NASAL SEPTUM AND ITS DISEASES DEPT OF OTORHINOLARYNGOLOG Y JJM M C DAVANAGERE
Nasal septum and its diseasesAnatomy of nasal septum:Nasal septum consists of three parts:1. Columellar septum2. Membranous septum3. 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.
Nasal septum and its diseaseso Septal cartilage forms a partition between right and left nasal cavities and provides support to tip and dorsum of cartilagenous part of nose.o Septal destruction may occur in septal abscess, injuries, tuberculosis, excess removal during SMR leads to depression of lower part of nose and drooping of tip.o 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.
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.
Fractures of nasal septumTypes :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.
Fractures of nasal septumTreatment: -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.
DEVIATED NASAL SEPTUMAETIOLOGY: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) Hereditary5) Racial: Caucasians are more affected6) Secondary: to a tumour, mass or polyp.
DEVIATED NASAL SEPTUMTypes: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
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
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
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
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
SMR Contraindications Acute URTI Patient below 17 yrs of age Bleeding disorders Uncontrolled hypertension and diabetes mellitus
SMR Anesthesia - Local anesthesia/ general anesthesia Positioning: reclining position with head end of the table raised
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
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
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
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
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
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
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
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
Differences between SMR andseptoplasty SMR Septoplasty1. Radical surgery 1. Conservative surgery2. Not done in children 2. Can be done in children3. Killian’s incision 3. Freer’s incision4. Flaps elevated on both 4. Flap elevated on concave sides side only5. Most of cartilage removed 5. Most of cartilage preserved6. Caudal dislocation not 6. Caudal dislocation corrected corrected7. Perforation chance higher 7. Perforation rare8. Post operative saddling 8. Post operative deformity may be present absent9. Revision surgery difficult 9. Revision surgery easier
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
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
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
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
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
Septal abscess Complications Depression of the cartilagenous dorsum Septal perforation Meningitis and cavernous sinus thrombosis (rare)
Nasal septal perforation Etiology Traumatic - post surgical, habitual nose picking, cauterization of septum with chemicals or galvano-cautery for epistaxis Pathological perforationa) Septal abscessb) Nasal myasisc) Rhinolith or neglected foreign bodyd) Chronic granulomatous conditions like TB, lupus, leprosy, syphilis, wegener’s Inhalant irritants- snuff and cocaine irritant, industrial toxins Malignancy idiopathic
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