Nasal septum & septoplasty

this seminar is regarding the anatomy of nasal septum its importance , and surgeries used to correct deviated septum.

1. NASAL SEPTUM By-Dr soumya singh

2. Embyology of nasal septum 5 facial prominences form the nose 1-frontal prominence Paired medial prominence Paired lateral prominence Septum begins as a downward growth of frontal prominence,as primary n secondary shelves join in ,descending septum fuses with the palate to separate the nasal cavity into 2 distinct nasal passages

3. Nasal septum Anatomy of nasal septum: Nasal septum consists of three parts: Columellar septum Membranous septum 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.

4. Nasal septum Mucosa : pseudostratified columnar epithelium along inferior two-thirds olfactory epithelium along superior one third forms a partition between right and left nasal cavities and provides support to tip and dorsum of cartilagenous part of nose. 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.

5. BLOOD SUPPLY-NASAL SEPTUM

6. FROM ICA >ophthalmic artery >ant. and post. Ethmoidal arteies FROM ECA- sphenopalantine artery br of int. maxillary artery Superior labial br of facial artery

7. NERVE SUPPLY-NASAL SEPTUM

8. LITTLE’S AREA (KIESSEL BACH’S PLEXUS) Anterior ethmoidal Septal branch of supeior labial Septal branch of sphenopalotine Septal branch of greater palatine

9. Vomeronasal organ Vomeronasal organ for olfaction (primordial) Aka Jacoben’s organ Located on anterior septum Found with endoscopy 76% of the time Don’t biopsy but recognize as normal anatomic structure

10. Factors affecting shape and position of nasal tip Lateral crural complex Thickness of the overlying skin Ligaments and fibrous attachments of nasal tip structures

11. DOME Anatmic dome : Junction of middle and lateral crura clinical dome: The most anterior projecting portion of lower lateral cartilage Tip defining point: The external projection of dome

12. Nasal valve Narrowest point of upper airway Small changes in nasal septal structure can have significant effects of airflow resistance n sensation of obstruction Boumdaries – 2dimensional plane slicing through caudal end of upper lateral cartilage superiorly Alae – laterally Bony nasal floor inferiorly Septum medially

13. 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. septal injuries with mucosal tears cause profuse epistaxis while with intact mucosa result in septal hematoma.

14. 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 . runs vertically from anterior nasal spine upwards to the junction of bony and cartilaginous dorsum of nose.

15. Fractures of nasal septum

16. 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.

17. DEVIATED NASAL SEPTUM AETIOLOGY : Trauma: lateral blow-displacement of septal cartilage from vomer . blow from front-buckling, fracture, duplication of septum with telescoping of fragments. 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) Congenital: abnormal intrauterine posture cause compressing forces acting on nose and upper jaw. Hereditary Racial: Caucasians are more affected Secondary: to a tumour , mass or polyp .

18. DEVIATED NASAL SEPTUM Types: 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 . Anterior Dislocation: seen on tilting the patients head backwards. Spurs: shelf like projection at the junction of bone and cartilage. may predispose for epistaxis and headache. Thickening: it may be due to organized haematoma or over-riding of dislocated septal fragments impacted septum-despite decongestants

19. DEVIATED NASAL SEPTUM-types

20. Mladina classification for nasal septal deviation Type 1- U/L vertical ridge in the valve region Type 2- same as type 1 but more severe obstrution n disturbance of nasal valve Type3- U/L vertical ridge at d level of head of middle turbinate Type 4- combination of type3 wid either type ½ Type 5- HZ septal crest in contrast wid lateral nasal wall Type 6- prominent maxillary crest C/L to deviation wid a septal crest on d deviated side Type 7- combination of previously described septal deformity types

21. Clinical features Nasal obstruction: the most common symptom mainly on side of DNS,C/L paradoxical nasal obstruction due to turbinate hypertrophy may be seen Headache-contact with lateral wall sluders neuralgia, sinusitis Recurrent attacks of cold due to sinusitis Epistaxis -stretched mucosa on DNS-dry crusting n bleeding on removal-stretched blood vessels over spur Anosmia / hyposmia -in high DNS External deformity Middle ear infection

22. 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

23. Cottle’s test

24. SEQUELAE SINUSITIS MOUTH BREATHING ATROPHIC RHINITIS AND MYIASIS OTITIS MEDIA

25. Differential diagnosis Polyps Septal haematoma Hypertrophied turbinates

26. History of septoplasty Edwin smith papyrus treating broken nose by placing 2 plugs of linen coated wid grease& ext packing wid stiff rolls of linen Bosworth opeartion ( late 19 th ) deviated part of septum amputed wid mucosa on convex side Asch (1899 )- full thickness cruciate incision on septal cartilage Freer (1902 ) - SMR of total septal cartilage Killian (1904 ) - SMR wid preservation of dorsal&caudal portion of cartilage Metzenbaum (1929)-swinging door technique for caudal dislocation Peer (1937)-removal of caudal septum n replacement after its alterartion Cottle (1948)-maxilla – premaxilla septoplasty

27. Preoperative assessment History Allergies Nasal obstruction (unilateral/bilateral, constant/intermittent, seasonal) Bilateral symptoms that change in severity (mucosal disease) Constant obstruction (fixed structural abnormality) Presence of epistaxis or rhinorrhea Prior nasal surgery Medication history (especially vasoconstrictive sprays, OC’s) Trauma Symptoms (crusting, dry mouth, frequent sore throats, sinus problems)

28. Anosmia/hyposmia University of Pennsylvania Smell Identification Test (UPSIT) Help identify malingering and gross degree of impairment 34% of patients scored lower postoperatively after septal surgery 66% improved or were unchanged

29. Rhinomanometry Anterior rhinomanometry Posterior rhinomanometry Pernasal rhinomanometry Objective information regarding respiratory function Quantifies nasal air flow and pressure Nasal resistance (pressure/flow)

30. Acoustic rhinomanometry Measures the cross-sectional area of the nasal cavity as a function of distance from the nostril Sound generator, wave tube, microphone, and a computer

31. Optimizing acoustic rhinomanometry Must form an acoustic seal with wave tube without distorting the nasal tip Results represent cross sectional area as a function of distance (cm) from end of nosepiece Does not detail shape of the airway, cannot provide information on nasal airway resistance

32. Physical exam External appearance of nose Mouth breather Adenoid facies (maxillary hypoplasia ) Location of deviation Tip support Nasal valve Remove all crusts (? Underlying perforation, exophytic lesion, etc) Any abnormal crusts, ulcerations, or polypoid changes should delay elective surgery for possible underlying systemic condition Examine with vasoconstrictor, endoscope

33. Goals of surgery Exposure of the pathologic portion of septum Removal or reconstruction of the defective portions Preserve nasal mucosa and lining Prevent external deformity of patient

34. Anaesthesia Lignocaine 2% wid epinephrine 1/100,000 Solution injected subperichondrially ( not used only as a hemostatic agent but for hydrodissection -with pressure lifting the mucosa and perichondrium from cartilage Performed in anterior to posterior direction and d mucosa should blanch as injection proceeds Injected bilaterally more the time taken for infillteration less is the time rqrd for Sx

35. You inject lidocaine with epinephrine and the patient becomes tachycardic , hypotensive , and syncope… Vasovagal ?, Allergic Reaction to PABA?, Intravascular Injection of Epinephrine? Vasovagal-Bradycardic , Cool skin, Hypotensive , Impending sense of doom Allergic Reaction- Tachycardic , Hypotensive , Flushed and warm skin Intravascular Epinephrine- Tachycardic (from epinephrine), Hypotensive from impaired ventricular filling of heart, Peripheral Vasodilation (depending on the dose) can occur

36. Incisions Kilian incision Preserves projection the best Should not be too far posterior (difficult to close) Hemitransfixion incision Full transfixion incision High and Low transfixion incision Open rhinoplasty incision

37. Technique Classic Submucosal Technique Scoring Morselization Sutures Swinging door Removal and replacement

38. 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

39. 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

40. SMR Contraindications Acute URTI Patient below 17 yrs of age Bleeding disorders Uncontrolled hypertension and diabetes mellitus

41. SMR Anesthesia - Local anesthesia/ general anesthesia Positioning: reclining position with head end of the table raised

42. 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

43. 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 ( L-struts ) Nasal packing

44. SMR – STEPS

45. Keystone areas Preserve along bony cartilaginous junction Preserve along nasal floor Diagram showing area of L SHAPED STRUT cartilage preserved

46. Submucous resection limitations and comlications Caudal end deformities are not addressed Poor access to nasal spine Dorsal deformities not addressed Saddle back defomity Septal hematoma Collopse of nasal tip n columella Nasal obstruction Mucosal tear TSS Septal perforation Cartilage n bone may have memory to return to original deformed position

47. Reconstitution Morselized cartilage replaced between flaps Less risk of septal perforation Future source of cartilage for rhinoplasty and easier dissection

48. Scoring the cartilage Which side do you score the cartilage on, concave or convex?

49. Deviated caudal septum

50. Eliminate all posterior bony attachments to mobilize the anterior septum

51. Shift caudal margin & inferior margin to opposite side of the Maxillary spine

52. Caudal margin & Inferior margin to the left of the maxillary spine

53. Eliminate all posterior bony attachments to mobilize the anterior septum

54. Shift caudal margin & inferior margin to opposite side of the Maxillary spine

55. CONSIDER RELAXING INCISIONS ON CAUDAL MARGIN

56. 1 . Anterior septum separated from Vomer and Ethmoid

57. Maxillary Spine 1 . Anterior septum separated from Vomer and Ethmoid

58. Maxillary Spine 1 . 2 . Anterior septum separated from Vomer and Ethmoid

59. Maxillary Spine 1 . 2 . 3 . Anterior septum separated from Vomer and Ethmoid

60. Maxillary Spine 1 . 2 . 3 . Anterior septum separated from Vomer and Ethmoid Anterior septum to midline

61. 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

62. 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

63. 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

64. Septoplasty (cont…) Contraindications Acute URTI Bleeding disorders Uncontrolled hypertension and diabetes mellitus

65. 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

66. 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

67. Post-operative complications Bleeding Septal haematoma Saddle nose Damage to surrounding structures Septal abscess Septal Perforation Depression of bridge Retraction of columella Synechiae Persistent deviation Infection- sinus and middle ear CSF rhinorrhoea Toxic shock syndrome

68. Differences between SMR and septoplasty SMR Radical surgery Not done in children Killian’s incision Flaps elevated on both sides Most of cartilage removed Caudal dislocation not corrected Perforation chance higher Post operative saddling may be present Revision surgery difficult Rhinoplasty incision cant combine Cartilage graft can be harvested Septoplasty Conservative surgery Can be done in children Freer’s incision Flap elevated on concave side only Most of cartilage preserved Caudal dislocation corrected Perforation rare Post operative deformity absent Revision surgery easier Can combine Cannot be harvested

69. ENDOSCOPIC SEPTOPLASTY Described by LANZA and STAMMBERGER ADVANTAGES : Minimally invasive Better for treatment of isolated spurs Improved access to deviation posterior to septal perforation Better assessment of relationship b/w septum n middle turbinate Possible to see d separation of collagenous fibres connecting the perichondrium and periosteum to underlying bone and cartilage Can be used as a teaching tool for residents mucosal disruptions are recognized immediately

70. Procedure Infilteration is given The nasal cavity is examined with a 0 degree endoscope to see location of deviation and spur Rest of the steps are same as conventional septoplasty

71. Directed septoplasty This approach is useful for managing isolated spurs in absence of larger septal deviations HZ incision is made over the apex of spur,mucosal flaps elevated in superior and inferior direction Spur incised using microdebrider or by traditional septal transfixion with resection of spurring cartilage/bone. Flaps redrapped to minimize exposure of raw mucosa Advantage :limited dissection and quicker post op healing

72. Complications Major complications are rare Minor complications include epistaxis . Septal hematoma, injury to nasopalantine nerve wid dental numbness, scarring,perforation and CSF leak are rare complications.

73. Paediatric septoplasy Absolute indications: Septal abscess Septal haematoma Severe deformity secondary to acute nasal fracture Dermoid cyst Cleft lip nose

74. A child coming wid nasal obstructions should be properly evaluated very rarely cause will be septal deviation alone Factors contributing are : Congenital nasal mass( dermoid,encephalocele,glioma ) Nasal polyp Choanal atresia Foreign body Septal hematoma Adenoid hypertrophy Reversible obstruction ( acut URTI,chronic sinusitis,allergic inflammation) Isolated spur Turbinate hypertrophy Deviated septum Midface hypoplasia

75. Nasal septal perforation Etiology : Traumatic - post surgical, habitual nose picking, cauterization of septum with chemicals or galvano-cautery for epistaxis Pathological perforation Septal abscess Nasal myasis Rhinolith or neglected foreign body Chronic granulomatous conditions like TB, lupus, leprosy, syphilis, wegener’s Inhalant irritants- snuff and cocaine irritant, industrial toxins Malignancy idiopathic

76. Septal Perforation History Crusting, bleeding, whistling if perforation is small Rhinorrhea and disruption of lamellar flow if perforation is large Pain signifies chondritis More anterior the perforation the more likely the patient will become occult

77. Septal Perforation Must rule out a chronic inflammatory disease process, cocaine abuse, granulomatous process in face of granulation tissue on perforation

78. Physical Exam Crusting on mucosa due to dry nonlaminar flow, not necessarily at site of perforation Bleeding at edge of perforation Picture with endoscope and ruler to assess size of perforation

79. What tests do I order? Nasal cultures for fungal and bacterial infections Skin testing for TB, fungi and anergy VDRL, FTA-Abs, C-ANCA Biopsy to rule out autoimmune process

80. Principle Perforation is unlikely to heal on its own More likely to contract and create a larger opening

81. Medical Therapy Petroleum based ointments Antiseptic wash per Fairbanks (1 teaspoon salt in warm water delivered by Water- Pik device +/- glycerin to moisturize + boric acid or vinegar) Medical button

82. Surgical therapy Endonasal repair Small perforations External approach Most perforations less than 2cm Tissue expander Free flap

83. Nasal septal perforation Clinical features Whistling sound Irritation and crusting Epistaxis Nasal obstruction

84. 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

85. Thank You