The nasal septum is the cartilage and bone in your nose. The septum divides the nasal cavity (inside your nose) into a right and left side. When the septum is off-center or leans to one side of the nasal cavity, it has “deviated.” Healthcare providers call this a deviated nasal septum.

2. DISEASES OF
THE NASAL
SEPTUM

3. NASAL SEPTAL DISEASES
 Anatomy of Nasal Septum
 Consists of three parts
 Columellar septum
 Membranous septum
 Septum proper

7. NASAL SEPTAL DISEASES
 Deviated nasal septum
 Fracture of nasal septum
 Septal Hematoma
 Septal Abcess
 Septal Perforation
 Nasal Synechia

8. DEVIATED NASAL SEPTUM (DNS)
 Definition
 Deviation of cartilage and/or bony framework of the nasal septum from the midline
associated with nasal symptoms.

9. ETIOLOGY
a) Trauma
a) Birth trauma especially during the face presentation. Kent et al. found DNS even in children born of cesarian
section
b) Trauma to the nose after birth, which may be due to blow, sports injuries, repeated falling on the face during
childhood, etc
b) Developmental error
c) Role of a high arched palate is doubtful. It may be associated with a high arched palate due to the
deviation that causes nasal obstruction and subsequent pulling of the palate superiorly.
d) Racial factor: It is more common In Caucasians than in Negroes.
e) Heredity: It could be genetically predisposed as often several members of the family are found to suffer
from a deviated nasal septum.
f) Other factors like age and sex may have a role to play because of the nature of day-to-day activities.

10.  Sites of DNS
 Cartilaginous/bony/both
 Anterior/posterior
 High/low
 Types of DNS
 S-shaped deviation
 C-shaped deviation
 Caudal dislocation
 Spur
 Thick septum
 Crooked septum

11. EFFECT OF DNS
a) Compensatory hypertrophy of the turbinates of the opposite
side C,-shaped deviation associated with hypertrophy of both
inferior and middle turbinates. While a S-shaped deviation is
associated with interior turbinate hypertrophy on one side and
middle turbinate hypertrophy on the other side.
b) External Deformity
c) Impairment of drainage to sinuses due to blockage of the
ostiomeatal complex.
d) Secondary atrophic Rhinitis on the roomier side of the nasal
cavity due to inadequate humidification.

12. CLINICAL FEATURES
 Symptoms
 Nasal Obstruction
 Headache
 External deformity
 Hyposmia/anosmia
 Epistaxis

13.  Signs
 Elevate the tip of the nose to look for caudal dislocation and the vestibule of the nose.
 Anterior rhinoscopy is done to determine the site and type of deviation as described above, presence
of compensatory hypertrophy, status of nasal mucosa, discharge from the meatus, crusting, etc.
 Local application of decongestant like cocaine/xylocaine with adrenaline helps in better assessment
of the deeper areas in the nasal cavity. Middle turbinate and middle meatus area should be inspected
for concha bullosa, contact areas, discharge and polyps.
 Cottle’s test - Pulling the cheek outwards at the nasofacial crease improves the nasal Patency at the
valve area.

14. INVESTIGATIONS
 Xray PNS (Water’s view and Caldwell view)
 CT Scan of the paranasal sinuses
 Diagnosis nasal endoscopy (DNE)
 Bleeding and clotting profile

15. TREATMENT
Medical Treatment for associated rhinitis /sinusitis.
 Surgical Treatment
 Surgery for the deviated nasal septum
 Septoplasty
 Submucosal resection
 Endoscopic septoplasty.
 Surgery for the external nasal deformity with deviated nasal septum (Septorhinoplasty) This term is used when
the septoplasty forms an integral part of rhinoplasty procedure. They can be of two types based on the approach
preferred.
 Internal
 External

16. OPERATIVE TECHNIQUES
SUMUSCOSAL RESECTION (SMR)
 Surface anesthesia
 By 4% Xylocaine nasal packing
 Infiltration by 2% Xylocaine and 1 in 100,000 adrenaline on either side of
the septum from anterior to posterior or posterior to anterior direction.
 Incision
 Flap Elevation
 Resection of cartilage
 Resection of bone
 Nasal packing

17. SEPTOPLASTY
 It is a tissue-sparing procedure where septal deviation
is corrected by minimal resection of cartilage and bone,
strategic crisscross incision and repositioning.
 Steps of Surgery
 Surface anesthesia
 Infiltration
 Freer's hemitransfixation incision is given at the
caudal end of the septum, usually on the concave
side of the cartilage.
 Flap elevation : The mucoperichondrial elevation is
done on the side of incision and three tunnels are
created.

18. CONTINUED..
 Anterior tunnel: Exposure of the quadrangular septal cartilage is
done on the concave side.
 Inferior tunnel: Periosteum is elevated and the anterior nasal
spine and maxillary crest on both the sides are exposed.
 Posterior tunnel: With sharp dissection the bony septum
comprising of the perpendicular plate of ethmoid and vomer is
exposed. A small incision is given at the bony cartilaginous
junction to elevate the mucoperiosteum of the opposite side.
 Disarticulation of bony cartilaginous junction: The cartilage is
freed from the bony attachments.

19. CONTINUED..
 Cartilage and bony resection
 Bone realignment
 Cartilage alignment
 Cartilage Tunneling

20. ENDOSCOPY SEPTOPLASTY AND TURBINOPLASTY
The traditional surgeries of the nasal septum improve the nasal airway but do not fulfill the
criteria for an ideal surgical correction in most instances.
Steps of Endoscopic Septoplasty
 Surface anesthesia
 Endoscopic infiltration of the nasal septum with 1% Xylocaine with 1 in 200,000 adrenaline on
the convex side of the cartilaginous septum along the crest and bony septum on both sides
including the spur whenever present.
 Incomplete incision at the caudal end of the septum in its lower half in most cases except when
there was a caudal dislocation or anterior buckling (hemi - transfixation).
 Incision is made on the convex side in cases with anterior deviation and on the concave side for
subluxation, spur or posterior deviation to expose the abnormality at the bony cartilaginous
junction.

21. CONTINUED..
 Elevation of the initial mucoperichondrial flap using Cottle's elevator and Pilchards nasal speculum.
 Excess of cartilage at the maxillary crest which usually overlaps the crest/ vomer precisely shaved
endoscopically.
 in case of posterior deviation or a deviation j at the ethmochondral junction, the bony septum is fractured to
realign in the midline or a minimum resection of the caudal end of the ethmoidal plate is performed.
 A C-shaped cartilaginous deviation is dealt with by precise multiple wedge resections aided by the
endoscope, placing them on strategic sites and planes. Criss-cross incisions are made on the cartilage on the
concave side.
 A spur without any other deviation of the septum is resected after incision and exposure made directly over
the spur.

22. CONTINUED..

23. COMPLICATION OF SEPTAL SURGERY
 Septa perforation
 Septal hematoma
 Septal abscess
 Saddle nose deformity
 Columellar retraction
 Flapping of septum
 Epistaxis
 Synechia

24. NASAL SYNECHIA
 They commonly occur due to adhesions between septum and the
lateral wall and/or between middle turbinate and the lateral wall
following nasal surgery and nasal packing. They can be prevented
by doing proper postoperative cleaning and proper lubrication of
nasal pack before insertion. Use of septal splints following surgery
helps in prevention in formation of synechia.

25. CLINICAL FEATURES
 Nasal obstruction is the most common presenting feature. Synechia between middle turbinate and
lateral wall can cause impairment of drainage of the sinuses leading to sinusitis and headache.
TREATMENT
 Treatment They can be excised and released using diathermy/ dipolar cautery/laser. A spacer like
dental wax plate, silastic sheets, etc. is kept between the two epithelial surfaces to prevent further
adhesions for about one week.

26. SEPTAL HEMATOMA
 Causes
 Traumatic
 Blunt injuries- Boxers. sports, RTA
 Iatrogenic- SMR, septoplasty
 Non-traumatic
 Bleeding/clotting disorders
 Clinical Features
 Bilateral constant usually acute nasal obstruction following trauma
 Mouth breathing
 Pain
 Septum thickened and bulging to both sides completely obstructing the nasal cavity.
 Investigations
 Bleeding, clotting and prothrombin time
 ESR
 Complete blood picture
 X-ray PNS

27. CONTINUED..
 Management
 Wide bore needle aspiration
 Incision and drainage
 Anterior nasal packing or quilting sutures to prevent re-accumulation
 Antibiotics, analgesics, etc.
 Complications
 Septal abscess and its consequences

28. SEPTAL ABSCESS
 Definition
 It is defined as collection of pus within the septum
 Causes
 Traumatic — usually follows septal hematoma
 Non-traumatic
 Furuncle of the nasal vestibule
 Immunocompromised states

29. CLINICAL FEATURES
 Symptoms
 Nasal obstruction, which is usually bilateral
 Pain in the nose
 Fever with chills and rigors which commonly occurs as a result of infection of a septal hematoma.
 Signs
 Tenderness +
 Pus pointing +/—
 Rupture with purulent discharge +/—
 External nasal deformity +/—
 Management
 Incision and drainage/ wide bore needle aspiration
 Anterior nasal packing
 Antibiotics, analgesics, etc.
 Complications
 Spread of infection
 External Nasal Deformity
 Septal perforation

30.  Causes
 Traumatic
 Mechanical-RTA, assault, sports, etc.
 Chemical-Chrome perforation (occupational)
 Thermal/ radiation trauma
 Fingernail trauma
 Iatrogenic-SMR
 Septal hematoma/abscess
 Atrophic rhinitis
 Chronic granulomatous conditions
 Nasal myiasis
 Neoplasm of the septum
 Cocaine addicts
SEPTAL PERFORATION

31. CONTINUED..
 Clinical Features
 Epistaxis if due to granulomatous conditions
 Small perforation
 Whistling/hissing noise during nasal breathing.
 Big perforation
 Atrophic changes and consequent crusting, epistaxis is, dry feeling in the nose, etc.
 Management
 Asymptomatic - No treatment is necessary
 Small perforation
 Obturator/ septal buttons can he used.
 Surgical closure
 Large perforation
 Surgical closure—Nasal/ buccal/ skin flaps

32. ANY QUESTIONS ???

33. THANK YOU