Nasal septum & septoplasty

1. 1. NASAL SEPTUM By-Dr soumya singh

2. 2. Embyology of nasal septum 5 facial prominences form the nose • 1-frontal prominence
• Paired medial prominence • Paired lateral prominence Septum begins as a downward
growth of frontal prominence,as primary n secondary shelves join in ,descending septum
fuses with the palate to separate the nasal cavity into 2 distinct nasal passages
3. 3. Nasal septum Anatomy of nasal septum: Nasal septum consists of three parts: 1.
Columellar septum 2. Membranous septum 3. Septum proper: principle constituents of
septum proper are a)perpendicular plate of ethmoid b)vomer c)septal(quadrilateral
cartilage) minor contributions from crest of nasal bone,nasal spine of frontal bone,rostrum
of sphenoid,crest of palatine and maxilla and anterior nasal spine of maxilla.
4. 4. Nasal septum o Mucosa :pseudostratified columnar epithelium o along inferior two-
thirds o olfactory epithelium along superior one third o forms a partition between right and
left nasal cavities and provides support to tip and dorsum of cartilagenous part of nose. o
Septal cartilage lies in a groove in the anterior edge of vomer and rests anteriorly on
anterior nasal spine. during trauma, it may get dislocated from nasal spine or vomer
causing caudal septal deviation and spur respectively.
5. 5. BLOOD SUPPLY-NASAL SEPTUM
6. 6. • FROM ICA >ophthalmic artery >ant. and post. Ethmoidal arteies • FROM ECA-
sphenopalantine artery br of int. maxillary artery Superior labial br of facial artery
7. 7. NERVE SUPPLY-NASAL SEPTUM
8. 8. LITTLE’S AREA (KIESSEL BACH’S PLEXUS)  Anterior ethmoidal  Septal branch of
supeior labial Septal branch of sphenopalotine Septal branch of greater palatine
9. 9. Vomeronasal organ  Vomeronasal organ for olfaction (primordial)  Aka Jacoben’s
organ  Located on anterior septum  Found with endoscopy 76% of the time  Don’t
biopsy but recognize as normal anatomic structure
10. 10. Factors affecting shape and position of nasal tip • Lateral crural complex • Thickness
of the overlying skin • Ligaments and fibrous attachments of nasal tip structures
11. 11. DOME  Anatmic dome : Junction of middle and lateral crura  clinical dome: The
most anterior projecting portion of lower lateral cartilage Tip defining point: The external
projection of dome
12. 12. Nasal valve • Narrowest point of upper airway • Small changes in nasal septal
structure can have significant effects of airflow resistance n sensation of obstruction •
Boumdaries – 2dimensional plane slicing through caudal end of upper lateral cartilage
superiorly Alae – laterally Bony nasal floor inferiorly Septum medially
13. 13. 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.
septal injuries with mucosal tears cause profuse epistaxis while with intact mucosa result
in septal hematoma.
14. 14. Fractures of nasal septum Types : 1} Jarjaway fracture: result from blow from front.
fracture line starts just above the anterior nasal spine and runs horizontally backwards
just above the junction of septal cartilage with the vomer. 2} Chevallet fracture: results
from blow from below. runs vertically from anterior nasal spine upwards to the junction of
bony and cartilaginous dorsum of nose.
15. 15. Fractures of nasal septum
16. 16. Fractures of nasal septum Treatment: -early recognition and treatment of septal
injuries is essential. -dislocated or fractured fragments should be repositioned and
supported between mucoperichondrial flaps. -haematomas should be drained.
Complications: a) deviation of cartilagenous nose. b) asymmetry of nasal tip,columella,or
nostril.
17. 17. DEVIATED NASAL SEPTUM AETIOLOGY: 1) Trauma: lateral blow-displacement of
septal cartilage from vomer. blow from front-buckling, fracture, duplication of septum with
telescoping of fragments. 2) Developmental: the septum should grow at the same rate as
that of face. if septum grows at faster rate it becomes buckled. unequal growth between
 palate and base of skull may also cause buckling (high arched palate) 3) Congenital:
abnormal intrauterine posture cause compressing forces acting on nose and upper jaw.
4) Hereditary 5) Racial: Caucasians are more affected 6) Secondary: to a tumour, mass
or polyp.
18. 18. DEVIATED NASAL SEPTUM Types: 1) Deviations: upper or lower, anterior or
posterior, C shaped, S shaped. nasal cavity on the concave side of the septum will be
wider and may show compensatory hypertrophy of turbinates. 2) Anterior Dislocation:
seen on tilting the patients head backwards. 3) Spurs: shelf like projection at the junction
of bone and cartilage. may predispose for epistaxis and headache. 4) Thickening: it may
be due to organized haematoma or over-riding of dislocated septal fragments 5)
impacted septum-despite decongestants
19. 19. DEVIATED NASAL SEPTUM-types
20. 20. Mladina classification for nasal septal deviation • Type 1- U/L vertical ridge in the
valve region • Type 2- same as type 1 but more severe obstrution n disturbance of nasal
valve • Type3- U/L vertical ridge at d level of head of middle turbinate • Type 4-
combination of type3 wid either type ½ • Type 5- HZ septal crest in contrast wid lateral
nasal wall • Type 6- prominent maxillary crest C/L to deviation wid a septal crest on d
deviated side • Type 7- combination of previously described septal deformity types
21. 21. Clinical features • Nasal obstruction: the most common symptom mainly on side of
DNS,C/L paradoxical nasal obstruction due to turbinate hypertrophy may be seen •
Headache-contact with lateral wall sluders neuralgia,sinusitis • Recurrent attacks of cold
due to sinusitis • Epistaxis-stretched mucosa on DNS-dry crusting n bleeding on removal-
stretched blood vessels over spur • Anosmia/hyposmia-in high DNS • External deformity •
Middle ear infection
22. 22. Clinical features • Cottle’s test: used in nasal obstruction due to abnormality of nasal
valve. In this test cheek is drawn laterally while the patient breathes quietly. If the nasal
airway improves on test side the test is positive and indicates abnormality of nasal valve
23. 23. Cottle’s test
24. 24. SEQUELAE • SINUSITIS • MOUTH BREATHING • ATROPHIC RHINITIS AND
MYIASIS • OTITIS MEDIA
25. 25. Differential diagnosis • Polyps • Septal haematoma • Hypertrophied turbinates
26. 26. History of septoplasty • Edwin smith papyrus treating broken nose by placing 2 plugs
of linen coated wid grease& ext packing wid stiff rolls of linen • Bosworth opeartion (late
19th) deviated part of septum amputed wid mucosa on convex side • Asch (1899)- full
thickness cruciate incision on septal cartilage • Freer (1902) -SMR of total septal cartilage
• Killian (1904) -SMR wid preservation of dorsal&caudal portion of cartilage •
Metzenbaum (1929)-swinging door technique for caudal dislocation • Peer (1937)-
removal of caudal septum n replacement after its alterartion • Cottle (1948)-maxilla –
premaxilla septoplasty
27. 27. Preoperative assessment  History 1. Allergies 2. Nasal obstruction
(unilateral/bilateral, constant/intermittent, seasonal) 3. Bilateral symptoms that change in
severity (mucosal disease) 4. Constant obstruction (fixed structural abnormality) 5.
Presence of epistaxis or rhinorrhea 6. Prior nasal surgery 7. Medication history
(especially vasoconstrictive sprays, OC’s) 8. Trauma 9. Symptoms (crusting, dry mouth,
frequent sore throats, sinus problems)
28. 28. Anosmia/hyposmia  University of Pennsylvania Smell Identification Test (UPSIT) 
Help identify malingering and gross degree of impairment  34% of patients scored lower
postoperatively after septal surgery  66% improved or were unchanged
29. 29. Rhinomanometry  Anterior rhinomanometry  Posterior rhinomanometry  Pernasal
rhinomanometry  Objective information regarding respiratory function  Quantifies nasal
air flow and pressure  Nasal resistance (pressure/flow)
30. 30. Acoustic rhinomanometry  Measures the cross- sectional area of the nasal cavity as
a function of distance from the nostril  Sound generator, wave tube, microphone, and a
computer
31. 31. Optimizing acoustic rhinomanometry  Must form an acoustic seal with wave tube
without distorting the nasal tip  Results represent cross sectional area as a function of
 distance (cm) from end of nosepiece  Does not detail shape of the airway, cannot
provide information on nasal airway resistance
32. 32. Physical exam • External appearance of nose • Mouth breather • Adenoid facies
(maxillary hypoplasia) • Location of deviation • Tip support • Nasal valve • Remove all
crusts (? Underlying perforation, exophytic lesion, etc) • Any abnormal crusts, ulcerations,
or polypoid changes should delay elective surgery for possible underlying systemic
condition • Examine with vasoconstrictor, endoscope
33. 33. Goals of surgery  Exposure of the pathologic portion of septum  Removal or
reconstruction of the defective portions  Preserve nasal mucosa and lining  Prevent
external deformity of patient
34. 34. Anaesthesia • Lignocaine 2% wid epinephrine 1/100,000 • Solution injected
subperichondrially (not used only as a hemostatic agent but for hydrodissection-with
pressure lifting the mucosa and perichondrium from cartilage • Performed in anterior to
posterior direction and d mucosa should blanch as injection proceeds • Injected bilaterally
• more the time taken for infillteration less is the time rqrd for Sx
35. 35.  You inject lidocaine with epinephrine and the patient becomes tachycardic,
hypotensive, and syncope…  Vasovagal?, Allergic Reaction to PABA?, Intravascular
Injection of Epinephrine?  Vasovagal-Bradycardic, Cool skin, Hypotensive, Impending
sense of doom  Allergic Reaction-Tachycardic, Hypotensive, Flushed and warm skin 
Intravascular Epinephrine-Tachycardic (from epinephrine), Hypotensive from impaired
ventricular filling of heart, Peripheral Vasodilation (depending on the dose) can occur
36. 36. Incisions  Kilian incision  Preserves projection the best  Should not be too far
posterior (difficult to close)  Hemitransfixion incision  Full transfixion incision  High and
Low transfixion incision  Open rhinoplasty incision
37. 37. Technique  Classic Submucosal Technique  Scoring  Morselization  Sutures 
Swinging door  Removal and replacement
38. 38. Treatment- surgery • Submucous resection of nasal septum (SMR) It is generally
done in adults It consists of elevating mucoperichondrial and mucoperiosteal flap on
either side of the septum, removing the deflected parts of bony and cartilagenous septum
and then repositioning the flaps
39. 39. SMR • Indications  Deviated nasal septum causing nasal obstruction and recurrent
headaches  Deviated nasal septum causing obstruction to ventilation of paranasal
sinuses and middle ear resulting in recurrent infections  Recurrent epistaxis from septal
spur  As a part of septorhinoplasty  Harvesting cartilage graft for tympanoplasty and
rhinoplasty  As an approach to surgeries of sphenoidal sinus, vidian nerve and pituitary
gland
40. 40. SMR • Contraindications Acute URTI Patient below 17 yrs of age Bleeding
disorders Uncontrolled hypertension and diabetes mellitus
41. 41. SMR • Anesthesia - Local anesthesia/ general anesthesia • Positioning: reclining
position with head end of the table raised
42. 42. SMR - STEPS • 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
43. 43. SMR – STEPS (cont…) • 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 ( L-
struts) • Nasal packing
44. 44. SMR – STEPS
45. 45. Keystone areas  Preserve along bony cartilaginous junction  Preserve along nasal
floor  Diagram showing area of L SHAPED STRUT cartilage preserved
46. 46. Submucous resection limitations and comlications  Caudal end deformities are not
addressed  Poor access to nasal spine  Dorsal deformities not addressed  Saddle
back defomity  Septal hematoma  Collopse of nasal tip n columella  Nasal obstruction
  Mucosal tear  TSS  Septal perforation  Cartilage n bone may have memory to return
to original deformed position
47. 47. Reconstitution  Morselized cartilage replaced between flaps  Less risk of septal
perforation  Future source of cartilage for rhinoplasty and easier dissection
48. 48. Scoring the cartilage  Which side do you score the cartilage on, concave or convex?
49. 49. Deviated caudal septum
50. 50. Eliminate all posterior bony attachments to mobilize the anterior septum
51. 51. Shift caudal margin & inferior margin to opposite side of the Maxillary spine
52. 52. Caudal margin & Inferior margin to the left of the maxillary spine
53. 53. Eliminate all posterior bony attachments to mobilize the anterior septum
54. 54. Shift caudal margin & inferior margin to opposite side of the Maxillary spine
55. 55. CONSIDER RELAXING INCISIONS ON CAUDAL MARGIN
56. 56. 1.Anterior septum separated from Vomer and Ethmoid
57. 57. Maxillary Spine 1.Anterior septum separated from Vomer and Ethmoid
58. 58. Maxillary Spine 1. 2. Anterior septum separated from Vomer and Ethmoid
59. 59. Maxillary Spine 1. 2. 3. Anterior septum separated from Vomer and Ethmoid
60. 60. Maxillary Spine 1. 2. 3. Anterior septum separated from Vomer and Ethmoid Anterior
septum to midline
61. 61. complications • Bleeding • Septal haematoma • Damage to surrounding structures •
Septal abscess • Septal Perforation • Depression of bridge • Retraction of columella •
Synichae • Flapping septum • Infection- sinus and middle ear • CSF rhinorrhoea
62. 62. Cottle’s line • A vertical line between the nasal process of frontal bone and nasal
spine of maxillary crest. it divides septum into anterior and posterior segments
63. 63. Septoplasty • It is a conservative approach to septal surgery as much of the septal
framework is retained • Indications:  Deviated nasal septum causing nasal obstruction
and recurrent headaches  Deviated nasal septum causing obstruction to ventilation of
paranasal sinuses and middle ear resulting in recurrent infections  Recurrent epistaxis
from septal spur  As a part of septorhinoplasty  As an approach to surgeries of
sphenoidal sinus, vidian nerve and pituitary gland
64. 64. Septoplasty (cont…) • Contraindications Acute URTI Bleeding disorders
Uncontrolled hypertension and diabetes mellitus
65. 65. Septoplasty (cont…) • Anesthesia: local or general anesthesia • Position: same as
SMR • Steps :  Infiltration  Incision: Freer’s incision– a unilateral hemitransfixation
incision at the caudal border of the septum  Exposure: the mucoperichondrial and
mucoperiosteal flap is elevated on only one side
66. 66. Septoplasty (cont…) Separate septal cartilage from vomer and ethmoid plate
Inferior strip of cartilage is removed Correct the bony septum by removing deformed
parts Minor deviations of cartilage are corrected by criss cross incision which breaks
spring action of cartilage Nasal packing
67. 67. Post-operative complications • Bleeding • Septal haematoma • Saddle nose •
Damage to surrounding structures • Septal abscess • Septal Perforation • Depression of
bridge • Retraction of columella • Synechiae • Persistent deviation • Infection- sinus and
middle ear • CSF rhinorrhoea • Toxic shock syndrome
68. 68. 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 10. Rhinoplasty incision cant
combine 11. Cartilage graft can be harvested Septoplasty 1. Conservative surgery 2. Can
be done in children 3. Freer’s incision 4. Flap elevated on concave side only 5. Most of
cartilage preserved 6. Caudal dislocation corrected 7. Perforation rare 8. Post operative
deformity absent 9. Revision surgery easier 10. Can combine 11. Cannot be harvested
69. 69. ENDOSCOPIC SEPTOPLASTY • Described by LANZA and STAMMBERGER
ADVANTAGES : • Minimally invasive • Better for treatment of isolated spurs • Improved
access to deviation posterior to septal perforation • Better assessment of relationship b/w
septum n middle turbinate • Possible to see d separation of collagenous fibres connecting
 the perichondrium and periosteum to underlying bone and cartilage • Can be used as a
teaching tool for residents • mucosal disruptions are recognized immediately
70. 70. Procedure • Infilteration is given • The nasal cavity is examined with a 0 degree
endoscope to see location of deviation and spur • Rest of the steps are same as
conventional septoplasty
71. 71. Directed septoplasty • This approach is useful for managing isolated spurs in
absence of larger septal deviations • HZ incision is made over the apex of spur,mucosal
flaps elevated in superior and inferior direction • Spur incised using microdebrider or by
traditional septal transfixion with resection of spurring cartilage/bone. • Flaps redrapped
to minimize exposure of raw mucosa • Advantage :limited dissection and quicker post op
healing
72. 72. Complications • Major complications are rare • Minor complications include epistaxis.
Septal hematoma, injury to nasopalantine nerve wid dental numbness,
scarring,perforation and CSF leak are rare complications.
73. 73. Paediatric septoplasy Absolute indications: • Septal abscess • Septal haematoma •
Severe deformity secondary to acute nasal fracture • Dermoid cyst • Cleft lip nose
74. 74. • A child coming wid nasal obstructions should be properly evaluated very rarely
cause will be septal deviation alone Factors contributing are: • Congenital nasal
mass(dermoid,encephalocele,glioma) • Nasal polyp • Choanal atresia • Foreign body •
Septal hematoma • Adenoid hypertrophy • Reversible obstruction (acut URTI,chronic
sinusitis,allergic inflammation) • Isolated spur • Turbinate hypertrophy • Deviated septum
• Midface hypoplasia
75. 75. Nasal septal perforation Etiology :  Traumatic - post surgical, habitual nose picking,
cauterization of septum with chemicals or galvano-cautery for epistaxis  Pathological
perforation a) Septal abscess b) Nasal myasis c) Rhinolith or neglected foreign body d)
Chronic granulomatous conditions like TB, lupus, leprosy, syphilis, wegener’s  Inhalant
irritants- snuff and cocaine irritant, industrial toxins  Malignancy  idiopathic
76. 76. Septal Perforation  History  Crusting, bleeding, whistling if perforation is small 
Rhinorrhea and disruption of lamellar flow if perforation is large  Pain signifies chondritis
 More anterior the perforation the more likely the patient will become occult
77. 77. Septal Perforation  Must rule out a chronic inflammatory disease process, cocaine
abuse, granulomatous process in face of granulation tissue on perforation
78. 78. Physical Exam  Crusting on mucosa due to dry nonlaminar flow, not necessarily at
site of perforation  Bleeding at edge of perforation  Picture with endoscope and ruler to
assess size of perforation
79. 79. What tests do I order?  Nasal cultures for fungal and bacterial infections  Skin
testing for TB, fungi and anergy  VDRL, FTA-Abs, C-ANCA  Biopsy to rule out
autoimmune process
80. 80. Principle  Perforation is unlikely to heal on its own  More likely to contract and
create a larger opening
81. 81. Medical Therapy  Petroleum based ointments  Antiseptic wash per Fairbanks (1
teaspoon salt in warm water delivered by Water-Pik device +/- glycerin to moisturize +
boric acid or vinegar)  Medical button
82. 82. Surgical therapy  Endonasal repair  Small perforations  External approach  Most
perforations less than 2cm  Tissue expander  Free flap
83. 83. Nasal septal perforation • Clinical features • Whistling sound • Irritation and crusting •
Epistaxis • Nasal obstruction
84. 84. Nasal septal perforation Treatment : Treat the root cause Inactive small
perforation can be surgically closed by plastic flaps or septal mucosal flaps Larger
perforations are difficult to close: their treatment is aimed to keep the nose crust free by
alkaline nasal douch and application of lubricants, silastic obturator may also be used
NOSE - Anatomy Nasal Septum
The nasal septum divides the nasal cavity into two halves.

The nasal septum has a:

 Bony part
 Cartilaginous part
 Membranous part
Bony part: This is made up of:

 Posterosuperiorly: The perpendicular plate of the ethmoid.

 Posteroinferiorly: Vomer BONE
Cartilaginous part:

 Anteriorly quadrilateral septal cartilage

 Medial crus of the alar cartilage
Membranous part:

 This is the anterior most part of the nasal septum lined by skin and fibrofatty tissue.
Articulation of the nasal septum:

 Superiorly: Sphenoid Rostrum

 Anteriorily: Nasal bones, nasal spine of frontal bones
 Inferiorily:

 Nasal crest of the maxilla

 Nasal crest palatine process
 Anterior nasal spine of maxilla
Blood Supply:

The blood supply of the septum:

Arterial is made up of:

 Anterior Ethmoidal Artery

 Superior Labial Artery
 Sphenopalatine Artery
 Greater palatine artery
The above four arteries form a plexus in the anterio–inferior portion of the nasal septum called the
Kiesselboch's plexus or Little area.

Venous Drainage:

 Sphenopalatine vein
 Anterior and posterior ethmoidal veins
 Anterior facial vein
 Cerebral veins
Nerve supply:

 Trigeminal nerve including anterior ethmoidal nerve.

 Sphenopalatines ganglion.
NOSE - Deviated Nasal Septum
Introduction

It is the deviation of the nasal bone dividing the nose into two nostrils to one side. Hence the patient may
have recurrent blockage of one nostril. Septal deviations, though common, require to be treated only if they
produce symptoms affecting nasal function.

What are the causes of deviated nasal septum?

 Birth Moulding theory: Abnormal intrauterine posture and second stage of labour lasting more than 15
minutes in primipara.However these are postulated theories.
 Trauma: Commonest cause of deviation.
 Secondary to a tumour, mass or polyps in the nose to compression.
 Developmental Buckling: If the septum starts growing rapidly it gets buckled to one side to accommodate
itself.
What are the types of Septal deviation?

 The deviation can be C shaped, S shaped high or low deviation.

 Dislocation: The anterior end or the lower border of septum gets displaced to one side.
 Septal spurs: They are seen at the. cartilago-bony junction of the septum.
 Thickened septum post trauma
What are the symptoms of deviated nasal septum?

Common symptoms of deviated nasal septum are:

 Nasal blockage
 Headache due to

 Sinusitis with vacuum headache

 Neuralgia
 Epistaxis
 Anosmia
What are the common signs seen on examination of deviated nasal septum?

Common signs of deviated nasal septum:

 External deformity of nose

 Anterior rhinoscopy reveals deviation of the nasal septum.
 Cottles test: Pulling the cheek outward and upward causes opening of internal nares and relieves
blockage.
What are the investigations required for confirming the diagnosis of deviated nasal septum?

Investigations for deviated nasal septum include:

 X-ray paranasal sinuses, Waters view and Caldwells view gives an idea of posterior deviation if any and
status of the sinuses.
 CT Scan paranasal sinuses (PNS) with the Axial and coronal sections.

 Shows the severity of sinusitis

 Any complications involving the orbit or optic nerve
 Diagnose sphenoidal sinusitis
What is the treatment for deviated nasal septum?

Depending on the severity of the symptoms and age, the patient is advised any of the following for deviated
nasal septum:

 SMR (Sub Mucous Resection) surgery

 Septoplasty Surgery.This is the more commonly done surgery
The above surgery is often combined with Functional Endoscopic Sinus Surgery if there is moderate to severe
disease in the sinuses.