septoplasty and smr

1. NASAL SEPTAL ANATOMY
AND SEPTOPLASTY
Dr Safika Zaman
PGT, Dept of ENT and head-Neck Surgery
VIMS,RKMSP

2. SEPTAL ANATOMY
• A. small anterior membranous portion
• B. cartilaginous portions, is composed of quadrilateral cartilage with contribution
from upper and lower alar cartilage.
• C. Bony portion is made up of the vomer and two bony crests of maxilla and palatine
inferiorly, and superiorly of perpendicular plate of ethmoid.

3. SEPTAL ANATOMY

4. BLOOD SUPPLY OF SEPTUM
Taken from Text
book of ENT by P L
Dhingra

5. NERVE SUPPLY OF SEPTUM
Image from Netters Atlas

6. HISTOLOGY
• Septum is covered with mucous membrane in its both
surface, the mucous membrane is predominately
respiratory with a small area of olfactory epithelium
superiorly.
• The respiratory epithelium is composed of ciliated and non
ciliated pseudostratified columner cells, basal pluripotent
stem cells and goblet cells.
• Seromucinous glands are found in the submucosa and are
more important in mucous production in nasal cavity than
the goblet cells .
Image sourse: Internet

7. CAUSES OF NASAL SEPTAL DEFORMITY
• Developmental disorder
• Septal trauma
• Septal infections
• Septal disease in systemic disorder

8. DEVELOPMENTAL CAUSES
• Cleft lip and cleft palate are two most
common congenital conditions in which
the septum is involved,
Other causes are- choanal atresia.
-congenital midline
teratoma.
-frontonasal dysplasia.
-bifid nose, etc.
Image source: internet

9. SEPTAL TRAUMA
• A septal trauma is very common, starting from
birth process it may happen at any stage of life.
• The type of fracture in nasal trauma depends
upon the side and magnitude of the impact. A
frontal trauma will frequently result in vertical
fractures, whereas lateral trauma can give
horizontal fructures.

10. SEPTAL INFECTIONS
• Septal abscess: most common cause is septal haematoma
• Syphilis
• Tuberculosis
• Diptheria
• leprosy

11. SYSTEMIC DISORDER
• Sarcoidosis
• Lupus erythematosus
• Takayasu disease
• Wegners granulomatosis
• Arteriosclerosis
• Midline T-cell lymphoma
Image of midline t cell lymphoma: image
taken from internet

12. SYMPTOMS RELATED TO THE SEPTAL
PATHOLOGY
• Nasal blockage.
• Dryness or crusting of nasal mucosa.
• Bleeding from nose.
• Itching
• Rhinorrhoea
• Anosmia
• Headache
• Cosmetic complaints.

13. DIAGNOSIS
• Physical examination: a. inspection of the external nose in
relation to the face.
• b. inspection of internal nose.
• Objective investigations: - Nasal endoscopy
-Rhino-manometry
-Acostic-rhinometry
-Olfactometry
Image of a Y-Tube olfactometer,
taken from internet

14. HISTORY OF SEPTOPLSTY
The Edwin Smith Papyrus (circa 1600 BC)
Bosworth operation: late 19th century.
Asch(1899): full thickness crusiate incision.
Freer(1902): SMR of total cartilage.
1904, Killian, with preservation of dorsal and caudal cartilage.
1929-Metzenbaum, concept of swing door technique.
1963- cottle and van dishoek give concept of reconstruction instead of resecting and to
deal with function and cosmetics in one procedure.

15. INDICATION OF SEPTOPLASTY
Common indications are nasal obstruction, crusting , rhinorrhoea, post nasal
discharge, recurrent sinus pain, snoring, sleep apnoea.
However there is a little evidence for a casual link between these symptoms and
septal deviation.
The indication for septoplasty for aesthetic reasons are in general more
straightforward.

16. GOAL OF SURGERY
• Exposure to the pathologic portion of septum
• Removal and reconstruction of the defective portion
• Preserve nasal mucosa and lining
• Prevent external deformity of nose.

17. PHASES OF SURGERY
• There are six phases:
• 1.Gaining access to septum
• 2.Correction of patology
• 3.Removing pathology
• 4.Shaping removed cartilage and bone
• 5.Reconstruction of the septum
• 6.Stabiliging the septum.

18. SMR
• In this technique, the L-strut is not addressed therefore a Killian incision for approach
would suffice. A Killian incision is placed about 1 cm cephalad from the caudal end of
the septum.
• At this point the perichondrium is less adherent to the underlying cartilage and the
flap can be raised more easily.
• The deviated part of the septum is freed from its peripheral cartilaginous and bony
attachments. The in-situ bony deviation can be in-fractured to put the bony septum in
midline or it can be excised conservatively.

19. Image sorce:
internet

20. SEPTOPLASTY
• In most cases of septal deviation, the
septal L-strut is involved. SMR is not
effective in these cases as it can not
address the caudal and dorsal struts.
Septoplasty techniques are needed to
address these problems and the approach
should provide access to the L-strut.

21. INCISION
• Hemi-transfixion incision is designed to provide access to
the whole septum including the caudal L-strut. The incision
is placed at the caudal edge of the septum. The length of the
incision depends on the access required.
Image souce : internet

22. TECHNIQUES OF SEPTOPLASTY
• :The deviated septum can be addressed by
• 1) Cutting techniques.
• 2) Grafting techniques.
• 3) Suturing techniques and
• 4) Relocating techniques.
• The techniques can be used alone or in combination.

23. CUTTING TECHNIQUES
• Scoring: scoring of the septal
cartilage on the concave side allows
the septum to become straight,
eliminating the deviation.
• swinging door technique: Caudal
septal deviation or dislocation is
often addressed by excising the
excess cartilage at the caudal arm of
the L-strut.
Image source: internet

24. GRAFTING
• GRAFTING TECHNIQUES:
• Often the deviated septum can be kept
in a straight line if it is splinted
against a graft. Both septal cartilage
and septal bone (from perpendicular
plate of ethmoid or from vomer) can be
used for this purpose.

25. RELOCATING TECHNIQUES
• These techniques are used when the septum is dislocated off the midline and it
only requires re insertion onto the maxillary crest. The septum needs to be secured
in its midline position and this is achieved by suturing the septum either onto the
periosteum of the anterior nasal spine.
• Often a deviated caudal septum can be improved by door-stop technique where the
septal cartilage is dissected free along the maxillary crest and is relocated over
thenasal spine which acts as a door stop and secures the caudal septum in a
straighter position

26. SUTURING
• SUTURING TECHNIQUES
• A mattress suture can be used to control the
septal curvature. In this technique, the
septum is first scored (preferably underscored)
just enough to make it pliable so it can be
shaped and kept in shape by fine sutures. The
entrance and exit sutures are placed on the
convex side and the knot is incrementally
tightened until the desired position and shape
is achieved.

27. ENDOSCOPIC SEPTOPLASTY
• This technique improves visualization
. It also allows minimal access dissection to reach
isolated deviated parts of the septum.
. Endoscopic septoplasty can be used
concomitantly along with sinus surgery.
It is also an effective teaching tool.

28. EXTERNAL APPROACH SEPTOPLASTY
• Most septoplasty techniques can be
performed through the endonasal
approach; in certain situations
especially where the dorsal L-strut
deformity is concerned, the external
approach septoplasty can improve
surgical access.

29. EXTRACORPORAL SEPTOPLASTY
In cases of a severely fractured and deformed septum, thecorrection and reconstruction can
be achieved through anextracorporeal technique
Method: The septum is excised inone piece as intact as possible. The septum is then
measured and a template is made to representthe new septum.
techniques
• 1. Re-orientation: The new L-strut is harvested froma straight section of the excised
septum and it is reinserted in place.
• 2. Reconstruction: The septum is reconstructed by a variety of technique and then
reinserted in its place.

30. PAEDIATRIC SEPTOPLASTY
studies have demonstrated that septal surgery performed in children as young as 6
years old provides long-term satisfactory .
Delaying operationon children with deformed nasal skeleton andseptal deformities
can adversely affect nasal and facial growth and it prolongs patients’ suffering from
nasal blockage.
Important is to resect the cartilage conservatively and to avoid disrupting the
endochondral ossification plates if possible. Excision should be kept to minimum and
any excised segment should be reinserted after remodelling.

31. NASAL SEPTAL PERFORATION
• • Free grafts:
• simple or composite autografts
• allografts
• • Pedicled flaps:
• local nasal mucosal
• buccal mucosal
• composite septal cartilage and mucosa
• composite skin/cartilage
• • Rotation/advancement of mucoperichondrial or
mucoperiostealflaps.

32. COMPLICATIONS
• Excessive bleeding
• Infection
• Poor healing of incision
• Persistence of previous symptoms despite surgery
• Septal perforation
• Change in shape of the nose –supra tip depression.
• Decrease in sense of smell
• Temporary numbing in upper gum or teeth
• Septal hematoma

33. DISCUSSION
Septoplasty can be one of the most challenging and yet rewarding operations due to
the complicated three-dimensional relationship between the nasal bones, ULCs and
LLCs, and septum. Because no two patients’ septal deformities are alike, the
septoplasty technique selected for each individual should be tailored to their
particular anatomical and functional needs.

34. THANK YOU