septum and its diseasese detail presentation .pptx

septum and its diseaseaa

1. NASAL SEPTUM & Its Diseases

2. NASAL SEPTUM Midline structure which divides the right and left nasal cavities. Consists of three parts 1.Columellar septum 2.Membranous septum 3.Septum proper.

3. Columellar septum. Formed of columella containing the medial crura of alar cartilages. United together by fibrous tissue Covered on either side by skin.   2. Membranous septum . D ouble layer of skin N o bony or cartilaginous support. L ies between the columella and the caudal border of septal cartilage. Both columellar and membranous parts are freely movable from side to side.

4. SEPTUM PROPER O steocartilaginous framework C overed with nasal mucous membrane. P rincipal Components are :   1 . P erpendicular plate of ethmoid. 2. The vomer L arge septal cartilage M inor contributions from I. Crest of nasal bones ii. Nasal spine of frontal bone Iii. Rostrum of sphenoid iv Crest of palatine bones V. Crest of maxilla vi. Anterior nasal spine of maxilla.

5. Blood Supply of Septum: Internal Carotid System Anterior ethmoidal artery Branches of ophthalmi c artery Posterior ethmoidal artery External Carotid System: Sphenopalatine artery branch of maxillary artery 2 . Septal branch of greater palatine artery branch of maxillary artery Septal branch of superior labial artery (branch of facial artery ).

6. LITTLE’S AREA OR Kiesselbach’s plexus Vascular area in the anteroinferior part of nasal septum just above the vestibule Exposed to the drying effect of inspiratory current & finger nail trauma. Common Site for epistaxis in children and young adults . Four arteries anastomose here. Anterior ethmoidal Septal branch sphenopalatine The greater palatine Septal branch of superior labial + corresponding veins

7. NERVE SUPPLY 1.   Nerves of Common Sensation. Anterior ethmoidal nerve . ( nasocillary nerve=> ophthalmic V1 division of trigeminal) Ii anterior superior alveolar nerve Branch of infraorbital nerve (maxillary divisin V2 of trigeminal nerve. Branches of pterygopalatine ganglion . (medial posterior superior nerve and spenopalatine /nasopalatine nerve) 2. Olfactory nerves.

8. FRACTURES OF NASAL SEPTUM Aetiopathogensis : Trauma. Fracture of septal cartilage or its dislocation from vomerine groove. Septal injuries: with mucosal tear-profuse epistaxis. with intact mucosa-Hematoma “ Jarjaway ” fracture of nasal septum : B lows from the front . starts just above the anterior nasal spine of maxilla and runs horizontally backwards just above the junction of septal cartilage with the vomer

9. “ Chevallet ” fracture of septal cartilage: B lows from below. Runs vertically from the anterior nasal spine of maxilla upwards to the junction of bony and cartilaginous dorsum of nose

10. TREATMENT   Haematomas should be drained. Dislocated or fractured septal fragments should be repositioned and supported between mucoperichondrial flaps with mattress sutures and nasal packing.. COMPLICATIONS Septum is important in supporting the lower part of the external nose. If its injuries are ignored, they would result in deviation of the cartilaginous nose, or asymmetry of nasal tip, columella or the nostril.

11. DNS AETIOLOGY: trauma . L ateral blow on the nose => displacement of septal cartilage from the vomerine groove and maxillary crest. C rushing blow from the front => buckling , twisting, fractures and duplication of nasal septum with telescoping of its fragments . Trauma at birth during passage via birth canal.   2. Developmental error. 3 . Racial Factors . Caucasians are affected more than black Americans . 4. hereditary Factors. Several members of the same family may have deviated nasal septum

12. TYPES OF DNS   1 . anterior dislocation . Septal cartilage may be dislocated into one of the nasal chambers. 2 . C-shaped deformity . Septum is deviated in a simple curve to one side . Nasal chamber on the concave side of the nasal septum will be wider and may show compensatory hypertrophy of turbinates . 3. S-shaped deformity . S shaped curve either in vertical or anteroposterior plane. cause bilateral nasal obstruction .

13. 4. Spurs. S helf-like projection often found at the junction of bone and cartilage. M ay press on the lateral wall and gives rise to headache . M ay also predispose to repeated epistaxis from the vessels stretched on its convex surface .   5. thickening. D ue to organized haematoma or overriding of dislocated septal fragments

14. CLINICAL FEATURES    1 . NASAL OBSTRUCTION. obstruction may be unilateral or bilateral. Site of obstruction vestibular (caudal septal dislocation ) N asal valve ( synechiae , usually post-rhinoplasty) (iii) attic (upper part of nasal septum due to high septal deviation) (iv) turbinal ( hypertrophic turbinates or concha bullosa) and (v) choanal

15. Cottle test. Used to know whether nasal obstruction is due to septal abnormality or not. C heek is drawn laterally while the patient breathes quietly. If the nasal airway improves on the test side, the test is + Indicates abnormality of the vestibular component of nasal valve

16. 2. Headache . E specially a spur, may press on the lateral wall of nose giving rise to pressure headache. 3. Sinusitis. May obstruct sinus ostia => poor ventilation of the sinuses. P redispose or perpetuate sinus infections. 4. Epistaxis . Mucosa over dns is exposed to the drying effects of air currents=> crusts, removal => bleed. Bleeding may also occur from vessels over a septal spur .

17. 5. Anosmia . Failure of the inspired air to reach the olfactory region may result in total or partial loss of sense of smell. 6. External deformity . Septal deformities may be associated with deviation of the cartilaginous or both the bony and cartilaginous dorsum of nose, deformities of the nasal tip or columella .   7. Middle ear infection. DNS also predisposes to middle ear infection.

18. TREATMENT: Minor degrees of septal deviation with no symptoms require no treatment. DNS produces mechanical nasal obstruction or symptoms than operation is indicated

19. SEPTAL HEMATOMA C ollection of blood under the perichondrium or periosteum of the nasal septum R esults from nasal trauma or septal surgery. May occur spontaneously in bleeding disorders. CLINICAL FEATURES Bilateral nasal obstruction is the commonest presenting symptom . M ay be associated with frontal headache and a sense of pressure over the nasal bridge

20. Examination reveals smooth rounded swelling of the septum in both the nasal fossae . Palpation may show the mass to be soft and fluctuant . TREATMENT Small haematomas can be aspirated with a wide bore sterile needle . Larger haematomas are incised and drained by a small anteroposterior incision parallel to the nasal floor. N ose is packed on both sides to prevent reaccumulation . Systemic antibiotics should be given to prevent septal abscess . COMPLICATIONS   if not drained, may organize into fibrous tissue leading to a permanently thickened septum . If secondary infection supervenes =>septal abscess with necrosis of cartilage and depression of nasal dorsum.

21. SEPTAL ABSCESS AETIOLOGY F rom secondary infection of septal haematoma . Occasionally follows furuncle of the nose or upper lip. M ay also follow acute infection such as typhoid or measles .

22. Clinical Features: S evere 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

23. 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.

24. Perforation of Nasal Septum 1.traumatic perforations . M ost common cause. Injury to mucosal flaps during SMR C auterization of septum with chemicals or galvanocautery for epistaxis. H abitual nose picking Occasionally , septum is deliberately perforated to put ornaments.   2. pathological perforations .   1. Septal abscess. 2. Nasal myiasis . 3. Rhinolith or neglected foreign body causing pressure necrosis

25. Chronic granulomatous conditions like lupus, tuberculosis and leprosy cause perforation in the cartilaginous part while syphilis involves the bony part . 5. Wegener’s granuloma is a midline destructive lesion which may cause total septal destruction . 3. drugs and chemicals 1. Prolonged use of steroid sprays in nasal allergy. 2. Cocaine addicts. 3. Workers in certain occupations, e.g. chromium plating, dichromate or soda ash (sodium carbonate) manufacture or those exposed to arsenic or its compounds . 4. idiopathic. many cases,no history of trauma or previous disease and the patient may even be unaware of the existence of a perforation . CLINICAL FEATURES Small anterior perforations cause whistling sound during inspiration or expiration. Larger perforations develop crusts which obstruct the nose or cause severe epistaxis when removed.

26. TREATMENT F inding of cause before treatment . May require biopsy from the granulations or biopsy of the edge of the perforation . Inactive small perforations can be surgically closed by plastic flaps . Larger perforations are difficult to close. treatment is aimed to keep the nose crust-free by alkaline nasal douches application of a bland ointment. Sometimes, a thin silastic button can be worn to get relief from the symptoms