area

Anterior ethmoid artery traverses the anterior ethmoid canal, descends into cavity through slit by the side of crista galli, runs along inner surface of nasal bone and supplies the nasal septum

Usually in a mesentry just below skull base between ethmoid fovea and lamina papyracea

Posterior ethmoid artery enters posterior ethmoid foramen situated 5mm anterior to optic canal,

Gives nasal branches which enters nasal cavity through the cribriform plate apertures and anstomoses with sphenopalatine artery br.

Nerve supply Maxillary division of trigeminal nerve Nasopalatine nerves supplies bulk of nasal

septum Enters via SPF passing medially across the roof

of upper septum and runs down and forwards to incisive canal

Anterosup part is supplied by the anterior ethmoidal branch of nasociliary nerve

Anteroinferior portion : anterior superior alveolar nerve

Posteroinf : nerve from pterygoid canal and posteroinferior branch of anterior palatine nerve

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.

Classification Nature of injury Extent of deformity Pattern of fracture

Extent of deformity Grade 0 : bones perfectly straight Grade 1 : boones deviated less than half the

width of bridge of nose Grade 2: deviated half to full width Grade 3: deviated greater than one full width Grade 4: bones almost touching cheek

Pattern of fracture Class 1: chevallet Low or moderate degrees of force Extent of deformity is less Simplest form is a depressed nasal bone Fractured segment is in position due to its inferior

attachment to upper lateral cartilages Nasal septum is not involved, except for in severe

injuries

Fracture line runs parallel to nasomaxillary suture, then connects across to contralateral side runs paralleljust below the dorsum

Cartilagenous septum is fractures 0.5 cm below the dorsum may extend posteriorly into bony septum through the perpndicular plate of ethmoid

Children : greenstick fracture

Class 2 : jarjavay Significant cosmetic

deformity Fracture nasal bones with

frontal process of maxilla and septum

Grade 2 Fracture begins just beneath

the nasal tip in quadrilateral cartilage, extends posteriorly through perp plate of ethmoid to the anterior border of vomer

And runs forward through lower part of perpendicular plate of ethmoid into inferior part of quadrilateral cartialge

Frontal impact can cause gross flattening and widening of dorsum

Lateral blow can cause a high deviation of nasal skeleton

Perpendicular plate of ethmoid inevitably involved

Correction of both septum and nasal bones for proper cosmetic results

Class 3 : high velocity trauma Naso orbital ethmoid fractures Ass with # of maxilla Quadrilateral cartilage falls back Saddled nose, nostrils facing more anteriorly

like the snout of a pig

Sypmtoms : nose bleed Nasal obstruction Diplopia, epiphora Watery rhinorrhea Hyposmia

Signs : External deformity difficult to examine in acute condition,

Better seen after the edema has reduced Look for movements of eye Palpate the nose to look for : deformity,

deviation, crepitus, mobility, any tenderness Look for septal hematoma, abscess Investigation : xray nasal bone In severe facial injury : ct pns to be done

Treatment Most patients don’t need any active treatment Reduction of fracture : under GA or LA Principle for reduction : mobilize the fragments

first by increasing and then decreasing the degree of deformity

An initial slight increase away from the side of impact, followed by steady movement back and then across the midline towards the side of blow

Instruments : freer hiller ashe walsham forcepsSplints may be necessary

Open reduction : b/l fractures with dislocation of nasal dorsum and significant septal deformity

Fractures of cartilagenous pyramid Infraction of nasal dorsum

Complications Residual deformity Nasal obstruction : septal deviation, collapse of

upper lateral cartilages, depressed nasal bones Septal complications : septal hematoma, septal

abscess Septal perforation

DEVIATED NASAL SEPTUM Extremly common May be present at birth Etiology : trauma with or without nasal bone fractures Birth mouldin theory given by Gray Abnormal intrauterine postures with compression

forces acting on the nose and upper jaws Post natal trauma Childs nose is cartilagenous, any trauma can cause

irreversible deviation of cartilage

Types : Spurs : sharp angulations occuring at the junction of

vomer below with the septal cartilage or ethmoid bone above.

Usually a result of vertical forces Fracture through the septal cartilage may also produce

spurs

Deviations Cartilagenous, C or s

shaped deviations either in vertical or horizontal plane

Cartilagenous deviations : upper bony septum and bony pyramid is central, deviation of the cartilagenous part

C shaped: displacement of upper bony septum to one side and whole of cartilagenous septum and vault to opposite side

S shaped : deviation of middle third is opposite to that of lower and upper one third

Disclocations : lower border ofseptal cartilage displaced from its median position and projects into one of the nostrils

Symptoms : nasal obstruction Can be on the same side of the deviation or opposite

side because of the hypertrophic changes in turbinate Snoring Mucosal changes : dryness, crusting Neurologic pain : pressure exerted by septal deviations

on adjacent sensory nerves Anterior ethmoidal nerve syndrome Deviations in region of nasal valve cause greatest

obstruction : cottle test

History of septal surgery 19th century : dns was identified and treated Acute spurs and angulations were removed by shaving

down convexities Langenbeck 1843 Dieffenbach 1845 Chassaignac 1851 Or complete removal of deviation with punch forceps Rubrent 1868 Resulted : perforations

Development of Submucus resection ( SMR ) 1881 Ingalls : earliest Refined by freers and killian Freers 1902 : radical approach Septal cartilage did not contribute to support of nasal

pyramid Septal cartilage culd be completely removed Saddling of dorsum in supratip region

Killian 1904 described technique of retention of both dorsal and caudal struts of cartilage

Prevents any external change in shape Septum is divided by a vertical line drawn from the

nasal process of frontal bone to nasal process of maxilla, any deviations posterior to this corrected by smr and anterior ones by septoplasty

Even then surgeries were followed by supra tip depression and columellar retraction

To minimize : killians technique was followed. Deviations in dorsal and caudal areas could not be

corrected

COTTLES LINE

Significant change brought about by Metzenbaum 1929

Avoided producing a large defect in cartilagenous septum by mobilizing and repositioning spetum in central position

Applicable to caudal dislocation of septum Compared the principle to a swinging door Incision given at the level of the deviation Free inferior border Posterior free border created by separating the septal

cartilage from the vomer

No anterior free border, septum tethered to displaced upper cartilage resulting in recurrence ofdeviation

Peer 1937 completely excised deviated caudal segment of cartilage

Reinserted as free graft

Galloway 1946 Removed the entire septal

cartilage and replaced it with single autograft cut from the excised cartilage

Graft was held in place with mattress sutures nd later suture removed

Problems with this method : unequal scar contraction : recurrence

Absorption of autograft : saddling of supratip Alternative solution : mobilization and

repositioning of septal cartilage : Cottle and then advocated by Rubin

INDICATIONSDNS causing symptoms of nasal obstruction and

recurrent headache. DNS causing obstruction of paranasal sinuses and

middle ear. Recurrent epistaxis from septal spur As a part of septorhinoplasty As a preliminary step in Hypophsectomy (Trans septal trans sphenoidal

approach) Vidian neurectomy (Trans septal apprach)

SMR 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

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)

Complications Bleeding Septal haematoma Damage to surrounding structures Septal abscess Septal Perforation Depression of bridge Retraction of columella Synichae Flapping septum

Septoplasty Incisions / approaches to

septum Killians : vertical incision in

septal mucoperichondrium 1.5 cm cranially from the caudal septal border

Mucoperichondrium is relatively easily elevated from this part of the septum and incision gives good access to all parts of septum except for the caudal most cartilagenous portion

Total transfixion incision Verticular vestibular skin incision caudally

from the caudal septal margin through the membranous septum

Good exposure of nasal valve area and dorsum Attachments of medial crura to the caudal

septum is sacrificed

Rethi incision Horizontal midcolumellar incision Used in rhinoplasty Elevation of skin from the nasal tip and

dorssum, medial crura of alar cartilages divided, membranous septum divided and then caudal border is exposed.

May also be used in septoplasty

Hemitransfixation incision

Also known as freers Vertical vestibular skin

incision at the level of caudal septal cartilage, mucocutaneous junction

Good access to entire septum

Steps : Infiltration Incision: Freer’s incision– a unilateral

hemitransfixation incision at the caudal border of the septum

Advantages of this incision : incision is in relatively avascular zone

Decreased risk of mucosal tears Easy access to whole septum including he caudal septal

bborder To combine with rhinoplasty it can be easily extended

to the opposite side and produce a transfixion incision

Exposure : usually best to expose the cartilagenous and bony septum by elevating the mucosal flap on concave side

Difficulty in flap elevation occurs mainly at the junction of septal cartilage above, with the anterior nasal spine and vomer below

Perichondrium encloses the septal cartilage in a complete envelope which does not fuse with the periosteum

Periosteum forms another envelope over adjacent bony septum

Anterior tunnel created between the cartilage and perichondrium from the freers incision

The periosteum over the anterior nasal spine incised and elevated backwards on both sides over premaxillary crest then vomer keeping below the chondrovomerine suture. This forms the inferior tunnel

Unite the anterior and the inferior tunnels using a knife : maxilla premaxilla approach

Inferior part of the septum separated from its osseous base, anterior nasal spine, premaxillary and maxillary crest

Incsion made between posterior part of septal cartilage and bony septum : posterior chondrotomy

Straightening Require removal of a stirp of cartilage, 3-4mm wide

from the lower border, and placed in saline during the procedure for later use

Straighten the vomerine crest to accommodate the septal cartilage

Anterior spine is deviated, can be fractured and repositioned.

Angulated spurs at junction between ethmoid and vomer, vertical incision is made just behind the cottles line

Mucosal flap is elevated and deviated portion of bone and cartilage removed.

While making the vertical incision careful not to make it too anteriorly

Reconstruction of septum Once the cartilage has been freed attempt made to

reposition it back in midline. Require removal of a stirp of cartilage, 3-4mm wide

from the lower border, and placed in saline during the procedure for later use

Pts own cartilage or ear or rib cartilage as substitutes

Stabilizing the septum Nasal packing Sutures Internal nasal splints

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 PERFORATION Majority involves septal cartilage Most common cause : trauma with or without

secondary infection Iatrogenic : septoplasty, mainly during smr ( killians

incision ) Tight nasal packing b/l cauterizations for nose bleed Inadequately treated septal hematoma/ abscess Foreign bodies intubation

Surface irritants Cocaine sufuric acid, chromic Decongestant nasal sprays phosphorus Arsenicals, mercury copper smelting fumes Hydrofluric acid, calcium nitrate

Infections:

Syphilis ( bony perforation ) rhinoscleroma

Wegners granulomatosis mucor

Leprosy rhinosporidiosis

Diphtheria histoplasmosis

Symptoms Mainly asymptomatic Size and site of perforation Anterior and large perforations symptomatic Drying, crusting Recurrent epistaxis Nasal obstruction Whisting sounds Saddling of nose

Management Nonsurgical and surgical No specific treatment for asymptomatic perforations Reducing the dryness, crusting Nasal douching, petroleum based ointments Cure the causative causes

Obturators Cover the inflamed mucosal

margin Usually silastic Prevent drying and encourage

epithelialization over the cartilage, bony septum.

Major disadvantage :cleaned or replaced regularly, can increase blockage

granuloma formation

SURGICAL Vertical height of perforation more critical than the ap

dia Approximation of mucoperichondrial edges from the

floor of nose to the dorsum of septum causes greatest tension

Extremely difficult to close perforations larger than 2cm in dia

Free grafts : simple or composite grafts allograftPedicled flaps : local nasal mucosal buccal mucosal composite septal cartilage composite skin / cartilage Rotation or advancement of mucoperichondrial or

mucoperiosteal flaps b/l mucosal flaps with main blood supply from

sphenopalatine vessels form the basis of most techniques

Grafts used temporalis fascia, mastoid periosteum, septal/ auricular cartilage

Small defects can be closed with bipedicled flaps Larger perforations require larger flaps which are

pedicled posteriorly based on sphenopalatine vessels Amount of mucosa available for closure is inversely

proportional to the dia of perforation Endonasl : broad based elevations via hemitransfixion

incisions and bipedicled flaps preserving anterior and posterior blood supplies

With horizontal relieving incisions and interposition grafts gives good results for perforations < 0.5cm

External rhinoplasty approach via trans columella approach or a columella – philtrum incision

Sectioning of columella below the medial crural footplates and connecting to transfixion and intercartilagenous incisions provides excellent exposure of septum and lower dorsum.

Alar crease incisions limited access not to be combined with transcolummellar approach

MIDFACE DEGLOVING APPROACH Extensive dissection of face for >2cm perforations Used with rotation transposition mucosal flaps

Septal hematoma It is collection of blood under the perichondrium or

periosteum of nasal septum When septum is subjected to a sharp buckling stress,

submucosal blood vesels are torn if mucosa remains intact this will result in hematoma

If severe injury , septal fracture, blood will flow to opp side and cause b/l hematoma

Blood accumulates in subperichondrial layer : interferes with vitality of cartilage

Cartilage can remain viable for 3 days, absorption follows

Symptom : nasal obstruction Examination will reveal smooth rounded b/l septal

swelling which often extends upto the lateral nasal wall

Treatment : early surgical drainage Long hemitransfixation incision made, blood

aspirated. If there is a defect in the cartilage, supported with a

homograft Complications : external deformity Septal abscess

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

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

Complications Depression of the cartilagenous dorsum Septal perforation Meningitis and cavernous sinus thrombosis

(rare)

Involvement of septum in systemic disorders Infectious diseases : tb, syphilis, leprosy,

diphtheria Autoimmune : wegners granulomatosis, lupus

erythematosus, sarcoidosis Vascular disorders : arteriosclerosis, osler weber

rendu

WEGNERS GRANULOMATOSIS Autoimmune disorder, necrotizing granulomatous

lesion of respiratory tract, vasculitis of small and medium arteries and glomerulonephritis

M:F 1:1, 20 – 40yrs Constitutional symptoms of fever, night sweats, wt

loss, malaise, weakness Nose : nose and pns r most frequently affected in head

and neck Foul smelling rhinorrhea, recurrent epistaxis Nasal obstruction, hyposmia or anosmia Nasal crusting, eythematous tissue, granulation tissue

Perforation in septum Chronic sinusitis Diagnosis : ANCA + Biopsy : pns tissue offers most favourable results Treatment : corticosteroids, immunosuppresive

therapy, cytotoxic drugs : cyclophosphamide, chlorambucil or azathioprine may b used

SYPHILIS Sexually transmitted disease, cause by spirochete,

treponema pallidum Primary syphilis presence of a chancre at the site of

treponemal inoculation Secondary syphilis represents hematogenous

dissemination followed by a latent or asymptomatic phase

This might progress into tertiary syphilis Congenital syphilis : early and late stages

Early congenital syphilisPurulent nasal dischargeFissuring and excoriation of nasal vestibule

Late congenital syphilisGummatous lesion destroy the nasal structureCorneal opacityDeafnessHutchinson’s teeth

Primary sysphilis of nose is rare, but occurs at the mucocutaneous junction

Secondary ssyphilis manifests as rhinitis with scant thick discharge and irritation of anterior nares

Tertiary : gummata of nose Septum is commonly involved and eventually

destroyed Diagnosis VDRL, FTA – ABS, TPHA TREATMENT : Benzathine penicillin 2.4 million units

i.m weekly x 3week

TUBERCULOSIS Primary nasal infection is rare Secondary to pulmonary T.B. Nodular infiltration of anterior part Ulceration and perforation of the cartilaginous part of

the septum Diagnosis by Biopsy Anti tubercular drug is the t/t

LUPUS VULGARIS Low grade tubercular infection Commonly involve the nasal vestibule and skin

of the face Characteristic feature is “apple-jelly nodules”

brown, gelatinous nodules Perforation of the cartilaginous septum Biopsy is diagnostic Anti-Tubercular t/t.

LEPROSY Caused by M.leprae Mostly by Lepromatous leprosy Starts from the nasal vestibule and involve the

septum and inf turbinate Nodular lesion Ulcers Perforation

Atrophic rhinitis Retraction of collumela Diagnosis by Biopsy Anti-leprotic therapy

SARCOIDOSIS Unknown etiology, mutiorgan disorder Young and middle aged Presents with b/l hilar lymphadenopathy, pulmonary

infiltration, ocular and skin lesions Formation of epitheloid granuloma, noncaseating Nose – obstruction, postnasal drip, headache, recurrent

sinus infections, purulent nasal discharge Dry friable lesions involving septum and inferior

turbinates with thick discharge and crusting Granulomatous inflammation result in subcutaneous

yellowish nodules Polypoid tissue and spetal perforations can occur

Diagnosis Clinical and radigraphic findings Histological finding of non caseating granuloma Exclusion of other diseases Biopsy : transbronchial lung biopsy, bronchoalveolar

lavage : cd 4/ cd 8 ratio increased Treatment : systemic corticosteroids

Mucormycosis Found in uncontrolled diabetics and pt with

immunosuppressive therapy Rapidly fatal condition Affinity of the fungus to artery ,causes thrombosis Black necrotic mass eroding the septum and hard palate T/t – Surgical debridement, amphotericin B ,control of

underlying cause.

Believe to be a type of Lymphoma, t cell / nk cell lymphoma

Stewart granuloma Destructive disease in the nose and mid facial

region Common in males, 5-6th decade Differentiated from Wegener's granulomatosis

by absence of pulmonary and renal involvement.

Purulent nasal discharge, persistent rhinorrhea with nasal obstruction,

Nasal crusting, necrosis Progressive destruction of nasal framework Gross mutilation of face Metastasis Diagnosis : biopsy Necrotic area with atypical cellular infiltrate Immunohistochemistry using monoclonal

antibodies against t cell differentiation antigen can b used for diagnosis

Tratment : radiotherapy