5 deviated-nasal-septum

Deviated Nasal Septum

Dr. Vishal Sharma

Aetiology1. 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.

Types1. 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

Anterior / caudal dislocation

C - shaped

S - shaped

Nasal septal spur

Thickened & impacted nasal septum

C-shaped DNS not touching lateral nasal wall

C-shaped DNS touching lateral nasal wall

Compensatory turbinate hypertrophy

Clinical features1. 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

Clinical features4. 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

Sequelae

• Sinusitis

• Mouth breathing snoring, pharyngitis

• Atrophic rhinitis & myiasis

• Otitis media

History of septal surgeries

• 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.

Edwin Smith Papyrus

• 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

Gustav Killian

Maurice Cottle

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

Septoplasty

Freer’s Incision

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.

Muco-perichondrial flap elevation on right side

Anterior + Inferior tunnels

Inferior cartilage strip removal

Dislocation of bony cartilaginous junction

Muco-periosteal flap elevation on both sides

Cartilage + Bone removed

Scoring & cross-hatching

Wedge excision & shaving

Anterior nasal packing

Outer nasal packing

Submucosal Resection

Killian’s incision

Muco-perichondrial flap elevation on right side

Cutting of cartilage & elevation of opposite flap

Excision of septal cartilage

Excision of septal cartilage

Cartilage + Bone removed

Anterior nasal packing

S.M.R. SeptoplastyRadical 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

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

Septal haematoma Collection of blood under perichondrium

& periosteum of nasal septum.

Aetiology:

1. Nasal trauma

2. Septal surgery

3. Bleeding disorders

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.

Septal Haematoma

Treatment

1. Small: wide bore needle aspiration

2. Large:

a. incision & drainage

b. nasal packing (prevent recurrence)

c. systemic antibiotics (prevent abscess)

Complications

• Thickened nasal septum

• Septal abscess with cartilage necrosis

• Saddle nose

• Supra-tip deformity

• Septal perforation

Septal abscessCollection 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

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

Septal Abscess

Septal abscess

Treatment

• Abscess drained immediately

• Incision made on most dependent part

• Pus & necrosed cartilage removed

• Nasal packing done

• Systemic antibiotics for 10 days

Complications

• Necrosis of septal cartilage

• Saddle nose

• Supra-tip deformity

• Septal perforation

• Meningitis

• Cavernous sinus thrombosis

Saddle nose

Nasal synechia

Perforated nasal septum

Aetiology1. 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

Clinical features

Small perforation: whistling sound

during respiration

Large perforation: nasal crusting

nasal obstruction

epistaxis on crust removal

Perforated nasal septum

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 poor.

Nasal mucosal flaps

Nasal mucosal flaps

Sublabial flap

Silastic obturator

Thank You