Nasal Septum and its Diseases, DNS

1. NASAL SEPTUM AND ITS
DISEASES
DR. HARJITPAL SINGH
ASSISTANT PROFESSOR,
DEPARTMENT OF ENT & HNS,
DR RKGMC HAMIRPUR

2. NASAL SEPTUM
Anatomy:
• Has 3 parts : Columellar Septum
Membranous Septum
Septum proper
Columellar Septum
• It is formed of columella.
• Containing the medial crura of alar cartilages
united together by fibrous tissue.
• Covered on either side by skin.

3. NASAL SEPTUM(cont)
Membranous Septum.
• It consists of double layer of skin with no bony
or cartilaginous support.
• It lies between the columella and the caudal
border of septal cartilage.
• Both columellar and membranous parts are freely
movable from side to side.

4. NASAL SEPTUM(cont)
Septum Proper
It consists of osteocartilaginous framework,
covered with nasal mucous membrane.
Cartilaginous portion composed of
Quadrilateral cartilage
Contributions from lower & upper lateral cartilages.
• Quadrilatral cartilage(Septal cartilage) not only forms a
partition between the right and left nasal cavities but
also provides support to the tip and dorsum of
cartilaginous part of nose.

5. NASAL SEPTUM(cont)
• Septal cartilage lies in a groove in the anterior edge of
vomer and rests anteriorly on anterior nasal spine
• Its destruction leads to drooping of nasal tip and
depression of nose
• It is 3-4 mm thick in its center and increases to 4-8 mm
anteroinferiorly, this is called the footplate
• Similar expansion of cartilage can be seen posteriorly
known as lateral posterior process at the junction of
lateral nasal cartilage
• Anteroinferior edge lies free in the columellar septum

6. NASAL SEPTUM(cont)
• It sits inferiorly in the nasal crest of the palatine
process of maxilla
• Its anterosuperior margin is connected to the
posterior border of the internasal suture
• Distal end of superior margin is connected by
fibrous tissue on each side to the medial
crurae of the major alar cartilage
• Posterosuperior border is continuous with the
perpendicular plate of ethmoid
• Posterior septal angle formed where septum
articulates with the nasal spine anteroinferiorly

7. NASAL SEPTUM(cont)

8. NASAL SEPTUM(cont)
• A : Anterior septal angle
• B : Mid septal angle
• C : Posterior septal angle

9. NASAL SEPTUM(cont)
Septum Proper
• Bony septum : mainly by Perpendicular plate of ethmoid
Vomer
• Minor contributions : Crest of nasal bone
Nasal spine of frontal bone
Rostrum of sphenoid
Crest of palatine bone
Crest of maxilla
Anterior nasal spine of maxilla

10. NASAL SEPTUM (cont)
Septum Proper
• Perpendicular plate of ethmoid forms the superior and
anterior bony septum, which is continuous above
with the cribriform plate and crista galli.
• Vomer defined as keel shaped bone, extends anteriorly
from sphenoid and superiorly from nasal crest of
maxilla and palatine bone.
• Vomer forms the posterior and inferior nasal septum and
articulates by its two alae with the rostrum of
sphenoid creating vomerinovaginal canals which
transmit pharyngeal branches of maxillary artery.

11. NASAL SEPTUM(cont)
Septum Proper
• Inferior border of vomer articulates with nasal crest
formed by maxillae and palatine bones.
• Anterior border articulates with perpendicular plate of
ethmoid and septal cartilage inferiorly.
• Posterior border forms the free edge

12. NASAL SEPTUM(cont)

13. NASAL SEPTUM(cont)
Arterial Supply
• Internal and external carotid system
 Sphenopalatine artery : posteroinferior septum
 Greater palatine artery anteroinferior part of septum
 Superior labial artery branch of facial artery
 anterior and posterior ethmoid arteries

15. NASAL SEPTUM(cont)
Arterial Supply
• Sphenopalatine artery : enters through the
sphenopalatine foramen and immediately
divides into posterior septal and posterior
lateral rami
• Posterior septal branch runs medially across the
sphenoid to the posterior part of septum
• Takes course anteroinferiorly in
mucoperichondrium
• Terminal branches anastomose in Littles area

16. LITTLE’S AREA

17. NASAL SEPTUM(cont)
Arterial Supply
• Anterior ethmoid artery traverses the anterior ethmoid canal,
descends into cavity through slit by the side of crista
galli, runs along inner surface of nasal bone and supplies
the nasal septum
• Usually in a mesentry just below skull base between ethmoid
fovea and lamina papyracea
• Posterior ethmoid artery enters posterior ethmoid foramen
situated 5mm anterior to optic canal,
• Gives nasal branches which enters nasal cavity through the
cribriform plate apertures and anstomoses with
sphenopalatine artery br.

18. NASAL SEPTUM(cont)
Nerve Supply
• Maxillary division of trigeminal nerve
• Nasopalatine nerves supplies bulk of nasal septum
• It enters via SPF passing medially across the roof of
upper septum and runs down and forwards to
incisive canal
• Anterosup part is supplied by the anterior ethmoidal
branch of nasociliary nerve
• Anteroinferior portion : anterior superior alveolar nerve
• Posteroinf : nerve from pterygoid canal and
posteroinferior branch of anterior palatine nerve

19. NERVE SUPPLY(cont)

20. NERVE SUPPLY(cont)

21. FRACTURES OF NASAL SEPTUM
Aetiopathogenisis:
-Trauma inflicted from front, side or below.the septum may
buckle on itself, fracture vertically, horizontally or get
crushed.
-Fracture of septal cartilage or its dislocation can occur
without nasal bones fracture in cases of trauma to
lower nose.
- Septal injuries with mucosal tears cause profuse epistaxis while
those with intact mucosa result in septal haematoma
which, if not drained early, will cause absorption of the
septal cartilage and saddle nose deformity.

22. FRACTURES OF NASAL SEPTUM(cont)

23. FRACTURES OF NASAL SEPTUM(cont)
Classification on Extent of deformity:
• Grade 0 : Bones perfectly straight
• Grade 1 : Bones deviated less than half the width of
bridge of nose
• Grade 2 : Deviated half to full width
• Grade 3 : Deviated greater than one full width
• Grade 4 : Bones almost touching cheek

24. FRACTURES OF NASAL SEPTUM(cont)
Jarjavay fracture results
from blows from the front.
It starts just above the
anterior nasal spine and
runs horizontally backwards
just above the junction of
septal cartilage with the
vomer

25. FRACTURES OF NASAL SEPTUM(cont)
Chevallet fracture
results from blows from
below.
It runs vertically from
the anterior nasal spine
upwards to the junction
of cartilaginous and
bony dorsum of nose

26. FRACTURES OF NASAL
SEPTUM(cont)
Symptoms :
• Nose bleed
• Nasal obstruction
• Diplopia, epiphora
• Watery rhinorrhea
• Hyposmia

27. FRACTURES OF NASAL
SEPTUM(cont)
Signs :
• External deformity difficult to examine in acute condition
• Better seen after the edema has reduced
• Look for movements of eye
• Palpate the nose to look for : deformity, deviation,
crepitus, mobility, any tenderness
• Look for septal hematoma, abscess
• Investigation : X-ray nasal bone
• In severe facial injury : CT PNS to be done

28. FRACTURES OF NASAL SEPTUM(cont)

29. FRACTURES OF NASAL SEPTUM(cont)
Treatment
• Most patients don’t need any active treatment
• Reduction of fracture : under GA or LA
• Principle for reduction : mobilize the fragments first by
increasing and then decreasing the degree of deformity
• An initial slight increase away from the side of impact,
followed by steady movement back and then across the
midline towards the side of blow

30. FRACTURES OF NASAL SEPTUM(cont)
Open Reduction
• B/L fractures with dislocation of nasal dorsum and
significant septal deformity
• Fractures of cartilagenous pyramid
• Infraction of nasal dorsum

31. FRACTURES OF NASAL SEPTUM(cont)
Complications
• Residual deformity
• Nasal obstruction : septal deviation, collapse of upper
lateral cartilages, depressed nasal bones
• Septal complications : septal hematoma, septal abscess
• Septal perforation

32. DEVIATED NASAL SEPTUM
• Extremly common
• May be present at birth
• Etiology : trauma with or without nasal bone fractures
• Birth moulding theory given by Gray
• Abnormal intrauterine postures with compression forces
acting on the nose and upper jaw
• Post natal trauma
• Child nose is cartilagenous, any trauma can cause
irreversible deviation of cartilage

33. DEVIATED NASAL SEPTUM(cont)
Types of Deviations
Depending upon the site it may be:
• Anterior or cartilaginous deviations
• Posterior or bony deviations
• Superior deviations
• Anterior dislocation of septum.
Depending upon the shape:
• May be C shaped or S shaped
• Impacted nasal septum: touching the lateral wall of the nose.
Cottle’s classification of deviated nasal septum (DNS):
• Simple DNS (Mild)
• Obstructed DNS (Moderate)
• Impacted DNS (Severe form).

34. DEVIATED NASAL SEPTUM(cont)
Deviations
• C shaped: Displacement of upper bony septum to one
side and whole of cartilaginous septum and vault to
opposite side
• S shaped : Deviation of middle third is opposite to that of
lower and upper one third.
• Subluxation : Lower border of septal cartilage displaced
from its median position and projects into one of
the nostrils
• Spurs. A spur is a shelf-like projection often found at the
junction of bone and cartilage.

35. DEVIATED NASAL SEPTUM(cont)
(A) Normal septum
(B) C-shaped deviation
(C) S-shaped deviation
(D) Subluxation of septum

36. DEVIATED NASAL SEPTUM(cont)
(A) Fracture of nasal septum
(B) Septal spur
(C) Deviated nasal septum to the left side with compensatory hypertrophy
of right inferior turbinate

37. DEVIATED NASAL SEPTUM(cont)
Symptoms :
• Nasal obstruction. Can be on the same side of the
deviation or opposite side because of the
hypertrophic changes in turbinate
• Snoring
• Mucosal changes : dryness, crusting
• Neurologic pain : pressure exerted by septal deviations
on adjacent sensory nerves
• Anterior ethmoidal nerve syndrome
• Deviations in region of nasal valve cause greatest
obstruction : Cottle Test

38. DEVIATED NASAL SEPTUM(cont)
COTTLES LINE
The imaginary vertical line that
divides the cartilaginous septum.
A vertical line drawn from the nasion
to the nasal spine of maxilla divides
the cartilaginous nose into an
anterior and posterior half.
The anterior half is essential to
maintain the integrity of the
external architecture of the nose
Any deviations posterior to this line is
corrected by SMR and anterior ones
by septoplasty

39. COTTLE TEST
• Test is done by drawing the
cheek laterally and the
patient breathes quietly.
• If the breathing becomes
normal on the test side,
it is positive Cottle test.
• If positive, indicates
abnormality of the
vestibular component of
nasal valve

40. DEVIATED NASAL SEPTUM(cont)
DNS may lead to:
• Repeated middle ear infection
• Chronic sinusitis
• Mouth breathing with dental anomalies
• Atrophic rhinitis sometimes
• Recurrent infection of lower respiratory tract.
• Epistaxis.
•. Anosmia
•External Deformity.

41. DEVIATED NASAL SEPTUM(cont)
Differential Diagnosis:
•Deviated nasal septum may be confused with mass in the
nose usually by a general practitioner.
• Septal hematoma, which is seen after trauma to the nose,
produces a soft bilateral swelling. It may get
organized and thicken the septum subsequently.

42. SEPTAL SURGERY
INDICATIONS
 DNS causing symptoms of nasal obstruction and
recurrent headache.
 DNS causing obstruction of paranasal sinuses and
middle ear.
 Recurrent epistaxis from septal spur
 As a part of septorhinoplasty
 As a preliminary step in
 Hypophsectomy (Trans septal trans sphenoidal
approach)
 Vidian neurectomy (Trans septal apprach)

43. SEPTAL SURGERY
CONTRAINDICATIONS
• Acute URTI
• Patient below 17 yrs of age
• Bleeding disorders
• Uncontrolled hypertension and diabetes mellitus

44. SEPTAL SURGERY(cont)
SMR
• Infiltration: subperichondrial infiltration with 2%
xylocaine with adrenaline
• Incision: killian’s incision- curvilinear incision 2-
3mm behind the anterior end of septal cartilage
• Elevation of flaps: the mucoperichondrial and
mucoperiosteal flap is elevated
• Incision of the cartilage- cartilage is incised just
posterior to the first incision
• Elevation of opposite mucoperichondrial and
mucoperiosteal flap

45. SEPTAL SURGERY(cont)
SMR
• Removal of cartilage and
bone - cartilage can be
removed with Ballinger
swivel knife or luc’s
forceps. Bony spur is
removed using gouge and
hammer
• Preserve a strip of 1cm
wide cartilage along the
dorsal and caudal borders
(struts)

46. SEPTAL SURGERY(cont)
SMR Complications
• Bleeding
• Septal haematoma
• Damage to surrounding structures
• Septal abscess
• Septal Perforation
• Depression of bridge
• Retraction of columella
• Synechae
• Flapping septum
• Infection- sinus and middle ear
• CSF rhinorrhoea-rare

47. SEPTAL SURGERY(cont)
Septoplasty
Incisions / approaches to septum
• Killians : vertical incision in septal
mucoperichondrium 1.5 cm
cranially from the caudal septal
border
• Mucoperichondrium is relatively
easily elevated from this part of the
septum and incision gives good
access to all parts of septum except
for the caudal most cartilagenous
portion

48. SEPTAL SURGERY(cont)
Septoplasty
Total transfixion incision
• Verticular vestibular skin incision caudally from the
caudal septal margin through the membranous septum
• Good exposure of nasal valve area and dorsum
• Attachments of medial crura to the caudal septum is
sacrificed

49. SEPTAL SURGERY(cont)
Septoplasty
Hemitransfixation incision
• Also known as Freers
• Vertical vestibular skin
incision at the level of
caudal septal cartilage,
mucocutaneous junction
• Good access to entire
septum

50. SEPTAL SURGERY(cont)
Septoplasty Steps :
• Infiltration
• Incision: Freer’s incision– a unilateral hemitransfixation
incision at the caudal border of the septum
• Advantages of this incision : incision is in relatively
avascular zone
• Decreased risk of mucosal tears
• Easy access to whole septum including The caudal septal
border
• To combine with rhinoplasty it can be easily extended to
the opposite side and produce a transfixion incision

51. SEPTAL SURGERY(cont)
Septoplasty Steps :
• Exposure : usually best to expose the cartilagenous and
bony septum by elevating the mucosal flap on concave
side
• Difficulty in flap elevation occurs mainly at the junction
of septal cartilage above, with the anterior nasal spine and
vomer below
• Perichondrium encloses the septal cartilage in a complete
envelope which does not fuse with the periosteum
• Periosteum forms another envelope over adjacent bony
septum

52. SEPTAL SURGERY(cont)
Septoplasty Steps :
• Anterior tunnel created between the cartilage and
perichondrium from the Freers incision
• The periosteum over the anterior nasal spine incised and
elevated backwards on both sides over premaxillary crest then
vomer keeping below the chondrovomerine suture. This
forms the inferior tunnel
• Unite the anterior and the inferior tunnels using a knife :
maxilla premaxilla approach
• Inferior part of the septum separated from its osseous base,
anterior nasal spine, premaxillary and maxillary crest
• Incsion made between posterior part of septal cartilage and
bony septum : posterior chondrotomy

53. SEPTAL SURGERY(cont)
Septoplasty Steps :
• Straightening: Require removal of a stirp of cartilage, 3-
4mm wide from the lower border, and placed in saline
during the procedure for later use
• Straighten the vomerine crest to accommodate the septal
cartilage
• Anterior spine is deviated, can be fractured and
repositioned.
• Angulated spurs at junction between ethmoid and vomer,
vertical incision is made just behind the cottles line

54. SEPTAL SURGERY(cont)
Septoplasty Steps :
• Mucosal flap is elevated and deviated portion of bone and
cartilage removed.
• While making the vertical incision careful not to make it too
anteriorly
• Reconstruction of septum : Once the cartilage has been
freed attempt made to reposition it back in midline.
• Require removal of a stirp of cartilage, 3-4mm wide from
the lower border, and placed in saline during the procedure
for later use
• Patient’s own cartilage of ear or rib cartilage as substitutes

55. SEPTAL SURGERY(cont)
Septoplasty Steps :
Stabilizing the septum
• Nasal packing
• Sutures
• Internal nasal splints

56. DIFFERENCES BETWEEN SMR AND SEPTOPLASTY
SMR
1. Radical surgery
2. Not done in children
3. Killian’s incision
4. Flaps elevated on both sides
5. Most of cartilage removed
6. Caudal dislocation not
corrected
7. Perforation chance higher
8. Post operative saddling
may be present
9. Revision surgery difficult
Septoplasty
1. Conservative surgery
2. Can be done in children
3. Freer’s incision
4. Flap elevated on concave side
5. Most of cartilage preserved
6. Caudal dislocation
corrected
7. Perforation rare
8. Post operative deformity
absent
9. Revision surgery easier

57. SEPTAL PERFORATION
• Majority involves septal cartilage.
• Most common cause : trauma with or without secondary
infection. Habitual nose picking and perforation of
septum for putting ornaments
• Iatrogenic :
Mainly during SMR ( killians incision )
Tight nasal packing
B/L cauterizations for nose bleed
Inadequately treated septal hematoma/ abscess
Intubation

58. SEPTAL PERFORATION(cont)

59. SEPTAL PERFORATION(cont)
• Nasal myiasis: Maggots nose „
• Foreign body: Rhinolith or neglected foreign body
• „Occupational: Chrome platters and painters, or
those exposed to arsenic or its compounds,
dichromate or soda ash (sodium carbonate) . „
• Wegener’s granuloma: This midline destructive
lesion may cause total septal destruction
• Drug induced: Snuff and cocaine addicts and
long-term use of topical corticosteroids

60. SEPTAL PERFORATION(cont)
• Chronic granulomatous conditions: Lupus,
tuberculosis and leprosy cause perforation in the
cartilaginous part of septum.
• Syphilis leads to perforation in the bony part
• Idiopathic

61. SEPTAL PERFORATION(cont)
Symptoms
• Mainly asymptomatic
• Size and site of perforation
• Anterior and large perforations symptomatic
• Drying, crusting
• Recurrent epistaxis
• Nasal obstruction
• Whisting sounds
• Saddling of nose

62. SEPTAL PERFORATION(cont)
Management
• No specific treatment for asymptomatic perforations
• Nonsurgical and surgical
• Reducing the dryness, crusting by alkaline nasal douches
petroleum based ointments
• Silastic button may be used to close the perforation and
lessen the symptoms.
• Small to medium size perforation can be closed by
raising flaps and stitching on the perforation.
• Cure the causative causes

63. SEPTAL PERFORATION(cont)
Obturators
• Cover the inflamed mucosal
margin
• Usually silastic
• Prevent drying and encourage
epithelialization over the
cartilage, bony septum.
• Major disadvantage :cleaned or
replaced regularly, can increase
blockage
• granuloma formation

64. SEPTAL HEMATOMA
• It is collection of blood under the perichondrium or
periosteum of nasal septum
• It often results from nasal trauma or septal surgery
• In bleeding disorders, it may occur spontaneously
• When septum is subjected to a sharp buckling stress,
submucosal blood vessels are torn if mucosa remains
intact this will result in hematoma
• If severe injury, septal fracture, blood will flow to opposite
side and cause b/l hematoma
• Blood accumulates in subperichondrial layer : interferes
with vitality of cartilage
• Cartilage can remain viable for 3 days, absorption follows

65. SEPTAL HEMATOMA(cont)

66. SEPTAL HEMATOMA(cont)
Sign & Symptoms :
• Nasal obstruction
• Examination will reveal smooth rounded septal swelling
which often extends up to the lateral nasal wall
• Palpation may show the mass to be soft and fluctuant
• Sense of pressure over nasal bridge
Treatment :
• Early surgical drainage
• Long hemitransfixation incision made, blood aspirated.
• If there is a defect in the cartilage, support with a
homograft

67. SEPTAL HEMATOMA(cont)
Complications :
•If not drained may organize into fibrous tissue leading to a
permanently thickened septum.
•If secondary infection supervenes leads to septal abscess with
necrosis of cartilage and saddling.

68. SEPTAL ABSCESS
It is the collection of pus between the
nasal septum and its perichondrium and periosteum
Etiology:
• Secondary infection of septal haematoma
• Furuncle of the nasal vestibule or other acute viral
infections such as typhoid and measles.

69. SEPTAL ABSCESS
Clinical features:
• Severe bilateral nasal obstruction
• Pain and tenderness over bridge of nose
• Fever with chills
• Frontal headache
• Skin over the nose may be red and swollen
• Smooth bilateral swelling of the nasal septum
• Congested septal mucosa

70. SEPTAL ABSCESS (cont)
Treatment
• Abscess should be drained as early as possible
• Pus and necrosed cartilage removed by suction
• Incision may be re-opened daily for 2-3 days to drain
any pus or remove any necrosed piece of cartilage
• Systemic antibiotics to be started as soon as possible
and continued for two weeks

71. SEPTAL ABSCESS (cont)
Complications:
• Depression of the cartilagenous dorsum
• Septal perforation
• Meningitis and cavernous sinus thrombosis (rare)

72. THANK YOU