Diseases of

theEarrNose
andThroat
P.D. BULL
MB,BCh,FRCS
Consul tant O tolary ngologist
Royal Hallamshire Hospital
andSheffteldChlldren'sHospital
Sheffreld

Hono-rary Seaior Clinical L e.,ttr q

inOtolaryngology
UniuersityoJsheffeld

Ninth Edition

Blackwell
Science
 The NasalSeptum 83

:.-:a;

Fig21.3 Submucous resection of the septum. (a) lncision througlr the muco-
perichondrium. (b) Elevation of
muco-peridrondrial flaps on either side of the
septal skeleton. (c)The displaced cartilage andbone has been resected,
alloudng the septum to resurne a midline position-

Where more sevene symptoms are pnesent, correction of the septat

deformity is justified (th"ugh never essential).

Submucous resection (SMR)

SMR (Fi& 2 l -3) is the operation of choice formid-septat deformitywhen the
" caudal septum is in a normal position. lt is to be avoided in chitdren, because
interfercncewithnasal grourrfiwill occur, ieading in turn, tg cotlapse ofthe
nasaldorcum.
Under local orgeneralanaesthetic, an incision is made I cm back from
the front edge of the cartilagethrough the muco-perichondrium, which is
elenated from the cartilage. The incision is then deepened through the
cartilage and the muco-perichondrium on the other side is elevated.
Deflected cartilage and bone are rlemoved with punch forceps and the
two mucosal flaps are allowed to hll back into the midline.
The nose is packed gently for 24 h to maintain apposition of the fl aps and
the patientmaygo homeafter2 days.

Septoplasgr
Septoplasty is the operation of choice (i) in children, (ii) when cornbined
with rhinoplasty, and (iii) when there is dislocation of the caudal end of the
M Chapter 2 I : The Nasal Septum

sePtal cartilage. The essential features of septoplasty are a minimum of

cartilage remonal and careful repositioning of the septal skeleton in the
midline after straightening or removingspurs and convexities.
It may be perforrned in conjunction with mid- or posterior-septal
resection. tt
avoids the drooping tip and supra-tip depression seen
sometimes after SMR and causes less interference with f,cial growth in
children.

Gornplications of septal surgery

I Post-operative haemorrhage, which may be severe.
7 Septal haematoma,which may require drainage.
3 Sepralperforation-seebelow.
4 Ertemal deformity-owing to scessive removal of septal cartilage,
ailowing tlre nasal dorsum to collapse from lack of support lt can be very
difficultto ccrrect
5 Anosmia-fortunately rare, but untreatable when it occurs-

AETIOLOGY
Perforation of the nasal septum is most common in its anterior cartilagi-
nous part an d rnay result from the following condkions:
I postoperative{particularlySMR};
2 nose-picking (ulceration occurs fi rst, perforafion later);
3 traurna;
4 Wegener'sgranuloma;
5 inhalation of fumes of chrome salts;
6 cocaineaddiction;
T rodentulceribasalcellcarcinoma);
I lupus;
9 slphilis (the gumma affects the entire septum and nasal bones, with
resulting deformity).

SYMPTOMS
symptoms consist of epistaxis and crusting which may cause considerable
obstruction. occasionally, whistlingon inspiration or expiration is present
Frequendy, the subject is syrnptom-free.

SIGNS
A per-foration is readily seen and often has unhealthy edges covered with
iarge crusts.