NASAL SEPTAL ANATOMY AND SMRCol Dr Anwar ul Haq ENT Consultant +923018513303
ANATOMY OF NASAL SEPTUM Columellar septum It is formed of columella Containing the medial crura of alar cartilages united together by fibrous tissue Covered on either side by skin
MEMBRANOUS SEPTUM It lies b/w columella and caudalborder of septal cartilage No bony or cartilaginous support Above two parts freely movablefrom side to side
SEPTUM PROPER Consist of osteocortilaginous frame work Its main Constitutes are Perpendicular plate of ethmoid vomer bone Large septal cartilage (quadrilateral) wedged between the above two bones anteriorly
SEPTUM PROPER Minor contributions Crest of nasal bone Nasal spine of frontal bone Rostum of spnenoid Crest of palatine bone Crest of maxilla and anterior nasal spine of maxilla
BLOOD SUPPLY OF NASAL SEPTUM Internal carotid system Anterior ethmoidal artery Branches of Post ethmoidal artery opthalmic artery
EXTERNAL CAROTID SYSTEM Spheno palatine artery (maxillary) Nasopalotine branches Post nasal septal branches Septal branch of great palatine artery(maxillary) Septal branch of superior labial artery (Facial)
LITTLE’S AREA (KIESSEL BACH’S PLEXUS) Anterior ethmoidal Septal branch of supeior labialSeptal branch of sphenopalotineSeptal branch of greater palatine
VENOUS DRAINAGE Posteriorly through sephenopalatine veinsinto pterygoid venous plexus Anteriorly drain into facial veins Superiorly in ethmoidal veins
NERVE SOPPLY OF NASAL SEPTUM Olfactory nerves Carry sense of smell Supply olfactory region of nose Can Carry sheath of dura, archnoid and pia matter
NERVE SUPPLY Nerves of common sensation Anterior ethmoidal nerve Branches of nasopalatine nerve Branches of infra orbital nerve
AUTONOMIC NERVES Parasympathetic nerve fibers supply nasalglands and control nasal secretions Greater superfacial petrosal nerve. Sympathetic nerve fibers Upper two thoracic segments Deep petrosal nerve
LYMPHATIC DRAINAGE Submandibular lymph nodes Rest of nasal cavity draininto upper jugular nodesdirectly or throughretropharyngeal nodes
SUBMUCOUS RESECTION OF NASAL SEPTUM• INDICATIONS – DNS causing symptoms of nasal obstruction and recurrent headache. – DNS causing obstruction of paranasal sinuses and middle ear. – Recurrent epistaxis from septal spur – As a part of septorhinoplasty – As a preliminary step in Hypophsectomy (Trans septal trans sphenoidal approach) Vidian neurectomy (Trans septal apprach)
CONTRA INDICATIONS• Pt’s below 17 years age• Acute respiratory infection• Bleeding diathesis• Untreated diabetes or hypertension
ANASTHESIA• LA is preffered• GA is used in children and apprehensive adults
POSITION• Reclining position with head-end of the table raised
STEPS OF OPERATION• Infiltration of nasal septum• Incision – A curvilinear incision with forward convexity is made at 5mm behind the mucocutaneous junction on the deviated side of septum
STPES OF OPERATION• Elevation of mucopeichondrial and periosteal flap.• Incision of the cartilage• Elevation of opposite mucopeichondrium and periostium.
STEPS OF OPERATION• Removal of cartilage & bone – Preserve a strip of cartilage about 1cm along the dorsal and caudal border of the septum to prevent collapse of the nasal bridge.• Stiching – One or two catgut or silk stitches are applied• Packing – Ribbon gauze, smeared with furacin oinment or liquid paraffin
POST OPERATIVE CARE• Semi sitting position• Soft diet• Analgesics• Antibiotic cover for 5-6 days.• Nasal pack removed after 24 hours• Decongestant and steam inhalation• Avoid nasal trauma
COMPLICATIONS• Bleeding• Septal haematoma• Septal abscess• Perforation• Depression of nasal bridge• Retraction of columella• Flapping of nasal septum• Toxic shock syndrome
SEPTOPLASTY• Septoplasty is a conservative approch to septal surgery as much of the septal framework as possible is retained• Mucoperichondrial / periosteal flap is generally raised only one side.
STEPS OF OPERATION• Infiltrate the septum with 1% lignocaine with adrenaline• In case of deviated septum make a slightly curveline incision 2-3 mm above the caudal end of septal cartiflage on the concave side in case of caudal dislocation a transfixition or hemi transfixition incision is made
• Raise mucoperichondrial / mucoperiosteal flap on one side only• Seprate septal cartilage from the vomer and ethmoid plate and raise mucoperiosteal flap on the apposite side of septum.
• Remove maxillary crest to realign the septal cartilage• Correct the bony septum by removing the deformed parts• Deformed septal cartilage is corrected by various methods such as – Scoring on the concave side – Cross hatching – Shaving – Wedge excision – Trans septal sutures are put to coapt mucoperichondrial flaps – Nasal pack
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