5 deviated-nasal-septum

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5 deviated-nasal-septum

  1. 1. Deviated Nasal Septum Dr. Vishal Sharma
  2. 2. Aetiology 1. Trauma: blow on nose 2. Developmental:  Birth moulding  High arched palate  Unequal growth b/w skull base & palate 3. Mass in opposite nasal cavity 4. Racial factors: common in Europeans 5. Hereditary: in posterior D.N.S.
  3. 3. Types 1. Anterior / caudal dislocation 2. C-shaped deformity 3. S-shaped deformity 4. Septal Spur: shelf-like projection 5. Septal Thickening: organized hematoma or over-riding of septal fragments 6. Impacted septum: despite decongestion
  4. 4. Anterior / caudal dislocation
  5. 5. C - shaped
  6. 6. S - shaped
  7. 7. Nasal septal spur
  8. 8. Thickened & impacted nasal septum
  9. 9. C-shaped DNS not touching lateral nasal wall
  10. 10. C-shaped DNS touching lateral nasal wall
  11. 11. Compensatory turbinate hypertrophy
  12. 12. Clinical features 1. Nasal block: present on side of D.N.S. C/L paradoxical nasal obstruction due to compensatory inferior turbinate hypertrophy. 2. Recurrent cold: due to associated sinusitis 3. Headache: due to contact with lateral wall (Sluder’s neuralgia), sinusitis
  13. 13. Clinical features 4. Epistaxis: stretched mucosa on DNS  dry crusting & bleeding on removal; stretched blood vessels over spur. 5. Hyposmia: seen in high D.N.S. 6. External nasal deformity
  14. 14. Sequelae • Sinusitis • Mouth breathing  snoring, pharyngitis • Atrophic rhinitis & myiasis • Otitis media
  15. 15. History of septal surgeries
  16. 16. • Edwin Smith Surgical Papyrus (dated 17th century BC): world's oldest surgical document & only surviving copy of a part of an Ancient Egyptian textbook on trauma surgery written in 3500 B.C. Listed are 48 traumatic injury cases, with description of examination, diagnosis & treatment. • Treatment of DNS: fracture reduction of DNS with internal pack using grease coated linen & external packing with stiff rolls of linen.
  17. 17. Edwin Smith Papyrus
  18. 18. • Bosworth operation (late 19th century): deviated part of septum amputated along with mucosa • Asch (1899): full thickness cruciate incisions on septal cartilage • Freer (1902): SMR of total septal cartilage • Killian (1904): SMR with preservation of dorsal & caudal portion of septal cartilage • Metzenbaum (1929): Swinging door technique for caudal septal dislocation • Peer (1937): Removal of caudal septum & replacement after its alteration • Cottle (1948) : Maxilla-Premaxilla septoplasty
  19. 19. Gustav Killian
  20. 20. Maurice Cottle
  21. 21. Indications for septal surgery 1. D.N.S.: nasal obstruction / sinusitis / headache / epistaxis 2. Along with rhinoplasty 3. Harvesting of septal cartilage graft 3. Trans-septal surgeries:  Hypophysectomy  Vidian neurectomy 4. Hereditary telengiectasia
  22. 22. Septoplasty
  23. 23. Freer’s Incision
  24. 24. Cottle’s line Drawn from frontal spine to anterior nasal spine. Deviations anterior to it can be treated by septoplasty only. Posterior to it by SMR or septoplasty.
  25. 25. Muco-perichondrial flap elevation on right side
  26. 26. Anterior + Inferior tunnels
  27. 27. Inferior cartilage strip removal
  28. 28. Dislocation of bony cartilaginous junction
  29. 29. Muco-periosteal flap elevation on both sides
  30. 30. Cartilage + Bone removed
  31. 31. Scoring & cross-hatching
  32. 32. Wedge excision & shaving
  33. 33. Anterior nasal packing
  34. 34. Outer nasal packing
  35. 35. Submucosal Resection
  36. 36. Killian’s incision
  37. 37. Muco-perichondrial flap elevation on right side
  38. 38. Cutting of cartilage & elevation of opposite flap
  39. 39. Excision of septal cartilage
  40. 40. Excision of septal cartilage
  41. 41. Cartilage + Bone removed
  42. 42. Anterior nasal packing
  43. 43. S.M.R. Septoplasty Radical surgery Conservative Not done below 17 yr Done after 4 yr Killian’s incision Freer’s incision Cannot correct anterior DNS Can correct B/L mucoperichondrium elevated One side only Radical removal of cartilage Only inferior strip Rhinoplasty incision can’t combine Can Revision surgery difficult Relatively easy Cartilage graft can be harvested No Complications common Rare
  44. 44. Complications of septal surgery 1. Haemorrhage 2. Septal haematoma 3. Septal abscess 4. Septal perforation 5. Saddle nose 6. Columellar retraction 7. Flapping septum 8. Persistent deviation 9. Nasal synechia 10. C.S.F. rhinorrhoea 11. Infection 12. Toxic shock syndrome
  45. 45. Septal haematoma Collection of blood under perichondrium & periosteum of nasal septum. Aetiology: 1. Nasal trauma 2. Septal surgery 3. Bleeding disorders
  46. 46. Clinical features • Bilateral nasal obstruction • Sense of pressure over nasal bridge • B/L smooth, rounded septal swelling • On palpation mass is soft & fluctuant • Absence of raised temperature, erythema, swelling & tenderness of skin over nose.
  47. 47. Septal Haematoma
  48. 48. Treatment 1. Small: wide bore needle aspiration 2. Large: a. incision & drainage b. nasal packing (prevent recurrence) c. systemic antibiotics (prevent abscess)
  49. 49. Complications • Thickened nasal septum • Septal abscess with cartilage necrosis • Saddle nose • Supra-tip deformity • Septal perforation
  50. 50. Septal abscess Collection of pus under perichondrium & periosteum of nasal septum. Aetiology: 1. secondary infection of septal hematoma 2. following furuncle of nose or upper lip 3. following typhoid or measles
  51. 51. Clinical Features • Bilateral nasal obstruction with fever • Skin over nose shows raised temperature, erythema, swelling & tenderness • B/L smooth, soft, fluctuant septal swelling • Septal mucosa congested • Submandibular node enlarged & tender
  52. 52. Septal Abscess
  53. 53. Septal abscess
  54. 54. Treatment • Abscess drained immediately • Incision made on most dependent part • Pus & necrosed cartilage removed • Nasal packing done • Systemic antibiotics for 10 days
  55. 55. Complications • Necrosis of septal cartilage • Saddle nose • Supra-tip deformity • Septal perforation • Meningitis • Cavernous sinus thrombosis
  56. 56. Saddle nose
  57. 57. Nasal synechia
  58. 58. Perforated nasal septum
  59. 59. Aetiology 1. Trauma: septal surgery, nose picking, septal cautery, ornamentation 2. Infection: septal abscess 3. Nasal Irritants: snuff, cocaine 4. Foreign body, Rhinolith, Nasal myiasis 5. Granuloma: TB, leprosy, syphilis, Wegener 6. Malignancy 7. Idiopathic
  60. 60. Clinical features Small perforation: whistling sound during respiration Large perforation: nasal crusting  nasal obstruction  epistaxis on crust removal
  61. 61. Perforated nasal septum
  62. 62. Treatment • Treat cause of septal perforation • Alkaline nasal douche for crusting • Small perforation: closed by mucosal advancement flaps • Large perforation: Silastic obturator, Alloderm. Results of surgery are
  63. 63. Nasal mucosal flaps
  64. 64. Nasal mucosal flaps
  65. 65. Sublabial flap
  66. 66. Silastic obturator
  67. 67. Thank You

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