DNS TREATMENT AND ITS MANAGEMENT TECHNIQUES

DNS TREATMENT.pptx

1. DNS TREATMENT BY DR.M.V.HARIKA M.S IN ENT

2. Submucous Res e c tion (SMR) O p e r a tion: I t is g e n e r a l l y done in adults u n d e r lo c a l a n ae sthesia . I t c onsists of e lev a ti n g the mu c op e richond r ial a nd mucoperioste a l fl a ps on e ith e r side of the s e ptal f r a me w ork b y a sin g l e incision made on one side of t h e s e ptum, r e moving the d e fl e c t e d p a rts of t h e bo n y a nd ca rtil a g inous s e ptum, a nd then r e positioning the f laps (s e e s ec tion on Op e r a tive Sur g e r y for d e tails). S e ptopl a s t y : I t is a c ons e rv a tive a ppr o ac h to s e pt a l sur g e r y . I n this op e r a tion, much of the s e ptal f r a m e w ork is re t a ined. O n l y t h e most d e vi a ted p a rts a r e r e mo v e d. R e st of the s e ptal f r a me w o rk is c orr ec ted a nd r e position e d b y p l a stic me a ns. Muco p e ri c hon d ri a l /p e rioste a l fl a p is g e n e r a l l y r a i s e d on l y o n one side of the s e ptum, r e taining t h e a tt ac h m e nt and blood supp l y on the oth e r. Se p topl a s t y h a s now a lmost r e plac e d SMR op e r a tion.S e ptal surg e r y is usu a l l y done a ft e r the a ge of 17 so a s n ot to int e r f e re with the g r owth of n a s a l sk e leton. Ho we v e r, if a c hild h a s sev e re s e ptal d e v iation c a using m a rk e d n a s a l obstru c tion, c ons e rv a tive s e ptal su r g er y ( s e ptopl a s t y ) c a n be p e r f orm e d to p rovide a g o od a ir w a y .

3. SEPT A L H A EMA T O M A A E T I O L O G Y : I t is c oll ec tion of blood under the p e ri c hond r ium or periosteum of the n a s a l s e ptum. I t oft e n r e sults f r om na s a l tr a uma or s e p t a l su r g e r y . I n bl e e di n g disord e rs, it m a y o cc ur s pontan e ous l y . C L I N I C A L F E A T URES : B il a te r a l na s a l obstru c t i on is the c ommon e st pr e s e nting s y mptom. This m a y be a ssoci a ted with f r ontal h ea d ac he a n d a s e nse of p r e ssu r e ov e r the n a s a l bri d g e . E x a min a tion r e v ea ls smooth ro u nd e d sw e lling o f the s e ptum in both the n a s a l foss ae .P a lpation m a y show the mass to be so f t and f luc t u a nt. TREATME N T : Small haematomas c a n b e a spir a t e d with a w ide bore ste r i l e n ee dle. L ar g e r h ae matomas are incis e d a nd d ra ined b y a small a nte r opost e rior incision p a r a ll e l to the n a s a l floo r . E x c ision of a small pie c e of mu c o s a f r om t h e e d g e of i n c ision g ives b e tt e r d r a i n a g e . F ollowing d r a in a g e , no s e is pa c k e d on both sid e s to pr e v e nt r ea c c umul a tion . S y stemic a ntibio t ics should be g i v e n to pr e v e nt sep t a l absc e ss. COM P L I CA T I O NS : S e ptal h ae matoma , if not drained, m a y o r g a ni z e into f ibrous tissue le a ding to a p e rm a n e nt l y thi c k e n e d s e ptum. I f s ec o nd a r y infe c tion sup e rv e n e s, it r e sults in s e ptal a bs ce ss with n e c r o sis of c artil a g e a nd d e p re ssion of n a s a l dorsum.

4. SEPTAL ABSCESS AETIOLOGY : Mostly, it results from secondary infection of septal haematoma. Occasionally, it follows furuncle of the nose or upper lip. It may also follow acute infection such as typhoid or measles. CLINICAL FEATURES: There is severe bilateral nasal obstruction with pain and tenderness over the bridge of nose. Patient may also complain of fever with chills and frontal headache. Skin over the nose may be red and swollen. Internal examination of nose reveals smooth bilateral swelling of the nasal septum . Fluctuation can be elicited in this swelling. Septal mucosa is often congested. Submandibular lymph nodes may also be enlarged and tender.

5. TREATMENT : Abscess should be drained as early as possible. Incision is made in the most dependent part of the abscess and a piece of septal mucosa excised. Pus and necrosed pieces of cartilage are removed by suction. Incision may require to be reopened daily for 2–3 days to drain any pus or to remove any necrosed pieces of cartilage. Systemic antibiotics are started as soon as diagnosis has been made and continued at least for a period of 10 days. COMPLICATIONS : Necrosis of septal cartilage often results in depression of the cartilaginous dorsum in the supratip area and may require augmentation rhinoplasty 2–3 months later. Necrosis of septal flaps may lead to septal perforation. Meningitis and cavernous sinus thrombosis following septal abscess, though rare these days, can be serious complications.

6. PER F ORA T I ON O F N AS A L SEPT U M A E T I O L O G Y: tr a umatic Per F or a tio n s - T ra uma is the most c o mmon ca us e . I nju r y to m u c os a l fl a ps duri n g SMR, ca ute r i z a tion of s e ptum with ch e mi ca ls or g a lvano c a u t e r y for e pist a x is and h a bitu a l nose picking a re t h e c o m mon fo r ms of tr a uma. Occ a sional l y , s e ptum is delib e r a te l y p e r f o r a ted to put orn a m e nts. p a tholo g i c a l P e r F o r a t i on s - Th e y ca n be c a us e d b y : 1. S e ptal a bs c e ss. 2 . N a s a l m y i a sis. 3. Rhinolith or ne g le c ted f o r e i g n bo d y ca usi n g p r e s s ure n e c rosis. 4. Chronic g r a nulom a tous c onditions like lupus, tu b e r c ulosis a nd lep r o s y ca u se p e r f o r a tion in the c a rtila g inous p a rt while s y philis involves the bo n y p a rt. I n the s e ca s e s, e vidence of the ca us a t ive dis ea se m a y a lso be s ee n in oth e r s y s t e ms of the bo d y . 5. W e g e n e r ’ s gr a nuloma is a m i dline d e s tru c tive lesion whi c h m a y ca u s e tot a l sept a l destru c tion. dr u g s a nd Ch e mi ca l s - Prolon g e d use o f st e r o id spr a y s in n a s a l aller g y . Co ca ine a ddicts . W ork e rs in c e rt a in oc c up a tions, e . g . c h romium platin g , dich r o m a te or soda a sh (sodium c a rbon a t e ) man u f a c tu r e or those e x pos e d to a r s e nic or its c ompou n ds . 4. idiop a thi c - I n ma n y c a s e s, the r e is no histo r y o f t ra uma or p r e vious dis e a se a nd the p a ti e nt m a y e v e n be u n a ware of the e x ist e n c e of a p e r f o ra tion.

7. C L I N I C A L F E A T URES : S mall ant e rior p e r f o r a tio n s ca use whistling sou n d du r ing inspir a tion or e x pir a tion. L ar g e r p e r f o r a tions d e v e l op c rusts whi c h obstru c t the nose or c a use s e v e re e pist a x is wh e n removed . TREATME N T : An a tt e mpt should a lw a y s be m a de to find out the c a use b e fo r e t r ea tm e nt of p e r f o r a tion. This m a y r e q uire biop s y f r om the g r a n ulations or biop s y of the e dge of the p e r f o r a tion. I n ac tive sm a ll p e r f or a tions c a n be su r g i c a l l y c losed b y plastic f lap s . L a r g e r p e r f o r a tions a re di f fi c ult to clos e . Th e ir tre a tm e nt is a im e d to ke e p the nose c rus t - fr e e b y a lkaline n a s a l douc h e s a n d a ppli ca tion of a bland o intment. Sometim e s, a t h in silastic button ca n be w o rn to g e t r e li e f f r om the s y mptoms .

8. S u b mu c o us Re se c t io n o f N a s a l S e p t u m (SMR Op e r a tion) INDICA T I O N S D e v iated n as a l s e ptu m (DN S ) ca u si n g sy mp t o ms o f n a - s a l o b str u ct i o n a n d rec u rre nt h ea d ac h es. DN S cau s i ng obs t ruc t ion t o ve n t i l a t i on of parana s al s i nuses and m i d d l e ea r, r e su l ti ng i n recu r r e nt s i nus i ti s and o t i ti s med i a. Rec u rre nt e p istaxis from sep t al s pur . A s a pa r t of sep t orh i n op l as t y for cos m e ti c c orrect i on o f ex t e rnal nasal de f or miti es. As a p rel i mi n ary step i n h y po p hy s e ct o my (tr a n s - s e p - tal t r a n s-sp h e n oid al a pp ro ac h ) o r v i d ian n e u rect o my (tran s -s e p tal a pp ro ac h). C O N T R A I N D I CA T I ON S P at i e n ts b el o w 1 7 y ea r s o f a g e. In su ch cas e s, a c o n - s e rvat i v e su r g ery (s e ptop last y ) s h o u l d b e don e. A cu t e e p i sode of resp i ra t ory i nfec t i on. Ble e din g d iat h esis. Un t reated d iabetes o r h yp ertension.

9. ANAESTHESIA : Local anaesthesia is preferred. General anaesthesia is used in children and apprehensive adults. POSITION : Reclining position with head-end of the table raised. STEPS OF O PE R A TI O N IN F IL T R A TI O N O F N A S A L S EPTU M : It i s done i n it s s ub - pe r ich o ndrial p la n es with 2% x y l o c ai ne a n d 1 : 50 , adr e na l i n e. I N C I S I ON : A cu r v ili near i nc i s i on w i t h for w a r d c on v e x - it y i s m ade at t he m ucocutaneous j unc t ion on t he l e f t s i de of t he sep t u m . It cu t s on l y t hrough t he m ucosa a n d pe r i chond r i u m . E L E V A T I O N O F M U C O P ERI C H O ND RIAL A N D M U C O - P ERIOS T E AL F LA P : Pla ne o f d is s ecti o n is i m po rta n t. It shou ld be benea t h t he pe r ich o n d rium and p e ri o steum ( F i g ure 8 7 . 1 A). I N CI S ION OF T H E C ART I LAGE : Cartila ge is i n c ised j u s t po steri o r to t he fir st i n cisio n . A vo id c u tti n g t he o p po site m u cope r i chond r i u m , o t he r w i se, i t w i ll result i n p e rfor a - ti on . E L E V A T I O N OF OPPOS I T E M U C OP E RI CH ONDR I U M AND P E R I OST EUM : W it h t he e l evator passed t h r ough t he ca r - t i l age i nc i s i on, m ucope r i chond r i al and per i os t eal f l ap i s ra i sed from t he oppos i t e s i de of t he sep t um .

10. RE MOV A L OF C A R T IL A GE A N D B O N E : N o w w o r k i n g b etwee n t he two fla p s, ca r tila ge and b one a re r e m o ved . C a r til age can be re m oved w i t h B a ll enger s w i vel kn i fe a n d bo ne with L u c ’ s f o r c e p s. Bo n y s p u r or ri dge can be r e - m ov e d wit h g o uge and ha mm e r. P r e ser ve a strip o f car - tila ge a bou t 1 c m wi de along t he do rsal and c a u dal bo r - d e r o f t he sep t u m to p r e v e n t co ll a p se o f t he b r i dge o f t h e n o se o r r e tra c ti o n o f co l u m ella ( Fi gu re 8 7 . 2 ). ST I T CH I N G : O ne or t w o catgut or s i l k s t i t ches a r e a p - p li ed i n t he i ni ti a l m ucope r i chond r i al i nc i s i on. P A CK I N G : A r i bbon ga u ze, s m ea r ed w it h an a n t i b i o t i c o i n t m e n t or li q u i d par a f f i n, i s packed on each s i de of t h e nasal c av it y t o prevent co ll e c t i on of b l ood be t w een t h e f l a p s. N asal dress i ng i s app li ed. P O ST O PE R A T I V E C A R E P at i e nt is p la c ed in s e m i -sit t ing p o sit i o n t o pr e v e n t oo zi n g o f b loo d. O u ter n as a l d ressin g i s c h a ng e d i f s o a k ed i n b l oo d . A so f t d i et shou l d be t aken i n t he f i rst t w o pos t ope r a - ti ve days t o m i n i m i ze ac t i ve m as ti c a ti on w h i ch ca u s e s b l eeding. Pa i n, i f a n y , shou l d be con t ro ll ed w i t h analg e s i cs. A nt i b i o ti c cover i s g i v en for 5 –6 days. N asal packs a r e gen tl y re m oved a f t er 24 h and t h e r e - a f t e r , deconges t ant nasal drops and s t eam inha l a ti ons a r e g i ven da il y for 5 –6 days. S il k s t it c h , i f a n y, i s r e m oved on 5 t h or 6 t h d a y. P a ti e n t s hou l d a v o i d t r a u m a t o t he no s e for s e v e r al d a y s .

11. CO M PLI C A T I O N S Bl ee d i n g : It m a y req u ire re p ac king, if s e v ere. S e p t a l h a e m a t o m a . : E v ac u ate th e h ae m at o ma an d g i v e in tranas a l p ac k i n g o n bo t h sid es o f se p t u m f o r e qu a l p ressure . S e p t a l a b s ce s s . T h is c a n f ol l o w i n fect i o n o f s e p tal h a e - m a to m a . P e r f ora t i o n . Wh e n t ea rs occur on oppos i ng s i des of t he m ucous m e m brane. D e p re s sion o f b r i dg e . Us u al l y o cc u rs in su p rat i p area du e to t o o much remo v al o f c a rt i lage al o n g t h e dorsal b o rder. R e t rac tion o f co l u m e ll a . Often s e en wh e n ca ud al stri p o f cart i lage is not p res e rv e d. P e rsist e n c e of d e viation. I t usu a l l y o c c urs due to inad e qu a te surg e r y a nd m a y r e quire r e vision op e r a ti o n. F lappi n g of n a s a l s e p tum . R a r e l y s e e n, wh e n too much of s e ptal f r a m e wo r k h a s b ee n r e mo v e d. S e ptum, whi c h n ow c onsists of two mucop e ri c hond r i a l fl a ps, moves to the ri g ht or l e ft with r e spir a tion. Toxic sho c k s y ndro me . I t is r a re a ft e r s e ptal su r g e r y . I t c a n follow staph y l o c o cca l (som e times str e ptoco c ca l) inf e c tion a nd is c h a r ac te r i z e d b y n a us e a , v o mitin g , purul e nt s ec r e tions, h y p otension a nd r a sh. I t s hould be dia g nos e d ea r l y . I t is tr e a ted b y r e moval of p a c kin g , h y dr a ti n g the p a ti e nt, maintaining blood p r e ssure a nd a dminist e ring p rop e r a ntibiotics. PRESE N T ST A T U S Th e se d a y s SMR op e r a tion h a s b ee n r e pl a ce d b y s e ptopl a s t y . As m u c h of the ca rtil a g e or bo n e a s possible should be r e tain e d. Sometim e s str a i g ht pie c e s of bone or c a rtilage c a n be put b ac k b e tw e e n the mucos a l fl a ps. On l y indi c a tion for SMR is wh e n ca rtilage or bone f r om the s e ptum is r e quir e d f o r a g r a ft.

12. Submucous resection of nasal septum. (A) Incision and elevation of flap on the left. (B) Elevation of flap on the right after incis - ing the septal cartilage. (C) Closing the incision. SMR operation. It is necessary to preserve dorsal and caudal struts of cartilage to avoid supratip depression or columellar recession, respectively.

13. S e ptopl a s t y is a c ons er v a tive a ppr o ac h to s e ptal su r g e r y ; a s much o f the s e ptal f r a me w o rk a s possible is r e tain e d. Mu c op e ri c ho n dri a l/p e rioste a l fl a p is g e n e r a l l y r a ised on l y on o n e side. This op e r a tion h a s a l m ost r e plac e d the SMR o p e r a tion. I ND I CA T I O NS D e viat e d s e ptum c a using n a s a l obstru c tion on one or b o th sid e s. As a p a rt of s e ptorhin o plas t y for c osmetic r ea s o ns. R ec ur r e nt e pist a x is u s u a l l y f rom the spu r . Sinusitis due to sept a l d e viation. S e ptal d e viation m a king c on t ac t with lat e r a l na s a l w a ll a nd c a using h ea d ac h e s. F or a ppr o ac h to middle me a tus or f r ontal re ce s s in e ndos c opic sinus sur g e r y wh e n d e viat e d s e ptum obstru c t s the vi e w a nd a cce ss to t h e se a r ea s. A c ce ss to e ndo s c opic d ac r y o c y storhinosto m y o p e r a t i on in some c a s e s. As a n a ppr o ac h to pituitary fossa (t r a n s - s e ptal tr a nssphenoid a l app r o ac h ). S e ptal d e viation c a us i ng sle e p a pno e a or h y po p no e a s y ndrom e . CO N TR A I N D I CA T I O NS A c ute n a s a l o r sinus inf e c tion. Unt rea ted di a b e tes. H y p e rt e nsi o n. B le e di n g diath e sis. septoplasty

14. A N A E ST H E S I A L o c a l or g e n e r a l PO S I T I O N S a me a s for SMR op e r a t i on. TECH N I Q U E I n filtr a te the s e ptum w ith 1% li g no ca ine with a dr e n a lin e , 1:100,000. I n c a s e s of d e viat e d s e ptum, make a sli g ht l y c urvilin ea r incision, 2 –3 mm a bove the ca ud a l e nd of s e ptal ca rtil a g e on the c on c a ve side ( K illi a n ’ s incision). I n c a se of c a ud a l dislo ca tion, a t r a nsfi x ion or h e mitr a nsf ix ion ( F r e e r ’ s ) incision is mad e . The latter is s e ptocolu m e ll a r incision b e tw ee n c a ud a l e nd of s e ptal c a rtil a g e a nd c olum e ll a . R a ise mu c op e ri c hon d ri a l / mu c op e rioste a l fl a p on o ne side on l y . S e p a r a te s e ptal c a rtil a g e f r om the vom e r a nd e t h moid plate a nd r a ise m u c op e rioste a l fl a p on the opposite side of s e ptum. R e move m a x illary c r e st to r e a li g n t h e s e ptal c a rtilag e . Cor r ec t the bo n y s e ptum b y r e movi n g t h e d e f o rm e d p a rts. Defo r med s e ptal ca rtil a ge is co r r e c t e d b y v a rious m e thods, su c h a s: ) Sc o ri n g on the c on c a ve side ( F i g u re 88.1 ) . C r oss - h a tchi n g or m o rs e li z in g . ) Shavi n g . W e d g e e x c ision. F ur t h e r manipulations like re a li g nment of n a s a l spine, s e p a r a tion of s e ptal c a rtilage f r om upp e r lat e r a l c a rtilag e s, implant a tion of ca rtil a g e strip in the c olum e lla or the dorsum of n o se m a y be r e quir e d. T ra ns - s e ptal sutu r e s a r e pla c e d to c o a pt mu c op e ri c hond r ial fl a ps. N a s a l pa c k.

15. POSTOPERA T I VE C A RE S e ptal sur g e r y is a d a y c a r e su r g e r y a nd the p a ti e nt ca n g o home a ft e r he ful l y r e c ov e rs f rom e f f e c ts o f s e d a tion with no post o p e r a ti v e n a us e a or bl e e d in g . P a ti e nts with obstru c tive sle e p a p no e a should b e tt e r b e obs e rv e d ov e rn i g ht. Avoid str e nuous e x e rcise a s it m a y ca use bl e e d i n g . P ac k, if k e pt is r e mo v e d the n e x t d a y a nd p a ti e nt be instru c t e d not to blow the no s e or sn ee z e h a rd. S e c r e ti o ns ca n b e drawn b a c kwards into the thro a t b y s n orting r a ther than blowing the nos e . S a line spr a y or st ea m i nh a lation a r e e n c ou ra g e d a ft e r p a c k r e moval. X y lo- o r o x y m e tazoline dro p s a r e us e d if nose b ec omes stuf f y . N a s a l splints, if us e d, a re r e moved on fou r th to e i g hth d a y a nd g e ntle su c tion of nose is don e . P a ti e nt should a void tr a uma to nos e , wipe the nose g e nt l y a nd in no ca se push the nose f r om one side to a n othe r . POSTOPERA T I VE C O M P L I CA T I O NS S a me a s in S MR op e r a tion. B le e di n g . S e ptal h ae matoma a nd a bs ce ss. S e ptal p e r f o r a tion. Supr a tip d e pr e ssion. S a ddle nose d e f o rmi t y . Colum e ll a r r e tra c tion. P e rsist e n c e of s e ptal d e viation, or e x te r n a l nasal de f ormi t y . C e r e brospin a l fluid rh i nor r ho e a r a r e l y o cc u rs if the p e rp e ndicu l a r pl a te o f e thmoid is a vulsed. To x ic sho c k s y n drom e .

16. Septal cartilage is straightened by scoring the cartilage on the concave side to remove interlocked cartilage stresses (A), or by shav - ing the convex side of cartilage (B). Dislocated septal cartilage can be replaced in the maxillary groove or on the anterior nasal spine by excision of the cartilage along the floor of nose and fixing it with a suture (C).

17. T YPES OF SEPT A L I N C I S I O N S I N SEPT O P L ASTY 1. Killian’s: In the nasal mucosa, cephalic to the caudal end of the septum (Figure 88.2). 2. Transfixion: Through and through incision, close to but caudal to caudal end of the septum. 3. Hemitransfixion : Same as the transfixion incision but on one side 4. Horizontal on the spur: For endoscopic spurectomy Septal incisions. (A) Killian’s incision. (B) Hemitransfixion incision.

18. It is extensive dissection of septum removing all deformed bony and cartilaginous parts preserving only a caudal and a dorsal strut of cartilage . 2. Not done before 17 years 3. Mucoperichondrial and periosteal flaps raised on both sides of the septum. 4. Bony and cartilaginous parts excised . 5. More chances of complications, e.g. supratip depression, columellar recession or flapping of septum 6.Re-operation is difficult. Limited selective dissection removing minimal cartilage and bone consistent with providing a good airway. Most of the cartilage and bone is preserved. Even deformed parts are corrected and reimplanted between mucoperichondrial or periosteal flaps. . It can be done even in children without affecting nasal growth. . Flaps are raised only on one side and limited elevation on the opposite side. Deformed cartilage is corrected by scoring, cross-hatching, wedge excision and realigning in the groove of the nasal crest. Sometimes straight pieces are joined outside the nose and replaced between flaps (extracorporeal septoplasty), and in case of spur, only spurectomy is done . . Less chances of complications. Re-operation is easier. DIFFERENCES BETWEEN SMR AND SEPTOPLASTY SMR SEPTOPLASTY

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