1. A deviated nasal septum is caused by trauma, developmental issues, masses in the nasal cavity, and racial or hereditary factors. 2. Types of deviations include anterior/caudal dislocation, C-shaped, S-shaped, spurs, and thickening. Clinical features include nasal blockage, recurrent colds, headaches, and epistaxis. 3. Surgical techniques to correct deviations include septoplasty, which involves scoring and removing portions of cartilage, and submucosal resection, which removes larger sections of cartilage. Complications can include hematomas, abscesses, perforations, and synechiae.

1. Deviated Nasal
Septum
Dr. Vishal Sharma

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. 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. Anterior / caudal dislocation

5. C - shaped

6. S - shaped

7. Nasal septal spur

8. Thickened & impacted
nasal septum

9. C-shaped DNS not touching
lateral nasal wall

10. C-shaped DNS touching
lateral nasal wall

11. Compensatory turbinate
hypertrophy

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. 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. Sequelae
• Sinusitis
• Mouth breathing  snoring, pharyngitis
• Atrophic rhinitis & myiasis
• Otitis media

15. History of septal
surgeries

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. Edwin Smith Papyrus

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. Gustav Killian

20. Maurice Cottle

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. Septoplasty

23. Freer’s Incision

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. Muco-perichondrial flap
elevation on right side

26. Anterior + Inferior tunnels

27. Inferior cartilage strip removal

28. Dislocation of bony
cartilaginous junction

29. Muco-periosteal flap
elevation on both sides

30. Cartilage + Bone removed

31. Scoring & cross-hatching

32. Wedge excision & shaving

33. Anterior nasal packing

34. Outer nasal packing

35. Submucosal
Resection

36. Killian’s incision

37. Muco-perichondrial flap
elevation on right side

38. Cutting of cartilage &
elevation of opposite flap

39. Excision of septal cartilage

40. Excision of septal cartilage

41. Cartilage + Bone removed

42. Anterior nasal packing

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. 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. Septal haematoma
Collection of blood under perichondrium
& periosteum of nasal septum.
Aetiology:
1. Nasal trauma
2. Septal surgery
3. Bleeding disorders

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. Septal Haematoma

48. Treatment
1. Small: wide bore needle aspiration
2. Large:
a. incision & drainage
b. nasal packing (prevent recurrence)
c. systemic antibiotics (prevent abscess)

49. Complications
• Thickened nasal septum
• Septal abscess with cartilage necrosis
• Saddle nose
• Supra-tip deformity
• Septal perforation

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. 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. Septal Abscess

53. Septal abscess

54. Treatment
• Abscess drained immediately
• Incision made on most dependent part
• Pus & necrosed cartilage removed
• Nasal packing done
• Systemic antibiotics for 10 days

55. Complications
• Necrosis of septal cartilage
• Saddle nose
• Supra-tip deformity
• Septal perforation
• Meningitis
• Cavernous sinus thrombosis

56. Saddle nose

57. Nasal synechia

58. Perforated
nasal septum

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. Clinical features
Small perforation: whistling sound
during respiration
Large perforation: nasal crusting
 nasal obstruction
 epistaxis on crust removal

61. Perforated nasal septum

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. Nasal mucosal flaps

64. Nasal mucosal flaps

65. Sublabial flap

66. Silastic obturator

67. Thank You