NASAL SEPTAL DISORDERS

DR. OMWENGA CLIFFE

Facilitator:
DR. KIPINGOR
 Outline
• Introduction
• Septum anatomy
• Classifications
 Aetiology
 Clinical features
 Investigations
 Management
 Complications

• Take home message

• Future and controversies
• References
 Introduction
• The nasal septum derived from latin: septum Nasi
• The nasal septum is a skeletal partition that
bisects the nasal cavities in the midline sagittal
plane.
• ‘’As goes the septum so goes the nose’’ (1)
• Intergral component of both cosmesis and nasal
function(2)
• 1. barelli . Rhinology:he collected writings of Maurice H Cottle.1987
• 2.parrilla. The role of septal surgery in cosmetic rhinoplasty 2013
Septum anatomy
 Septum anatomy
Topographyic anatomy of the nose

Fig 28.2a,b Sataloffs H&N surg vol.3

Classification
 Fractures of the nasal septum
Causes
• Trauma ( sports, falls, assault, RTAs) (3)
• Variables-force, direction, nature of stricking
object, age.
Fate of septum -buckling
Horizontal /vertical fratures
Crush injury
greenstick
Types; -chevallet fracture
-jarjaway fracture.
3.Hwang k. Outcome analysis of sports related facial fractures. J. Craniofacial surg.2009.
Fractures of the nasal septum
 Fractures of the nasal septum
symptoms signs
• Epistaxis • External deformity
• Nasal obstruction • Eye movements
• Hyposmia • Palpate; defomity, septal
• Diplopia deviation, crepitus,
• Ephiphora mobility, tenderness
• Septal hematoma, abscess
Investigations
• X ray nasal bone-false Postive
• CT scan PNS
 Septal fractures:Management

• Early recognition and

treatment
• Golden 3-10 days.
• Hematoma should be drained
• Dislocated and fractured
septal fragments repositioned
(Asch forceps)
• Using Nasal packing /matress
sutures
• External splinting
 Septal fractures:Management
complications
• Septal hematoma
• Septal abscess

• Septal perforation
• Residual deformity.
 Deviated Nasal septum
• Some amount of deviation of nasal septum is
common and having a perfectly straight
septum is a rarity (4)
• 90% asymptomatic incidental finding during
examination(5)
• Role in laminar air flow, aesthetics, snoring (6)

• 4.Gray . Deviated Nasal Septum. Incidence and Etiology. Annals of Otology 1978
• 5 . sedaghat. Clinical assessment is an accurate predictor of which patients will need septoplasty. 2013
• 6. Hsia J.C. Snoring exclusive during nasal breathing. J. Sleep & breathing 2014
 Deviated Nasal septum

Causes
• Trauma
• Developmental
• Congenital
• Racial
• Secondary
Types on DNS
 DNS

Clinical features
• Asymptomatic (5)
• Nasal obstruction
• Headache
• Epistaxis
• Anosmia
• Nasal deformity
• Middle ear infections
• Snoring
• 5. sedaghat. Clinical assessment is an accurate
predictor of which patients will need
septoplasty. 2013.
 DNS Diagnosis
• History Cottle test
• History is key(5)
• General exam of nose, face and
oral cavity(5)
• Cottles test
• Anterior and posterior
rhinoscopy
• Nasal endoscopy
Investigations
• X ray nose
• CT scan PNS
• 5. sedaghat. Clinical assessment is an accurate predictor
of which patients will need septoplasty. 2013
 Management
• Minor degrees of DNS - no treatment
• Treatment in those causing mechanical
obstruction and symptomatic
• Medical: decongestants, antihistamines and
nasal steroid sprays.
• Surgery - submucous resection (SMR)
- septoplasty
 SMR VS SEPTOPLASTY INCISIONS

Pgblaster.wordpress.com
DNS endonasal approach

Fig 41.5 A,B pg 599 Sataloff textbook of H&N surg vol.2

 DNS : Principle rule

• : Lateral view of the “L-

strut

Fig 41.6 .pg 600 sataloff of H&N surg vol

2
DNS management
DNS management
 Post op complications

• Septal hematoma
• Septal abscess
• Septal perforation
• Depressed nasal bridge
• Retraction of collumellar
• Synachie
• Infections- sinus and middle
ear
• CSF Rhinorrhea
 Differences between SMR and
septoplasty
SMR
• Most cartilage removed
• Killian incision
• Both sides of flap elevation
• High chance of perforation
• Caudal dislocation not
corrected
• High risk of saddle
deformity
• Revision surgery difficulty
septoplasty
• More cartilage preserved
• Freers incision
• One side flap elevation
• Perforation rare
• Corrects caudal dislocation
• Saddle deformity rare
• Revision surgery easier.
 SEPTAL HEMATOMA

• Collection of blood under the

perichondrium or periosteum of
nasal septum
• Bilateral or unilateral
Causes
• Trauma
• Post operative
• Bleeding disorders
 Septal hematoma
Clinical features
• Bilateral nasal obstruction
• Frontal headaches
• Senseof pressure over the nasal bridge
• Examination-smooth rounded nasal septal
swelling. Soft and fluctuant
 Septal hematoma: management
• Timely identification and treatment
• Small hematoma- wide bore needle aspiration
• Large hematoma- I& D
-anteroposterior incision parallel to nasal
floor
-Nasal packing
- Antibiotics
Complications
Permanent thickening of the nasal septum
Septal abscess and depressed nasal dorsum
SEPTAL ABSCESS
SEPTAL ABSCESS
 Septal abscess: Management
Treatment Complications
• I&D • Septal cartilage necrosis
• Most fluctuant part • Saddle nose
• Pus and necrotic mucosa • Supra tip deformity
and cartilage excised • Septal perforation
• Nasal packing • Meningitis
• Daily cleaning and dressing • Cavenous sinus thombosis
• Systemic antibiotics
 NASAL SEPTAL PERFORATION
• 0.9% of general popn(7)
• Violation of all the three
tissue layers of the
septum.
• Inhalational irritants –snuff,
Causes cocaine, industrial toxins

• Traumatic • Malignancy
• Iatrogenic –nasal surgery, • Infections –TB, syphillis
cauterization
• Idiopthic
• Drugs – INS
• Inflammatory causes- • 7. watson. Surgical management of the septal perforation.
vasculitidies, Wegener granulomatosis Otolaryngol 2009
 Septal perforation: pathophysiology
• Disruption of lamina flow
• Turbulent eddy currents
• Mucosal dysfunction, loss of cilia
• Dryness ,crusting
• Low grade perichondritis
• Enlargement of perforation
• Disruption of the L-strut
• External nasal deformity
Septal perforation: clinical features (8)

• Size and site of perforation

• Crusting 43%
• Epistaxis 58%
• Whistling sensation 10%
• Pain 17%
• Rhinorrhea 22%
• Paradoxical nasal
Endoscopic view of an anterior septal
obstruction. perforation that
8. Lanier B.Pathophysiology and progression of nasal septal
perforation. Ann Allergy 2007 developed after a prior septoplasty surgery.
 Septal perforation; clinical
evaluation
Anterior Rhinoscopy
• Shape of septum
• Septal deviatons
• Residual cartilage at the
edges
• Mucosal inspection
Nasal Endoscopy
– Size ,extent
– Patient images
- biopsy
 Septal perforation: management
Surgical and nonsurgical
• Reducing dryness and
crusting
• Nasal douching, emollients-
petroleum based
• Septal buttons
• Address the causative
agent.
Surgical options
• Intranasal advancement
flaps
• Inferior turbinate flaps
• Buccal/ skin grafts
Success –size/height of
perforation
• Endonasal
• External rhinotomy
 NASAL SYNECHIE

• Adhesions between septum

and lateral wal
• Following nasal surgery

Clinical features

• Nasal obstruction
• Headaches
• sinusitis
 NASAL SYNECHIE
• Intraoperative- avoid injury to opposing
mucosa
• Lubrication of nasal packs
• Proper post operative cleaning and toilet
• Septal splints post surgery.
 Septal involvement in systemic
disorders
condition features diagnosis management
Wegeners Auto-immune ANCA CORTICOSTEROIDS
granulomatosis URT,vessels,glomerulonephriti BIOPSY Cytotoxic drugs
s
Rhinorrhea, crusting, epistsxis,
Septal perforation
Midline Lymphma-T cell, NK cells Biopsy DXT
granuloma Destructive to nose, mid face, Chemotherapy
palate,
Purulent nasal
discharge,crusting , necrosis
Excludes pulmonary and renal
sarcoidosis ? Autoimmue Biopsy- corticosteroids
Lymphadenopathy, pulmonary Non
infiltrates, causeating
Nasal obstruction,headache , granuloma
sinusitis, nodular mucosa
 Septal involvement in systemic
disorders
Tuberculosis Nodular infiltrates biopsy Anti-TBs
Septal Ulceration , perforation

Leprosy M . Leprae biopsy Anti-Leprosy

Lepromatous leprosy – rare
Nodular lesions-ulceration,
perforation,athrophic rhinitis,
Retraction of collumellar
Syphilis Primary – anterior VDRL Benzathine
septal/vestibule ulcer FTA-ABS/TPHA penicillin
Tertiary –gummatous lesion
destroys the septum
Saddledeformity
mucomyosis Uncontrolled DM Surgical
Black nerotic mass eroding debridement
septum , hard palate. Amp-B
Arterial thrombosis Dm control
Rapidly fatal
 Take home message
• Early recognition and treatment of septal fractures
is essential to prevent complications
• Septal hematomas should be drained early and
nasal packing done.
• During nasal surgery avoid tearing two opposite
surfaces
• Adequate dorsal and caudal strut, as well as
preservation of mucoperichondrium forms the
mainstay of good surgical technique in septoplasty
 Future and controversies (9)
• Standardization technique for repair of septal
peforations.
• Use of bioresorbable staples for
mucoperichondrial flap coaptation in
septoplasty.

• 9. Tami. A clinical evaluation of bioresorbable staples for

mucoperichondrial flap coaptation in septoplasty.2010
 References
• 1.barreli PA, Loch WE. Rhinology: The collected writings of Maurice H Cottle. MD
Rochester. Americal Rhinology society ,1987;11(14)190-192.
• 2.  Parrilla C, Artuso A, Gallus R, Galli J, Paludetti G. The role of septal surgery in
cosmetic rhinoplasty. Acta Otorhinolaryngologica Italica. 2013;33(3):146. [
PMC free article] [PubMed]
• 3.Hwang k. Outcome ananalysis of sports related facial fractures. J craniofacial
surg.2009 may. 20(3):825-9.
• 4. Gray, L.P. (1978) Deviated Nasal Septum. Incidence and Etiology. Annals of Otology,
Rhinology, and Laryngology, 87, 3-20
• 5. Sedaghat AR, Busaba NY, Cunningham MJ, Kieff DA. Clinical
assessment is an accurate predictor of which patients will need septoplasty.
Laryngoscope. 2013;123(1):48-52.
6. J. C. Hsia, M. Camacho, and R. Capasso, “Snoring exclusively during nasal breathing:
a newly described respiratory pattern during sleep,” Sleep & Breathing, vol. 18, no. 1,
pp. 159–164, 2014.View at Publisher · View at Google Scholar · View at Scopus
 References
7.Watson D, Barkdull G. Surgical management of the septal perforation. Otolaryngol
Clin North Am. 2009;42(3):483-93.
• 8. Lanier B, Kai G, Marple B, et al. Pathophysiology and progression of nasal septal
perforation. Ann Allergy, Asthma Immunol. 2007;99(6):473-9; quiz 80-1, 521
• 9. Tami TA, Kuppersmith RB, Atkins J. A clinical evaluation of bioresorbable staples
for mucoperichondrial flap coaptation in septoplasty. Am J Rhinol Allergy. 2010
Mar. 24(2):137-9. [Medline]