SEPTUM

• DEVELOPMENT
• PARTS
• BLOODSUPPLY AND NERVE SUPPLY
• ABNORMALITIES OF SEPTUM
• MANAGEMENT
• COMPLICATIONS
 DEVELOPMENT
• PRIMITIVE PALATE-FUSION OF MAXILLARY AND
FRONTO-NASAL PROCESS
• THE NASAL SEPTUM DEVELOPS AS A DOWN
GROWTH FROM THE MERGED MEDIAL NASAL
PROCESSES AND THE FRONTO-NASAL PROCESS
• THE NASAL SEPTUM AND THE PALATINE
PROCESSES BEGIN TO FUSE ANTERIORLY
DURING THE NINTH WEEK AND FUSION IS
COMPLETED POSTERIORLY BY THE TWELTH
WEEK
• ON EITHER SIDES OF THE OF ANTERIOR SEPTUM IN
RELATION TO THE PARA-SEPTAL CARTILAGE AN
INVAGINATION OF ECTODERM FORMS THE VOMERO-
NASAL ORGAN-DISAPPEARS IN MAN
• PRIMITIVE SEPTUM IS ENTIRELY MADE OF
CARTILAGE
• THE SUPERIOR PART OSSIFIES TO FORM THE
PERPENDICULAR PLATE OF ETHMOID [FROM
CRISTAGALLI DOWNWARDS]AND THE VOMER IN
THE POSTERIO-INFERIOR PORTION LEAVING AN
ANTERIO-INFERIOR QUADRILATERAL CARTILAGE
•
PARTS
• COLUMELLAR SEPTUM:IT IS FORMED OF
COLUMELLA CONTAINING THE MEDIAL
CRURA OF ALAR CARTILAGES UNITED
TOGETHER BY FIBROUS TISSUE AND
COVERED ON EITHER SIDE BY SKIN
• MEMBRANOUS SEPTUM:IT CONSISTS OF
DOUBLE LAYER OF SKIN WITH NO BONY
OR CARTILAGINOIS SUPPORT,IT LIES
BETWEEN COLUMELLA AND THE CAUDAL
BORDER OF SEPTAL CARTILAGE
 SEPTUM PROPER
• PERPENDICULAR PLATE OF ETHMOID
• THE VOMER
• QUADRILATERAL CARTILAGE
• CRESTS OF NASAL BONE ,NASAL SPINE OF
FRONTAL BONE,ROSTRUM OF
SPHENOID,CRESTS OF THE PALATINE
BONE AND THE MAXILLA AND THE
ANTERIOR NASAL SPINE OF THE MAXILLA
• THE QUADRILATERAL CARTILAGE IS 3-4MM
THICK IN THE CENTRE BUT INCREASES TO 4-
8MM ANTERO-INFERIORLY AN AREAWHICH
HAS BEEN TERMED THE FOOT PLATE
• THE UPPER MARGIN OF THE CARTILAGE
ALSO EXPANDS WHERE IT IS CONNECTED
TO THE UPPER LATERAL CARTILAGES
FORMING THE ANTERIOR-SEPTAL
ANGLE,JUST CRANIAL TO THE DOME OF
LOWER LATERAL CARTILAGES
• IT IS BOUND FIRMLY TO THE NASAL
BONES AND TO PERPENDICULAR
PLATE OF ETHMOID AND VOMER
AND WHERE IT SITS INFERIORLY IN
THE NASAL CREST OF THE PALATINE
PROCESS OF THE MAXILLA THE
FACIAL ATTACHMENT FORMS A
PSEUDOARTHROSES
• THE PERPENDICULAR PLATE FORMS THE
SUPERIOR AND ANTERIOR BONY SEPTUM
CONTINUOS ABOVE WITH CRIBRIFORM PLATE
AND CRISTA GALLI AND ABUTS VARIABLE A
AMOUNT OF THE NASAL BONE
• VOMER FORMS THE POSTERIOR AND INFERIOR
NASAL SEPTUMAND ARTICULATES BY ITS TWO
ALAE WITH THE ROSTRUM OF
SPHENOID,THEREBY CREATING THE VOMERO-
VAGINAL CANALS WHICH TRANSMIT THE
PHARYNGEAL BRANCHES OF THE MAXILLARY
ARTERY
 HISTOLOGY
• THE MUCOPERICHONDRIUM AND
MUCOPERIOSTEUM OF THE SEPTUM IS SEPARATE
FROM THAT OVERLYING THE MAXILLARY CREST
• THE MUCOUS MEMBRANE IS PREDOMINANTLY
RESPIRATORY WITH A SMALL AREA OF
OLFACTORY EPITHELIUM SUPERIORLY
ADJACENT TO THE CRIBRIFORM PLATE
• RESPIRATORY EPITHELIUM IS COMPOSED OF
CILIATED AND NON CILIATED PSEUDO
STRATIFIED COLUMNAR CELLS,BASAL
PLURIPOTENT STEM CELLS AND GOBLET CELLS
BLOOD SUPPLY
• SPHENOPALATINE
ARTERY-BR OF
MAXILLARY ART
SUPPLIES THE POSTERIO-
INFERIOR SEPTUM
• GREATER PALATINE ART-
ANTERO-INF PORTION
ENTERING THROUGH
INCISIVE CANAL
• SUP LABIAL ART BR OF
FACIAL ART-ANTERIORLY
• INTERNAL CAROTID ARTERY SUPPLIES SEPTUM VIA
ANTERIOR AND POSTERIOR ETHMOIDAL ARTERIES
• KIESSELBACHS PLEXUS COMPOSED OF UNUSUALLY LONG
CAPILLARY LOOPS-COMMON SOURCE OF EPISTAXIS

• ANTERIOR SEPTAL TUBERCLE OR INTUMESCENCE-

DESCRIBED FIRST BY MORGAGNI IS A SINUSOID SYSTEM
IN THE NASAL SUBMUCOSA UNDER AUTONOMIC CONTROL
PRESENT ON THE SEPTUM ADJACENT TO THE INFERIOR
TURBINATE AND ON THE MOST ANTERIOR SEPTUM-
RELATED TO THE CONTROL OF AIR FLOW TO THE
OLFACTORY CLEFT
• DRAINAGE IS VIA SPHENOPALATINE
VESSELS IN TO THE PTERYGOID PLEXUS
POSTERIORLY AND IN TO THE FACIAL
VEINS ANTERIORLY
• SUPERIORLY THE ETHMOIDAL VEINS
COMMUNICATE WITH THE SUPERIOR
OPHTHALMIC SYSTEM AND THERE MAY
BE DIRECT INTRACRANIAL CONNECTIONS
THROUGH THE FORAMEN CAECUM IN TO
THE SUPERIOR SAGITTAL SINUS
NERVE SUPPLY
• MAXILLARY DIVISION OF
THE TRIGEMINAL NERVE
PROVIDES MAJOR SUPPLY
• NASOPALATINE NERVE
SUPPLIES BULK OF BONY
SEPTUM
• ANTERO-SUPERIOR PART-
ANTERIOR ETHMOIDAL
BRANCH OF THE
NASOCILIARY NERVE
• ANTERO-INFERIOR
PORTION RECIVES FROM
ANTERO-SUPERIOR
ALVEOLAR NERVE
• SEROMUCINOUS GLANDS ARE
FOUND IN THE SUBMUCOSA –MORE
IMPORTANT IN MUCOUS
PRODUCTION
AREAS OF COTTLE
• ONLY THE PORTION OF THE NASAL
SEPTUM ANTERIOR TO PYRIFORM
APERTURE SUPPORTS THE NOSE
• ANTERIOR SEPTAL COMPONENTS
ARE CRITICAL TO NASAL SUPPORT
AND SHOULD BE STRUCTURALLY
RESTORED
 DEVIATED NASAL SEPTUM
• TRAUMA IN MOST OF THE CASES
• ERRORS OF DEVOLOPMENT
• BIRTH MOULDING THEORY BY GRAY-1972
• ABNORMAL INTRAUTERINE POSTURE-MAY
RESULT IN COMPRESSIVE FORCES ACTING
ON THE NOSE AND UPPER
JAW,DISPLACEMENT OF SEPTUM CAN
RESULT AND THE NOSE CAN BE EXPOSED
TO FURTHER TORSION FORCES DURING
PARTURITION
• MOULDING PRESSURES MINIMAL-
ELECTIVE CAESARIAN SECTION
• MODERATE-NORMAL VERTEX
PRESENTATION
• SEVERE-PERSISTANT OCCIPITO-
POSTERIOR POSITION
• SIR FRANCIS GALTON-GENETIC AND
ENVIRONMENTAL FACTORS MAY PLAY
AROLE
• GRYMER AND MELSON STUDIED
IDENTICAL TWINS
• RESULTS :ANTERIOR DEVIATION-
EXTERNAL CAUSE[TRAUMA]
• POSTERIOR DEVIATION –GENETIC FACTOR
• UNEQUAL GROWTH BWN PALATE
AND BASE OF SKULL MAY CAUSE
BUCKLING OF SEPTUM
• ADENOID HYPERTROPHY
• CLEFT LIP AND PALATE
• DENTAL ABNORMALITIES
 PATHOLOGICAL
ABNORMALITIES
• DEFORMITIES CAN BE CLASSIFIED IN TO SPURS
AND DEVIATIONS
• SPURS:THESE ARE SHARP ANGULATIONS WHICH
MAY OCCUR AT THE JN OF VOMER BELOW WITH
THE SEPTAL CARTILAGE AND /OR ETHMOID
BONE ABOVE-THIS IS DUE TO VERTICAL
COMPRESSION FORCES
• Fractures through septal cartilage can also
produce sharp angulations
 DEVIATIONS
• C or S Shaped which usually occurs in
vertical/Horizontal plane-usually involve
cartilage /bone
• Dislocation:Lower border of septal cartilage is
usually displaced from its median position and
projects in to the nostril
• Thickening:It may be due to Organised
haematoma/overlying dislocated septal fragments
 COTTLES CLASSIFICATION
• SIMPLE DEVIATION:HERE THERE IS MILD
DEFLECTION OF THE SEPTUM WHICH DOES NOT
CAUSE OBSTRUCTION
• OBSTRUCTION:THERE IS A MORE SEVERE
DEVIATION OF THE NASAL SEPTUM WHICH MAY
TOUCH THE LATERAL WALL OF THE NOSE ON
VASO CONSTRICTION THE TURBINATES SHRINK
AWAY
• IMPACTION:VERY MARKED ANGULATION OF THE
SEPTUM WITH A SPUR WHICH LIES IN CONTACT
WITH THE LATERAL WALL EVEN AFTER THE
APPLICATION OF VASOCONSTRICTOR
• NASAL VALVE ANGLE:THE JUNCTION BETWEEN
THE NASAL SEPTUM AND THE INFERIOR PART OF
THE OF UPPER LATERAL CARTILAGE FORMS THE
NASAL VALVE ANGLE WHICH WIDENS AND
NARROWS UNDER THE INFLUENCE OF THE
NASAL MUSCULATURE DURING RESPIRATION
• NARROWEST PART OF NASAL CAVITY 10-15
DEGRESS IN CAUCASIANS AND WIDER IN ASIANS
AND NON CAUCASION PATIENTS
 INTERNAL NASAL VALVE
• THE NASAL VALVE REFERS TO THE
CROSSECTIONAL AREA OF THE NASAL CAVITY
BODERED BY THE JUNCTION OF THE CAUDAL
MARGIN OF UPPER LATERAL CARTILAGE AND
THE NASAL SEPTUM
• NASAL VALVE AREA IS A FUNCTIONAL UNIT
WHICH INCLUDES THE NASAL SEPTUM ,UPPER
LATERAL CARTILAGE,PYRIFORM APERTURE AND
ANTERIOR HEAD OF INFERIOR TURBINATE
• DEFORMITIES OF THE ADJACENT NASAL SEPTUM OR LOSS
OF ANATOMIC SUPPORT STRUCTURES CAN PRE-DISPOSE
THE VALVE TO COLLAPSE OR NARROW THERE BY
CAUSING NASAL AIRWAY OBSTRUCTION
• THE UPPER LATERAL CARTILAGE AT ITS JUNCTION WITH
THE SEPTUM MAY BE THICKENED,TWISTED AS A RESULT
OF WEAKNESS /TRAUMA OR EVEN BE ABSENT IF THERE
WAS PRIOR SURGERY
• WEBS OF SCARED MUCOSA BTWN SEPTUM AND LATERAL
WALL-NARROW THE VALVE AREA
• ADHESIONS THAT RESULT IN VALVE NARROWING CAN
CREATE A FIXED OBSTRN WITH FALSE NEGATIVE COTTLE
MANOUVERE
 EXTERNAL NASAL VALVE
• IT IS A LATERALLY BASED SPACE BOXED
BY PYRIFORM APERTURE,THE ULC,AND
LLC ATTACHMENTS AND THE CAUDAL
SEPTUM
• OBSTRUCTION DUE TO EXTERNAL NASAL
VALVE MAY BE A POST RHINOPLASTY
PHENOMENON,AGING ,TRAUMA,CAUDAL
SEPTAL DISLOCATION
• SEPTAL TURBINATE:IT REPRESENTS
AN AREA [OFTEN VISIBLE ON CT]OF
ENGORGED VASCULAR NASAL
MUCOSA ON THE SEPTUM
• CAN BE UNILATERAL OR BILATERAL
AND BE A SOURCE OF PROFOUND
EPISTAXIS
• TREATMENT-SMR
 TESTS
• COTTLE TEST:WILL COMFIRM THAT THE
OBSTRUCTION IS IN THE VALVE AREA
• THE PATIENT PULLS THE CHEEK
OUTWARDS AND OPENS UP THE
INTERNAL NARES AND THUS REDUCES
THE BLOCKAGE
• NEWBORN:SEPTAL DEVIATION IS SOME
TIMES ASSOCIATED WITH ASYMMETRY
OF THE NOSTRILS
• AN OBLIQUE COLUMELLA AND TIP POINTS IN THE
DIRECTION WHICH IS OPPOSITE THE DEVIATION
• MOST CASES DIAGNOSED BY ANTERIOR RHINOSCOPY AND
THE USE OF GRAYS STRUTS
• THESE ARE 4MM WIDE AND 2MM THICK,INSERTED IN TO
THE NOSTRILS,PUSHED BACK WARD HUGGING THE FLOOR
• NORMALLY THE STRUTS CAN BE INTRODUCED FOR A
DISTANCE OF 4-5CM,IN CASES OF DEVIATION
OBSTRUCTION IS USUALLY ENCOUNTERED 1.5-2CM
• COMPRESSION TEST:NASAL TIP IS PUSHED BACK WARD
AND IF THERE IS A SEPTAL DISLOCATION IT WILL
COLLAPSE AGAINST THE PHILTRUM OF UPPER LIP
 SEPTAL SURGERY
• DEVOLOPMENT:IN THE LATE 18TH CENTURY ACUTE
ANGULATIONS AND SPURS WERE REMOVED BY EITHER
SHAVING DOWN
CONVEXITIES[LANGENBACH,DIFFENBACH OR BY
PERFORMING A COMPLETE REMOVAL OF THE DEVIATION
BY PUNCH FORCEPS RUBRECHT-1868
• SMR-EARLIEST NAME ASSOCIATED WITH IT WAS INGALLS
IN 1881
• KILLIAN IN1904 DESCRIBED THE TECHNIQUE WHICH IS
PRACTISED TODAY WITH THE RETENTION OF BOTH THE
DORSAL AND CAUDAL STRUTS OF CARTILAGE TO
PREVENT ANY SUBSEQUENT CHANGE IN THE SHAPE OF
THE NOSE
• FREER IN 1902 ADOPTED A MUCH MORE RADICAL
APPROACH AS IN HIS VIEW THE SEPTAL CARTILAGE DID
NOT CONTRIBUTE TO THE SUPPORT OF NASAL PYRAMID
• METZENBAUM-1929 USED THE PRINCIPLE OF SWINGING
DOOR TO REDUCE COMPLICATIONS ASSOCIATED WITH
SMR
• PEER IN 1937 TO OVERCOME THE COMPLICATIONS
EXCISED THR DEVIATED CAUDAL SEGMENT OF THE
CARTILAGE AND INTRODUCED IT AS A FREE GRAFT
• GALLOWAY 1942-REMOVED ENTIRE NASAL CARTILAGE
AND REPLACED THE ANTERIOR SEPTUM WITH A SINGLE
FREE AUTOGRAFT
•
 DRAW BACKS
• UNEQUAL SCAR CONTRACTION BTWN THE TWO SEPTAL
FLAPS SOME TIMES LED TO THE RECURRENCE OF
DEVIATION
• ABSORPTION OF AUTOGRAFT SOME TIMES OCCURRED
LEADING TO SADDLING OF SUPRATIP REGION
• LOWER END OF GRAFT SOME TIMES IMMOBILISED THE
MEMBRANOUS SEPTUM
• THUS THE ALTERNATE SOLUTION OF MOBILISATION AND
REPOSITIONING OF CARTILAGE REVIVED-SEPTOPLASTY
• POPULARISED BY COTTLE
• PERMANENT CHANGE IN THE SHAPE OF CARTILAGE BY
MORSELIZATIONHAS BEEN ADVOCATED BY RUBIN-1983
 PRINCIPLES OF SEPTAL
SURGERY
• SEPTOPLASTY • SMR
• DONE FOR POSTERIOR
• DONE FOR SEGMENT DEVIATION
ANTERIOR • KILLIAN INCISION
SEGMENT • TO OBTAIN GRAFT
DEVIATION MATERIAL FOR
RHINOPLASTY
• FREER
• TO OBTAIN SURGICAL
HEMITRANSFIXATI ACESS FOR
ON INCISION HYPOPHYSECTOMY/V
VIDIAN NEURECTOMY
 SEPTOPLASTY
• NOT A STANDARDISED PROCEDURE -SHOULD BE
TAILORED TO THE NEEDS OF INDIVIDUAL
PATIENTS
• GENERAL PRINCIPLES:INCISION:FREER :LOWER
BORDER OF SEPTAL CARTILAGE
• DISPLACING COLUMELLA TO OPP SIDE,INCISION
MADE TILL
PERICHONDRIUM,SUBPERICHONDRIAL FLAP
ELEVATED
• EXPOSURE:USUALLY BEST TO EXPOSE THE CARTILAGE –BONY
SEPTUM BY ELEVATING THE MUCOSAL FLAP ON THE CONCAVE
SIDE
• COTTLE MAXILLARY-PREMAXILLARY APPROACH AS THE SUB
PERICHONDRIAL PLANE OF CARTILAGE IS NOT CONTINUOS WITH
THE SUB PERI-OSTEUM
• MOBILIATION AND STRAIGHTENING:SEPTAL CARTILAGE FREED
FROM ALL ATTACHMENTS EXCEPT FROM MUCOSAL FLAP ON OPP
SIDE
• MANY DEVIATIONS ARE MAINTAINED BY EXTRINSIC FACTORS
SUCH AS CAUDAL DISLOCATION FROM VOMERINE CREST-
MOBILISTATION ALONE WILL CORRECT
• INTRINSIC CAUSES SUCH AS HEALED FRACTURES-COMBINE
WITH DIRECT EXCISION OF CARTILAGE/SMR,BONY DEVIATION
ARE TREATED BY EITHER FRACTURE REPOSITIONING
• FIXATION:AT THE END SEPTUM HAS TO BE LYING
FREELY IN THE MIDDLE
• FIG OF 8 SUTURE
• SUPPORT WITH SPLINTS[SILASTIC]
 SMR
• KILLIAN INCISION
• OBLIQUE INCISION 5MM ABOVE THE CAUDAL
BORDER OF THE SEPTAL CARILAGE
• 2ND INCISION IS MADE THROUGH SEPTAL
CARTILAGE ABOUT 1CM ABOVE AND PARALLEL
TO ITS LOWER BORDER,INCISION MADE
THROUGH THE CARTILAGE BUT NOT THROUGH
THE OPPOSITE PERICHONDRIUM
• 1 CM DORSAL AND CAUDAL STRUTS ARE
PRESERVED -
 CHILDREN
• HAYTON –1948 EARLIEST WORK
• NO SURGERY WHICH INVOLVES RADICAL REMOVAL OF
CARTILAGE SHOULD BE PERFORMED IN CHILDREN
• NEWBORN:SEPTAL DISLOCATION SHOULD BE UNDERTAKEN
AS EARLY AS POSSIBLE [METZENBAUM-1932]
• USUALLY IMPOSSSIBLE AFTER ABOUT 3 MONTHS OF AGE
• GREYS MODIFICATION OF WALSHAMS FORCEPS
• MIDDLE PART FIRMLY PRESSED DOWN FOR 15-20 SECONDS
• SEPTUM MANIPULATED INTO MID LINE
 SEPTAL INJURY
• CHEVALLET FRACTURE
• JARJAVAY FRACTURE
 Complications
• Crusting
• Septal perforation
• Supra tip deformity
• Columella retraction
• Collapse of pyramid
 SEPTAL PERFORATION
CLASSIFICATIONc
• Small upto 1 cm
• Medium 1 to 2 cm
• Large more than 2 cm
 Management
• Treat the cause
• Care for nose
• Surgical correction
– Larger defect more difficult
 BIBLIOGRAPHY
• SCOT BROWN 6TH EDN
• CLINICAL RHINOLOGY-ARNOLD
G.D.MARAN
• CUMMINGS 4TH EDN
• LOGAN TURNERS DISEASESOF EAR
NOSE AND THROAT-10TH EDN