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Deviated Nasal Septum Dr. Vishal Sharma

5 Deviated Nasal Septum

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this document describes you the consequences of the deviated nasal septum

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Deviated Nasal SeptumDr. Vishal Sharma

1 Aetiology1. Trauma: blow on nose 2. Developmental: Birth moulding High arched palate Unequal growth b/w skull base & palate 3. Mass in opposite nasal cavity4. Racial factors: common in Europeans5. Hereditary: in posterior D.N.S.2Types1. Anterior / caudal dislocation2. C-shaped deformity3. S-shaped deformity4. Septal Spur: shelf-like projection 5. Septal Thickening: organized hematoma or over-riding of septal fragments6. Impacted septum: despite decongestion3Anterior / caudal dislocation

4C - shaped

5S - shaped

6Nasal septal spur

7Thickened & impacted nasal septum

8C-shaped DNS not touching lateral nasal wall

9C-shaped DNS touching lateral nasal wall

10Compensatory turbinate hypertrophy

11Clinical featuresNasal block: present on side of D.N.S. C/L paradoxical nasal obstruction due to compensatory inferior turbinate hypertrophy.2. Recurrent cold: due to associated sinusitis3. Headache: due to contact with lateral wall (Sluders neuralgia), sinusitis12Clinical features4. Epistaxis: stretched mucosa on DNS dry crusting & bleeding on removal; stretched blood vessels over spur.5. Hyposmia: seen in high D.N.S.6. External nasal deformity

13SequelaeSinusitisMouth breathing snoring, pharyngitisAtrophic rhinitis & myiasisOtitis media14History of septal surgeries15Edwin Smith Surgical Papyrus (dated 17th century BC): world's oldest surgical document & only surviving copy of a part of an Ancient Egyptian textbook on trauma surgery written in 3500 B.C. Listed are 48 traumatic injury cases, with description of examination, diagnosis & treatment. Treatment of DNS: fracture reduction of DNS with internal pack using grease coated linen & external packing with stiff rolls of linen.16Edwin Smith Papyrus

17Bosworth operation (late 19th century): deviated part of septum amputated along with mucosa Asch (1899): full thickness cruciate incisions on septal cartilageFreer (1902): SMR of total septal cartilage Killian (1904): SMR with preservation of dorsal & caudal portion of septal cartilage Metzenbaum (1929): Swinging door technique for caudal septal dislocationPeer (1937): Removal of caudal septum & replacement after its alteration Cottle (1948) : Maxilla-Premaxilla septoplasty18Gustav Killian

19Maurice Cottle

20Indications for septal surgery1. D.N.S.: nasal obstruction / sinusitis / headache / epistaxis2. Along with rhinoplasty3. Harvesting of septal cartilage graft3. Trans-septal surgeries: Hypophysectomy Vidian neurectomy4. Hereditary telengiectasia21Septoplasty22Freers Incision

23Cottles line Drawn from frontal spine to anterior nasal spine. Deviations anterior to it can be treated by septoplasty only. Posterior to it by SMR or septoplasty.

24Muco-perichondrial flap elevation on right side

25Anterior + Inferior tunnels

26Inferior cartilage strip removal

27Dislocation of bony cartilaginous junction

28Muco-periosteal flap elevation on both sides

29Cartilage + Bone removed

30Scoring & cross-hatching

31Wedge excision & shaving

32Anterior nasal packing

33Outer nasal packing

34Submucosal Resection35Killians incision

36Muco-perichondrial flap elevation on right side

37Cutting of cartilage & elevation of opposite flap

38Excision of septal cartilage

39Excision of septal cartilage

40Cartilage + Bone removed

41Anterior nasal packing

42S.M.R.SeptoplastyRadical surgeryConservativeNot done below 17 yrDone after 4 yrKillians incisionFreers incisionCannot correct anterior DNSCan correctB/L mucoperichondrium elevatedOne side onlyRadical removal of cartilageOnly inferior stripRhinoplasty incision cant combineCanRevision surgery difficultRelatively easyCartilage graft can be harvested NoComplications commonRare43Complications of septal surgery1. Haemorrhage 2. Septal haematoma3. Septal abscess 4. Septal perforation5. Saddle nose 6. Columellar retraction7. Flapping septum 8. Persistent deviation9. Nasal synechia 10. C.S.F. rhinorrhoea11. Infection 12. Toxic shock syndrome44Septal haematoma Collection of blood under perichondrium & periosteum of nasal septum.Aetiology:1. Nasal trauma 2. Septal surgery 3. Bleeding disorders45Clinical featuresBilateral nasal obstruction Sense of pressure over nasal bridge B/L smooth, rounded septal swellingOn palpation mass is soft & fluctuant Absence of raised temperature, erythema, swelling & tenderness of skin over nose.46Septal Haematoma

47Treatment 1. Small: wide bore needle aspiration 2. Large: a. incision & drainage b. nasal packing (prevent recurrence) c. systemic antibiotics (prevent abscess)48ComplicationsThickened nasal septum Septal abscess with cartilage necrosisSaddle nose Supra-tip deformitySeptal perforation49Septal abscessCollection of pus under perichondrium & periosteum of nasal septum.Aetiology:1. secondary infection of septal hematoma 2. following furuncle of nose or upper lip 3. following typhoid or measles 50Clinical FeaturesBilateral nasal obstruction with feverSkin over nose shows raised temperature, erythema, swelling & tenderness B/L smooth, soft, fluctuant septal swellingSeptal mucosa congested Submandibular node enlarged & tender 51Septal Abscess

52Septal abscess

53TreatmentAbscess drained immediatelyIncision made on most dependent part Pus & necrosed cartilage removed Nasal packing doneSystemic antibiotics for 10 days54ComplicationsNecrosis of septal cartilage Saddle nose Supra-tip deformitySeptal perforationMeningitis Cavernous sinus thrombosis 55Saddle nose

56Nasal synechia

57Perforated nasal septum58Aetiology1. Trauma: septal surgery, nose picking, septal cautery, ornamentation 2. Infection: septal abscess 3. Nasal Irritants: snuff, cocaine4. Foreign body, Rhinolith, Nasal myiasis 5. Granuloma: TB, leprosy, syphilis, Wegener6. Malignancy 7. Idiopathic 59Clinical features Small perforation: whistling sound during respiration Large perforation: nasal crusting nasal obstruction epistaxis on crust removal60Perforated nasal septum

61Treatment Treat cause of septal perforation Alkaline nasal douche for crustingSmall perforation: closed by mucosal advancement flaps Large perforation: Silastic obturator, Alloderm. Results of surgery are poor.62Nasal mucosal flaps

63Nasal mucosal flaps

64Sublabial flap

65Silastic obturator

66Thank You

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