Developmental disorders of the nasal septum are rare, occurring in about 1 in 10,000 births. The septum can be involved in conditions like choanal atresia, congenital midline nasal masses, and cleft lip and palate. Cleft lip and palate are among the most common birth defects involving the septum. Septal trauma is also very common and can cause issues like septal hematomas, abscesses, and fractures. Physical examination of the nose includes inspecting the septum and nasal cavity to diagnose septal pathology. Conditions like deviations, perforations, and structural deformities can be identified. Septoplasty is often performed to correct significant septal abnormalities that cause nasal obstruction or other symptoms

1. The septum
Pathology
Developmental disorders
Although developmental disorders of the septum are rare. Posterior part of the septum can be
involved in a choanal atresia. Seen in one case in 10000 births. Approximately 50% cases are
bilateral.
The septum may be involved in Congenital midline nasal masses, teratomas or frontonasal dysplasia
& bifid nose.
Cleft lip & cleft palate are two of the most common congenital conditions in which the septum are
involved.
The maxillary process & palatine process form the palate & fuse in the midline with the septum.
Failure of this process will result in a cleft palate. If only one side does not develop, other side still
fuse with the septum. Consequently a cleft can be found to the right or to the left of the septum(left
or right sided cleft palate). When there is insufficient growth of the palatine & maxillary processes
from both sides, infrerior part of the septum will be free(complete cleft palate).
When the maxillary process does not reach the frontonasal process, this will result in a cleft lip
which can be unilateral or bilateral.
Septal trauma
Septal trauma is very common, it may occur any age of life. Often a septal deformity is the only sign
of trauma.
Septal haematoma
Internal bleeding that can not escape through the mucous membranes or skin will result in a
haematoma. If an incision in the mucosa is made to drain a haematoma, it should be horizontal
incision to avoid disruption of the mucociliary transport.
Septal abscess
The most common causes of septal abscess is a septal haematoma. Fever & bilateral nasal blockage
may occur. The treatment consists of drainage of the abscess, antibiotics. Reconstruction of the
defect in the acute phase will reduce growth impairment.
Septal fractures
Frontal trauma results in vertical fractures whereas ,lateral trauma can give horizontal fractures. In
the vertical fractures,there may be a luxation or subluxation of the caudal part of the quadrilateral
cartilage. In case of a luxation, caudal rim of the cartilage can be seen to the left or right of the
columella. In case pf a subluxation, this may be only seen after the tip of the nose is lifted or
retracted.

2. Mucosal trauma
Since the mucosa is the effector organ of the nose, the blood vessels of the mucoperichondrium lie
in close to the cartilage& damage during surgery can lead to severe atrophy of the mucosa with
symptoms such as foetor, crusting, congestion, epistaxis, headache.
Too vigorous surgery of the inferior turbinate can change the aerodynamics of the nose in such a
way that serious trauma of the mucosa may result.
Septal perforation
Septal perforation are either the result of trauma or systemic disease. A mucosal laceration over a
sound skeleton has strong healing capacity.
When there is no skeleton to prevent drying of the back of the mucosa opposite to the mucosal
laceration, the mucosa on both sides of the septum will disappear & this leads to a perforation. This
explains why perforations are seen in deep trauma of the septum which not only involve the mucosa
but also the underlying skeleton. Examples are cautery for epistaxis, nose pricking & cocaine abuse.
In SMR operation, a septal perforation is a common complication, because in the case of mucosal
defect the inner surface of the opposite mucosa is not protected against dehydration by the
skeleton(as cartilage has been removed). At last, the mucosa on the both sides will be lost. The
result will be perforation.
Although septal perforation can be asymptomatic, they may present to the surgeon with debilitating
symptoms such as nasal blockage, dryness, crusting, epistaxis, atrophy of the mucosa, whistling&
headache.
Nasal blockage & whistling are related to abnormal aerodysnamics. Others symptoms are the results
of the poor condition of the mucosa.
Perforation in the anterior part of the septum present more symptoms than perforations in the
posterior part. Small perforations have a tendency to produce sounds than larger ones. In larger
perforations, patients complaints can be mild.
Septal luxation in the newborn
Repositioning the caudal septum with a forceps covered with silastic or rubber tube has been
advocated. There is insufficient evidence that correction of a birth trauma of the septum has a
positive effect in the long term.
Septal deformities
The most common clinical findings are septal deviations, septal perforations, (sub)Luxation of the
caudal septum, crests due to fractures, spurs, & spine. Cartilaginous hump or saddle nose, deviations
of the cartilaginous pyramid, lack of tip projection.

3. Septal disease in systemic disorders
Many diseases manifested themselves at the nasal septum. The septum is often first site in which
they can be found. Common symptoms are nasal blockage, foetor, discharge, crusting, &nose
bleeding.
Vascular: arteriosclerosis , Osler-weber-Rendu
infectious diseases: syphilis, Tuberculosis, Leprosy, Diphtheria.
Autoimmune : sarcoidosis, lupus erythematosus, Takayasu disease & wegener’s granulomatosis.
Cleaning of the crusts by nasal lavage reduces the symptoms, local steroids are often beneficial.
Symptoms/signs related to septal pathology
The symptoms/signs accompanying septal pathology may be nasal blockage, dryness, crusting,
bleeding, rhinorrhoea, hyposmia, anosmia, headache, cosmetic complaints.
Nasal blockage is non specific & often misinterpreted as a sign of airflow obstruction. It is frequently
seen in cases where the nasal cavity is too wide as in atrophic rhinitis( sensory modalities are
responsible for a feeling of nasal blockage). It is interesting that drugs like menthol give a feeling of
opening the nose without in fact reducing congestion of the mucosa.
Diagnosis
Physical examination of the nose begins with an inspection of the external nose in relation to face.
The objective is to see if the dimension of the nose are in harmony with face. As a rule of thumb,
the length of the nose should be 1/3rd of the distance between the hairline above & lower border of
the chin. Futhermore, attention must be paid to the projection & protection of the tip.
The projection is the distance between tip of the nose & the face. The retrograde position of the
mandible can accentuate the projection of the nose.
The protection is the resistance against deformation of the tip by the septal cartilage. Nasal trauma
in childhood manifests itself in a small infantile nose or a deviation. A cartilaginous saddle nose & a
retracted columella are signs of poor support of the nasal pyramid by the septum.
Inspection of the internal nose begins with the nostrils, vestibule & valve area. At this stage no
specula should be inserted. Inpection of nasal cavity can be undertaken with naked eye (anterior
rhinoscopy) although Hopkin’s endoscpe may be very helpful.
Photography ,rhinomanometry, acoustic rhinometry & olfactometry are the standardized objective
investigations to evaluate septal pathology.
Photography : a minimum of four photographs should be taken, consists of a frontal view, a left &
right side view & a basal view.
In rhinomanometry : two graphs are produced, one representing the relationship between the
pressure& flow in the right half of the nose & other in the left half of the nose.

4. Acoustic rhinometry: is a means of measuring the cross-sectional area of the nose as a function of
distance into the nose . reflections of sound wave sent into the nose represent these cross-sectional
area. Cross-sectional areas from the vestibule & valve area are more accurately measured than
those from the posterior part of the nose.(nasal obstruction interfering reflections of sound).
Olfactometry : is indicated when the symptoms are related to smell disorders or for medicolegal
reasons.
Indication for septoplasty
There are clear cut indications such as
1.complete or nearly complete obstructon of air flow.
2.impaired drainage of the sinus
3. inaccessibility of the nasal cavity for surgery, as for nasal polyposis
4. Septal corrections for aesthetic reasons more straightforward than those for functional reasons.
In addition to these, epistaxis, headache, snoring & sleep apnoea may be needed for septoplasty.
Septoplasty Technique
The basic concepts are to reconstruct instead of resect & to deal with function & cosmetics in one
procedure. In the surgical procedure there are six phases:
1.Gaining access to the septum: Hemitransfixation is the basic incision used to gain access to the
septum. The incision is not made in the membranous septum but over the cartilaginous septum
parallel to the caudal edge, approximately 2 mm posterior to the edge.( transfixation is through
membranous septum). Then between the cartilage & the perichondrium an anterior tunnel is made
on both sides. If necessary , inferior tunnels complete the access to the septum. In making the
inferior tunnels, there is a posterior & an anterior approach. The latter is called maxilla-premaxilla
approach.
After tunnelling, inferior part of the septum can be detached from the anterior nasal spine,
premaxilla& maxillary crest.
Next an incision between the posterior part of the septal cartilage & the bony septum can be made.
This is called a posterior chondrotomy.
After these two procedures, the septum can be moved aside, rather like a swing door. This swing-door
technique gives access to the posterior or bony septum.
2.Correction of septal pathology:A deviation due to tension in the septum or an inferior edge that
has slid along the spine or a maxillary crest, can be corrected by removing an inferior cartilaginous
strip.
3.Removing septal pathology: Duplications, spines, crests, convexities are the main indications for a
resection. Any removed materal is saved for reconstruction later. Straight parts are carefully
preserved to provide large struts necessary to give support to the dorsum, tip & columella.

5. 4.Reshaping cartilage & bone: Cartilage does not heal. Fracture& defects will be filled up by
connective tissue. Retraction of connective tissue can alter a good result immediately after surgery
into a poor result after some months to a year. The dynamic of the healing process must be
understood to enable appropriate correction of the septum. Reshaping should be done with as little
trauma as possible, with maximum preservation of straight portions of the septum.
5.Reconstration of the septum: Only the patient’s own septal cartilage meets the reqiurments for
optimum reconstruction. Others material such as ear cartilage or rib cartilage.
Tip projection is preserved & retraction of the columella is prevented by a strip of cartilage in the
caudal part of the septum.
6.Stabilizing the septum: First of all, a dressing is put into the nose to bring the mucosa together.
A)Nasal splints; are effective in stabilizing reconstructions. They have advantage to allow the patient
to breath through the nose. B)Nasal packs; are very uncomfortable C) Suture techniques: to fixate
the reconstructed septal parts.

6. 4.Reshaping cartilage & bone: Cartilage does not heal. Fracture& defects will be filled up by
connective tissue. Retraction of connective tissue can alter a good result immediately after surgery
into a poor result after some months to a year. The dynamic of the healing process must be
understood to enable appropriate correction of the septum. Reshaping should be done with as little
trauma as possible, with maximum preservation of straight portions of the septum.
5.Reconstration of the septum: Only the patient’s own septal cartilage meets the reqiurments for
optimum reconstruction. Others material such as ear cartilage or rib cartilage.
Tip projection is preserved & retraction of the columella is prevented by a strip of cartilage in the
caudal part of the septum.
6.Stabilizing the septum: First of all, a dressing is put into the nose to bring the mucosa together.
A)Nasal splints; are effective in stabilizing reconstructions. They have advantage to allow the patient
to breath through the nose. B)Nasal packs; are very uncomfortable C) Suture techniques: to fixate
the reconstructed septal parts.