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