Nasal septum and its diseases

1. NASAL SEPTUM AND ITS DISEASES
DEPT OF
OTORHINOLARYNGOLOG
Y
J J M M C
DAVANAGERE

2. Nasal septum and its diseases
Anatomy of nasal septum:
Nasal septum consists of three parts:
1.Columellar septum
2.Membranous septum
3.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.

3. Nasal septum and its diseases
oSeptal cartilage forms a partition between right and left
nasal cavities and provides support to tip and dorsum of
cartilagenous part of nose.
oSeptal destruction may occur in septal abscess, injuries,
tuberculosis, excess removal during SMR leads to
depression of lower part of nose and drooping of tip.
oSeptal 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.

4. BLOOD SUPPLY-NASAL SEPTUM

5. NERVE SUPPLY-NASAL SEPTUM

6. 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.

7. 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.

8. Fractures of nasal septum

9. 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.

10. 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)Hereditary
5)Racial: Caucasians are more affected
6)Secondary: to a tumour, mass or polyp.

11. 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

12. DEVIATED NASAL SEPTUM-types

13. 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

14. 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

15. Cottle’s test

16. Differential diagnosis
Polyps
Septal haematoma
Hypertrophied turbinates

17. 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

18. 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

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

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

21. 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

22. 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

23. SMR – STEPS

24. 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

25. 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

26. 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

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

28. 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

29. 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

31. 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

32. Differences between SMR and
septoplasty
SMR
1.Radical surgery
2.Not done in children
3.Killian’s incision
4.Flaps elevated on both
sides
5.Most of cartilage removed
6.Caudal dislocation not
corrected
7.Perforation chance higher
8.Post operative saddling
may be present
9.Revision surgery difficult
Septoplasty
1.Conservative surgery
2.Can be done in children
3.Freer’s incision
4.Flap elevated on concave
side only
5.Most of cartilage preserved
6.Caudal dislocation
corrected
7.Perforation rare
8.Post operative deformity
absent
9.Revision surgery easier

33. 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

34. 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

35. 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

36. Septal haematoma

37. 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

38. 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

39. Septal abscess
Complications
Depression of the cartilagenous dorsum
Septal perforation
Meningitis and cavernous sinus thrombosis
(rare)

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

41. Nasal septal perforation
Clinical features
Whistling sound
Irritation and crusting
Epistaxis
Nasal obstruction

42. 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