DNS, Septal abscess, Septal perforation

1. Conditions of the Nasal
Septum
Dr. Krishna Koirala
2017-08-15

2. Deviated Nasal Septum
( DNS)

3. Etiology
• Traumatic
• Developmental
− Birth moulding
− High arched palate
− Unequal growth between skull base and palate
• Mass in opposite nasal cavity
• Racial factors
• Hereditary : posterior DNS

4. Types of DNS
• Anterior / caudal dislocation
• C - shaped deformity
• S-shaped deformity
• Septal Spur : shelf-like projection between
bone and cartilage
• Septal Thickening: organized hematoma or
over-riding of septal fragments

5. Types of DNS

6. Cottle’s classification of DNS
• Simple
• Obstructed
• Impacted

7. Clinical features
• Nasal obstruction
– On side of DNS
– Paradoxical nasal obstruction on opposite side due
to compensatory inferior turbinate hypertrophy
• Recurrent cold
– Associated sinusitis, allergy
• Headache : Sluder’s neuralgia, sinusitis

8. • Epistaxis
– Stretched mucosa on DNS  dry crusting 
bleeding on removal
– Stretched blood vessels over spur
• Hyposmia
– High D.N.S.
• External nasal deformity

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

10. 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 route to
− Hypophysectomy
− Vidian neurectomy
4. Hereditary Hemorrhagic telengiectasia

11. •Commonly performed Surgeries
to correct the deviated nasal
septum
–Septoplasty
–Submucosal resection of the
septum (SMR)

12. Cottle’s line
Imaginary line drawn from
frontal nasal spine to
maxillary nasal spine
• Deviations anterior to it can
be corrected only by
septoplasty
• Deviations posterior to it
can be corrected either by
SMR or septoplasty

13. S.M.R. Septoplasty
Radical surgery Conservative
Not done below 17 yrs of age Done after 4 yrs
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
Can’t be combined with rhinoplasty Can
Revision surgery difficult Relatively easy
Cartilage graft can be harvested No
Complications common Rare

14. Septoplasty

15. Incision : Freer’s

16. Muco - perichondrial flap elevation

17. Creation of Anterior and Inferior
tunnels
Ant
tunnel
Inf tunnel

18. Dislocation of bony cartilaginous
junction

19. Muco-periosteal flap elevation on both
sides

20. Removal of inferior cartilage strip

21. Spur and deviated portion of Cartilage and Bone
removed

22. Scoring and cross-hatching

23. Wedge excision and shaving

24. Anterior nasal packing

25. Bolster application (Outer pack)

26. Submucosal Resection

27. Killian’s incision

28. Muco-perichondrial flap elevation

29. Cutting of cartilage and elevation of
opposite flap

30. Excision of septal cartilage

31. Excision of septal cartilage

32. Cartilage + Bone removed

33. Anterior nasal packing

34. Complications of septal surgery
1. Hemorrhage
2. Septal hematoma/ infection/ abscess /perforation
3. Saddle nose / supratip depression/ Columellar retraction
4. Flapping septum
5. Persistent deviation
6. Nasal synechia
7. C.S.F. rhinorrhoea
8. Infection
9. Toxic shock syndrome

35. Septal Hematoma

36. • Collection of blood under the perichondrium/
periosteum of nasal septum
• Etiology
–Nasal trauma
–Septal surgery
–Bleeding disorders

37. Clinical features
• Bilateral nasal obstruction
• Sense of pressure over nasal bridge
• B/L smooth, fusiform, round septal swelling
• On palpation mass is soft & fluctuant
• Absence of raised temperature, erythema, swelling &
tenderness of skin over nose

39. Treatment
1. Small: wide bore needle aspiration
2. Large:
–Incision and drainage
–Nasal packing (prevent recurrence)
–Systemic antibiotics (prevent abscess)

40. Complications
• Septal abscess with cartilage necrosis
• Septal perforation
• Saddle nose
• Supra-tip deformity
• Thickened nasal septum due to organized
hematoma

41. Septal abscess

42. • Collection of pus under perichondrium /periosteum
of nasal septum
• Etiology
– Secondary infection of septal hematoma
– Following furuncle of nose or upper lip
– Following typhoid or measles
– Immunocompromised hosts

43. Clinical Features
• Bilateral nasal obstruction with fever
• Skin over nose shows raised temperature, erythema,
swelling and tenderness
• B/L smooth, soft, fluctuant septal swelling
• Septal mucosa congested
• Submandibular node enlarged and tender

45. Treatment
• Abscess drained immediately by making an
incision on the most dependent part
• Pus and necrosed cartilage removed
• Nasal packing done
• Systemic antibiotics administered for 7-10
days

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

47. Septal Perforation

48. Etiology
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’s
6. Malignancy
7. Idiopathic

49. Clinical features
• Small perforation
–Whistling sound during respiration
• Large perforation
–Nasal crusting  nasal obstruction 
epistaxis on crust removal

51. Treatment
• Treat the 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 poor

52. Nasal mucosal flaps

53. Sublabial flap

54. Silastic obturator