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Diseases of Nasal

Septum
Dr. Mukundan

Columellar Septum

Membranous Septum
Septum Proper

Deviated Nasal Septum


Straight Septal Deviations -----------CURIOSITY
Not severe enough to cause Sx

Etiology
Direct Trauma

Birth moulding theory- Gray


No H/o Trauma
Abnormal Intrauterine
Posture
DNS to R in c/o LOA
presentation
DNS to L with ROA
presentation

Differential growth between nasal septum and


palate- Most accepted

Types
1. Anterior / caudal dislocation
2. C-shaped deformity
3. S-shaped deformity
4. Septal Spur: shelf-like projection

Anterior / Caudal
dislocation
Septal Cartilage Dislocated
Tilt Patients head Backwards

C - shaped

C-shaped DNS not touching lateral nasal


wall

C-shaped DNS touching lateral nasal wall

Compensatory turbinate hypertrophy

S - shaped

Nasal septal spur


Sharp angulations occuring at the junction of the vomer below, with the
septal cartilage and / or ethmoid bone above
Due to vertical compression forces

Clinical features
Nasal block: present on side of
D.N.S.
C/L paradoxical nasal obstruction
due to compensatory inferior
turbinate hypertrophy
High Septal Deviations- More
Obstruction

. Recurrent cold due


to associated
sinusitis
Poor Sinus Ventilation

Headache:
Due to
contact with
lateral wall
(Sluders
neuralgia)
Sinusitis

Clinical features
4. Epistaxis: Mucosa over DNS drying Effect of Air
Currents Crusting & bleeding on removal; Stretched
blood vessels over spur
5. Hyposmia:
in high DNS
6. External nasal deformity
7. ASYMPTOMATIC- Majority

seen

Examination

Cottle Test

Investigations/ Treatment
Only when Patient is
Symptomatic
Develops Recurrent Sinusitis/
Epistaxis/ Middle Ear
Infection

Antibiotics
Anti Histaminics
Decongestants
Intranasal Steroids

SURGERY LA/GA

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

Cottles 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.

Septoplasty
Correction of DNS achieved with Minimal
Sacrifice of Cartilagionous/ Bony Septum
Useful in Children/ Anterior Deviations

Freers Incision- Hemi Transfixion Incision- Concave side

Muco-perichondrial flap elevation on Concave (right) side


Anterior Tunnel

Anterior + Inferior tunnels


Inferior Tunnel by
Elevating
Mucoperiosteum
over Maxillary Crest
Join The two
Tunnels
Create Inferior
Tunnel on Opposite
Side

Mobilization &
Straightening of
Septum
Free Septal
Cartilage from
Bony Attachment
Inferiorly &
Posteriorly
Remove Inferior
Strip of Cartilage

Some Techniques of Correction

Other Techniques:
Shaving Excessive
Convexity

Excising Dislocated Lower end of cartilage & Replacing in Groove of


Maxillary Crest

Fixation
Correct Bony
Deviations if Present
Reposit Flaps back
Pack The nose

Submucosal Resection

Killians incision
Curvilinear incision
with forward
convexity is made at
the mucocutaneous
junction
Elevation of
mucoperichondrial
and periosteal flap

Muco-perichondrial flap elevation


on right side

Cutting of cartilage & elevation of


opposite flap
Incision of the
cartilage.
Cartilage is incised
just posterior to the
first incision.
Avoid cutting the
opposite
mucoperichondriu
m, otherwise, it will
result in
perforation.

Elevation of
opposite
mucoperichondrium
and periosteum

Excision of septal cartilage


Removal of cartilage and bone
Cartilage can be removed with
Ballenger swivel knife
Bone with Luc's forceps
Bony spur or ridge can be
removed with gouge and
hammer.
Preserve a strip of cartilage
about 1 cm wide along the
dorsal and caudal border of
the septum to prevent collapse
of the bridge of nose or
retraction of columella
Flaps Reposited

S.M.R.

Septoplasty

Radical surgery

Conservative

Not done below 17 yr

Done after 4 yr

Killians incision

Freers incision

Cannot correct anterior DNS

Can correct

B/L mucoperichondrium elevated One side only


Radical removal of cartilage

Only inferior strip

Rhinoplasty incision cant


combine
Revision surgery difficult

Can

Cartilage graft can be harvested

No

Complications common

Rare

Relatively easy

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)

Septal abscess
Collection 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

Nasal synechia

Perforated nasal septum

Aetiology
1. 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.

Thank You