Dev|ated Nasa|

Septum
troduct|o
W SepLal devlaLlons are preLLy common
occurrence
W lnfacL a doL cenLral nasal sepLum ls a cllnlcal
curloslLy
W Lven Lhough sepLal devlaLlons are common
Lhey are usually noL severe enough Lo cause
sympLoms
et|o|ogy
W lrecL Lrauma
W 8lrLh mouldlng Lheory
W lfferenLlal growLh beLween nasal sepLum and
palaLe
D|rect trauma
W ,any sepLal devlaLlons are a resulL of dlrecL
Lrauma and Lhls ls frequenLly assoclaLed wlLh
damage Lo oLher parLs of Lhe nose such as
fracLures of nasal bone
|rth mou|d|g theory
W abnormal lnLrauLerlne posLure may resulL ln
compresslon forces acLlng on Lhe nose and
upper [aws
W lsplacemenL of sepLum can occur ln Lhese
paLlenLs due Lo Lorslon forces LhaL occur
durlng parLurlLlon
W lslocaLlons are more common ln prlmlpara
and when Lhe second sLage of labour lasLed
for more Lhan 13 mlnuLes
D|fferet|a| growth betwee asa|
septum ad pa|ate
W @hls ls Lhe mosL accepLable Lheory Loday
When Lhe nasal sepLum grows fasLer ln cerLaln
lndlvlduals Lhan Lhe palaLe Lhen Lhe nasal
sepLum sLarLs Lo buckle under pressure
9athophys|o|ogy
eformlLy of nasal sepLum may be classlfled
lnLo
1 Spurs
2 evlaLlons
3 lslocaLlons
Spurs
W @hese are sharp angulaLlons seen ln Lhe nasal sepLum
occurlng aL Lhe [uncLlon of Lhe vomer below wlLh Lhe
sepLal carLllage and / or eLhmold bone above
W @hls Lype of deformlLy ls Lhe resulL of verLlcal
compresslon forces
W lracLures LhaL occur Lhrough nasal sepLum durlng
ln[ury Lo Lhe nose may also produce sharp angulaLlons
@hese fracLures heal by flbrosls LhaL exLend Lo Lhe
ad[acenL mucoperlchondrlum @hls lncreases Lhe
dlfflculLy of flap elevaLlon ln Lhls area
Dev|at|os
W ,ay be C shaped or S shaped
W @hese can occur ln elLher verLlcal or horlzonLal
plane
W lL may also lnvolve boLh carLllage and bone
D|s|ocat|os
W ln Lhls Lhe lower border of Lhe sepLal carLllage
ls dlsplaced from lLs medlal poslLlon and
pro[ecLs lnLo one of Lhe nosLrlls
W ln paLlenLs wlLh sepLal devlaLlon a
compesatory hypertrophy of the turb|ates
ad bu||a may occur on Lhe slde opposlLe Lo
Lhe devlaLlon
W lf compresslon forces are lnvolved Lhe sepLal
devlaLlons are ofLen asymmeLrlcal and may
also lnvolve Lhe maxllla produclng flaLLenLlng
of Lhe cheek elevaLlon of Lhe floor of Lhe
affecLed nasal cavlLy dlsLorLlon of Lhe palaLe
and assoclaLed orLhodonLlc abnormallLles
W @he maxlllary slnus ls usually sllghLly smaller
on Lhe affecLed slde
evlaLlons may affecL any of Lhe Lhree verLlcal
componenLs of Lhe nose causlng
1 CarLllagenous devlaLlons
2 @he C devlaLlon
3 @he S devlaLlon
art||ageous dev|at|os
W ln Lhese paLlenLs Lhe upper bony sepLum and
Lhe bony pyramld are cenLral buL Lhere ls a
dlslocaLlon / devlaLlon of Lhe carLllagenous
sepLum and vaulL
@he dev|at|o
W ere Lhere ls dlsplacemenL of Lhe upper bony
sepLum and Lhe pyramld Lo one slde and Lhe
whole of Lhe carLllagenous sepLum and vaulL
Lo Lhe opposlLe slde
@he dev|at|o
@he S dev|at|o
W ere Lhe devlaLlon of Lhe mlddle Lhlrd (Lhe upper
carLllagenous vaulL and assoclaLed sepLum) ls
opposlLe Lo LhaL of Lhe upper and lower Lhlrds
W WlLh devlaLlons of Lhe nose Lhe domlnanL facLor
ls Lhe poslLlon of Lhe nasal sepLum hence Lhe
adage as the septum goes so goes the ose
W @he flrsL sLep Lherefore ln LreaLlng Lhe LwlsLed
nose ls Lo sLralghLen Lhe sepLum and lf Lhls
ob[ecLlve ls noL achleved Lhere ls no hope of
successfully sLralghLenlng Lhe exLernal pyramld
@he S dev|at|o
ffects of septa| dev|at|o
W -asal obsLrucLlon
W ,ucosal changes
W -eurologlcal changes
Nasa| obstruct|o
W @hls ls always found on Lhe slde of Lhe
devlaLlon and can also be presenL on Lhe
opposlLe slde as a resulL of hyperLrophlc
changes of Lhe LurblnaLes
,ucosa| chages
W @he lnsplraLory alr currenLs are abnormally dlsplaced
and frequenLly geLs concenLraLed on small areas of
nasal mucosa produclng excesslve drylng effecL
W CrusLlng wlll occur and Lhe separaLlon of Lhe crusLs
ofLen produces ulceraLlon and bleedlng
W Slnce Lhe proLecLlve mucous layer ls losL Lhe reslsLance
Lo lnfecLlon ls reduced
W @he mucosa around a sepLal devlaLlon may become
oedemaLous as a resulL of erou||||s pheomeo
@hls oedema furLher lncreases nasal obsLrucLlon
Neuro|og|ca| chages
W 9ressure may be exerLed by sepLal devlaLlons
on ad[acenL sensory nerves can produce paln
W @hls was flrsL explalned by Sluder and Lhe
resulLanL condlLlon became known as the
ater|or ethmo|da| erve sydrome
W ln addlLlon Lo Lhese dlrecL neurologlcal effecLs
reflex changes perhaps may resulL from sepLal
deformlLles whlch affecL Lhe nasopulmonary
and nasal reflexes
Symptoms
W @he sympLoms caused by sepLal devlaLlons are
enLlrely Lhe resulL of Lhelr effecLs on nasal
funcLlon
W @he domlnanL sympLom belng nasal
obsLrucLlon buL Lhls ls rarely severe enough Lo
cause anosmla
S|gs
W SepLal devlaLlons are evldenL on anLerlor rhlnoscopy
W @hls should be done wlLhouL Lhe use of nasal
speculum because Lhe lnserLlon of speculum ls
sufflclenL Lo sLralghLen Lhe nasal sepLum When Lhe Llp
of Lhe nose ls llfLed sepLal devlaLlon become evldenL
W -asal obsLrucLlon may also be presenL on Lhe opposlLe
slde (paradoxlcal nasal obsLrucLlon) @hls ls due Lo Lhe
presence of hyperLrophled LurblnaLes
W lf Lhe hyperLrophy ls llmlLed Lo LurblnaLe mucosa alone
Lhen lL wlll shrlnk when decongesLanL drugs are used ln
Lhe nasal cavlLy lf Lhe hyperLrophy ls bony Lhen
decongesLanL drops ls useless
ott|es test
W SepLal devlaLlons ln Lhe reglon of Lhe nasal valve
area cause Lhe greaLesL obsLrucLlon slnce Lhls ls
Lhe narrowesL parL of Lhe nasal cavlLy @hls can
be ldenLlfled by Lhe coLLle LesL
W A poslLlve coLLle LesL wlll conflrm Lhe facL LhaL
narrowlng ls presenL ln Lhe nasal valve area
W @hls ls done by asklng Lhe paLlenL Lo pull Lhe
cheek ouLwards and Lhls manuver ls supposed
Lo open up Lhe area Lhus reduclng Lhe block
ott|e has c|ass|f|ed septa| dev|at|os
|to three types
W Slmple devlaLlons
W CbsLrucLlon
W lmpacLlon
S|mp|e dev|at|os
W ere Lhere ls mlld devlaLlon of nasal sepLum
Lhere ls no nasal obsLrucLlon
W @hls ls Lhe commonesL condlLlon encounLered
W lL needs no LreaLmenL
bstruct|o
W @here ls more severe devlaLlon of Lhe nasal
sepLum whlch may Louch Lhe laLeral wall of
Lhe nose
W buL on vasoconsLrlcLlon Lhe LurblnaLes shrlnk
away from Lhe sepLum
W ence surgery ls noL lndlcaLed even ln Lhese
cases
mpact|o
W @here ls marked angulaLlon of Lhe sepLum
wlLh a spur whlch lles ln conLacL wlLh laLeral
nasal wall
W @he space ls noL lncreased even on
vasoconsLrlcLlon
W Surgery ls lndlcaLed ln Lhese paLlenLs
Sub ,ucous kesect|o
d|cat|os for submucous resect|o
of asa| septum
1 ,arked sepLal devlaLlon occurrlng behlnd Lhe verLlcal
llne passlng beLween Lhe nasal processes of Lhe fronLal
and maxlllary bones @hls devlaLlon musL be Lhe cause
for Lhe paLlenLs sympLoms
2 Closure of sepLal perforaLlons
3 Source of grafLlng maLerlal
4 @o obLaln surglcal access ln hypophysecLomy and
vldlan neurecLomy
W Surglcally Lhe sepLum ls dlvlded lnLo anLerlor
and posLerlor segmenLs by a verLlcal llne
passlng beLween Lhe nasal processes of fronLal
and maxlllay bones
S,k
S,k
W 9rocedure
W 4 xylocalne ls used as Loplcal anesLheLlc agenL by nasal
packlng
W 2 xylocalne ls used as lnfllLraLlve anesLheLlc agenL lL ls
mlxed wlLh 1 ln 1 lakh adrenallne
W lnfllLraLlon ls done aL Lhe mucocuLaneous [uncLlon on boLh
sldes [usL behlnd Lhe columella @he floor of Lhe nasal cavlLy
ls also lnfllLraLed on Lhe concave slde
W ||||as |c|s|o ls preferred for S, operaLlons kllllans
lnclslon ls Lhe commonly used lnclslon lL ls an obllque
lnclslon glven abouL 3mm above Lhe caudal border of Lhe
sepLal carLllage
S,k
W @he carLllagenous and bony nasal sepLum ls exposed by
elevaLlon of mucoperlchondrlal and mucoperlosLeal
flaps on boLh sldes
W @hls ls done by sllclng Lhe sepLal carLllage [usL above
Lhe columella Lo access Lhe opposlLe slde
W llaps are elevaLed on boLh sldes of Lhe nasal sepLum
W Lhe carLlalge ls fully exposed from boLh sldes and ls
remove uslng a Lucs forceps or a 8allangers swlwel
|fe
W @he flaps are allowed Lo fall back ln place and wound ls
closed wlLh caLguL
W 8ony devlaLlons along Lhe floor of Lhe nose lf any are
also chlssled ouL before wound closure
S,k
W S, should noL be performed ln chlldren
because lL may affecL growLh
omp||cat|os of S,k
1 SepLal hemaLoma
2 SepLal abscess
3 SepLal perforaLlon
4 -asal deformlLles due Lo excesslve removal of dorsal
sLruL of Lhe sepLum
3 emoval of Lhe columella carLllage wlll cause plg snouL
deformlLy
Septop|asty
@hls ls a more conservaLlve procedure @he anesLhesla ls Lhe
same as descrlbed for S, operaLlon
c|s|o
W @he lnclslon ls always slLed on Lhe concave
slde of Lhe sepLum
W reers hem|trasf|xat|o lnclslon ls
preferred
W @hls ls made aL Lhe lower border of Lhe sepLal
carLllage
W A unllaLeral lreers lnclslon ls sufflclenL for
sepLoplasLy @hree Lunnels are creaLed as
shown ln Lhe flgure
xposure
W @he carLllagenous and bony sepLum are
exposed by a compleLe elevaLlon of a mucosal
flap on one slde only
W Slnce flap ls reLalned on Lhe opposlLe slde Lhe
vascularlLy of Lhe sepLum ls noL compromlsed
,ob|||sat|o ad stra|ghte|g
W @he sepLal carLllage ls freed from all lLs aLLachmenLs
aparL from Lhe mucosal flap on Lhe convex slde
W ,osL of Lhe devlaLlons are malnLalned by exLrlnslc
facLors such as caudal dlslocaLlon of carLllage from Lhe
vomerlne groove
W ,oblllsaLlon alone wlll correcL Lhls problem
W When devlaLlons are due Lo lnLrlnslc causes llke Lhe
presence of healed fracLure llne Lhen lL musL be exclsed
along wlLh a sLrlp of carLllage
W 8ony devlaLlons are LreaLed elLher by fracLure and
reposlLlonlng or by resecLlon of Lhe fragmenL lLself
|xat|o
W @he sepLum ls malnLalned ln lLs new poslLlon
by suLures and spllnLs
dvatages of reers |c|s|o
1 @he lnclslon ls clLed over Lhlck skln maklng
elevaLlon of flap easy
2 @here ls mlnlmal rlsk of Learlng Lhe flap
3 @he whole of Lhe nasal sepLum ls exposed
4 lf need arlses hlnoplasLy can be done by
exLendlng Lhe same lnclslon Lo a full LransflxaLlon
one
dvatages of Septop|asty
1 ,ore conservaLlve procedure
2 9erformed even ln chlldren
3 Less rlsk of sepLal perforaLlon
4 Less rlsk of sepLal hemaLoma
@ND