Deviated Nasal Septum. Dr. Vishal Sharma. Aetiology. 1. Trauma: blow on nose 2. Developmental: Birth moulding High arched palate Unequal growth b/w skull base & palate 3. Mass in opposite nasal cavity 4. Racial factors: common in Europeans
Deviated Nasal Septum Dr. Vishal Sharma
Aetiology 1.Trauma: blow on nose 2.Developmental: Birth moulding High arched palate Unequal growth b/w skull base & palate 3.Mass in opposite nasal cavity 4.Racial factors: common in Europeans 5.Hereditary: in posterior D.N.S.
Types 1. Anterior / caudal dislocation 2. C-shaped deformity 3. S-shaped deformity 4. Septal Spur: shelf-like projection 5. Septal Thickening: organized hematoma or over-riding of septal fragments 6. Impacted septum: despite decongestion
Clinical features • Nasal 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 sinusitis 3. Headache: due to contact with lateral wall (Sluder’s neuralgia), sinusitis
Clinical features 4. 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
Sequelae • Sinusitis • Mouth breathing snoring, pharyngitis • Atrophic rhinitis & myiasis • Otitis media
Edwin 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.
Bosworth operation (late 19th century):deviated part of septum amputated along with mucosa • Asch (1899):full thickness cruciate incisions on septal cartilage • Freer (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 dislocation • Peer (1937):Removal of caudal septum & replacement after its alteration • Cottle (1948) :Maxilla-Premaxilla septoplasty
Indications for septal surgery 1. D.N.S.: nasal obstruction / sinusitis / headache / epistaxis 2. Along with rhinoplasty 3. Harvesting of septal cartilage graft 3. Trans-septal surgeries: Hypophysectomy Vidian neurectomy 4. Hereditary telengiectasia
Cottle’s 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.
Complications of septal surgery 1. Haemorrhage 2. Septal haematoma 3. Septal abscess 4. Septal perforation 5. Saddle nose 6. Columellar retraction 7. Flapping septum 8. Persistent deviation 9. Nasal synechia 10. C.S.F. rhinorrhoea 11. Infection 12. Toxic shock syndrome
Septal haematoma Collection of blood under perichondrium & periosteum of nasal septum. Aetiology: 1. Nasal trauma 2. Septal surgery 3. Bleeding disorders
Clinical features • Bilateral nasal obstruction • Sense of pressure over nasal bridge • B/L smooth, rounded septal swelling • On palpation mass is soft & fluctuant • Absence of raised temperature, erythema, swelling & tenderness of skin over nose.
Treatment 1. Small: wide bore needle aspiration 2. Large: a. incision & drainage b. nasal packing (prevent recurrence) c. systemic antibiotics (prevent abscess)
Complications • Thickened nasal septum • Septal abscess with cartilage necrosis • Saddle nose • Supra-tip deformity • Septal perforation
Septal abscess Collection 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