Deviated nasal septum and other septal conditions

1,621 views 54 slides Jun 30, 2020
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About This Presentation

Slides prepared by highly experienced ENT teacher, Dr. Krishna Koirala from Nepal , for teaching undergraduate and postgraduate MBBS students in the field of otorhinolaryngology. A clear and concise explanation of the basic concepts in the subject matter concerned.


Slide Content

Conditions of the Nasal
Septum
Dr. Krishna Koirala
2017-08-15

Deviated Nasal Septum
( DNS)

Etiology
•Traumatic
•Developmental
−Birthmoulding
−Higharchedpalate
−Unequalgrowthbetweenskullbaseandpalate
•Massinoppositenasalcavity
•Racialfactors
•Hereditary:posteriorDNS

Types of DNS
•Anterior / caudal dislocation
•C -shaped deformity
•S-shaped deformity
•Septal Spur : shelf-like projection between
bone and cartilage
•Septal Thickening: organized hematoma or
over-riding of septal fragments

Types of DNS

Cottle’sclassificationofDNS
•Simple
•Obstructed
•Impacted

Clinical features
•Nasal obstruction
–On side of DNS
–Paradoxical nasal obstruction on opposite sidedue
to compensatory inferior turbinate hypertrophy
•Recurrent cold
–Associated sinusitis, allergy
•Headache : Sluder’s neuralgia, sinusitis

•Epistaxis
–Stretched mucosa on DNS dry crusting 
bleeding on removal
–Stretched blood vessels over spur
•Hyposmia
–High D.N.S.
•External nasal deformity

Sequelae
•Sinusitis
•Mouth breathing snoring, pharyngitis
•Atrophic rhinitis and myiasis
•Otitis media

Indications for septal surgery
1.D.N.S.:nasalobstruction/sinusitis/headache/epistaxis
2.Alongwithrhinoplasty
3.Harvestingofseptalcartilagegraft
3.Trans-septalrouteto
−Hypophysectomy
−Vidianneurectomy
4.HereditaryHemorrhagictelengiectasia

•CommonlyperformedSurgeries
tocorrectthedeviatednasal
septum
–Septoplasty
–Submucosalresectionofthe
septum(SMR)

Cottle’s line
Imaginarylinedrawnfrom
frontalnasalspineto
maxillarynasalspine
•Deviationsanteriortoitcan
becorrectedonlyby
septoplasty
•Deviationsposteriortoit
canbecorrectedeitherby
SMRorseptoplasty

S.M.R. Septoplasty
Radical surgery Conservative
Not done below 17 yrs of ageDone after 4 yrs
Killian’s incision Freer’s incision
Cannot correct anterior DNS Can correct
B/L mucoperichondrium elevatedOne side only
Radical removal of cartilageOnly inferior strip
Can’t be combined with rhinoplastyCan
Revision surgery difficult Relatively easy
Cartilage graft can be harvested No
Complications common Rare

Septoplasty

Incision : Freer’s

Muco -perichondrial flap elevation

Creation of Anterior and Inferior
tunnels
Ant
tunnel
Inf tunnel

Dislocation of bony cartilaginous
junction

Muco-periosteal flap elevation on both
sides

Removal of inferior cartilage strip

Spur and deviated portion of Cartilage and Bone
removed

Scoring and cross-hatching

Wedge excision and shaving

Anterior nasal packing

Bolster application (Outer pack)

Submucosal Resection

Killian’s incision

Muco-perichondrial flap elevation

Cutting of cartilage and elevation of
opposite flap

Excision of septal cartilage

Excision of septal cartilage

Cartilage + Bone removed

Anterior nasal packing

Complications of septal surgery
1.Hemorrhage
2.Septal hematoma/ infection/ abscess /perforation
3.Saddle nose / supratip depression/ Columellar retraction
4.Flapping septum
5. Persistent deviation
6.Nasal synechia
7.C.S.F. rhinorrhoea
8.Infection
9. Toxic shock syndrome

Septal Hematoma

•Collectionofbloodundertheperichondrium/
periosteumofnasalseptum
•Etiology
–Nasaltrauma
–Septalsurgery
–Bleedingdisorders

Clinical features
•Bilateral nasal obstruction
•Sense of pressure over nasal bridge
•B/L smooth, fusiform, round septal swelling
•On palpation mass is soft & fluctuant
•Absence of raised temperature, erythema, swelling &
tenderness of skin over nose

Treatment
1. Small: wide bore needle aspiration
2. Large:
–Incision and drainage
–Nasal packing (prevent recurrence)
–Systemic antibiotics (prevent abscess)

Complications
•Septal abscess with cartilage necrosis
•Septal perforation
•Saddle nose
•Supra-tip deformity
•Thickened nasal septum due to organized
hematoma

Septal abscess

•Collection of pus under perichondrium /periosteum
of nasal septum
•Etiology
–Secondary infection of septal hematoma
–Following furuncle of nose or upper lip
–Following typhoid or measles
–Immunocompromised hosts

Clinical Features
•Bilateralnasalobstructionwithfever
•Skinovernoseshowsraisedtemperature,erythema,
swellingandtenderness
•B/Lsmooth,soft,fluctuantseptalswelling
•Septalmucosacongested
•Submandibularnodeenlargedandtender

Treatment
•Abscess drained immediately by making an
incision on the most dependent part
•Pus and necrosed cartilage removed
•Nasal packing done
•Systemic antibiotics administered for 7-10
days

Complications
•Necrosis of septal cartilage
•Saddle nose
•Supra-tip deformity
•Septal perforation
•Meningitis
•Cavernous sinus thrombosis

Septal Perforation

Etiology
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’s
6. Malignancy
7. Idiopathic

Clinical features
•Small perforation
–Whistling sound during respiration
•Large perforation
–Nasal crusting nasal obstruction 
epistaxis on crust removal

Treatment
•Treat the 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

Nasal mucosal flaps

Sublabial flap

Silastic obturator