Transcript Document
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 Anterior / caudal dislocation C - shaped S - shaped Nasal septal spur Thickened & impacted nasal septum C-shaped DNS not touching lateral nasal wall C-shaped DNS touching lateral nasal wall Compensatory turbinate hypertrophy Clinical features 1. 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 History of septal surgeries • 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. Edwin Smith Papyrus • 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 Gustav Killian Maurice Cottle 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 Septoplasty Freer’s Incision 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. Muco-perichondrial flap elevation on right side Anterior + Inferior tunnels Inferior cartilage strip removal Dislocation of bony cartilaginous junction Muco-periosteal flap elevation on both sides Cartilage + Bone removed Scoring & cross-hatching Wedge excision & shaving Anterior nasal packing Outer nasal packing Submucosal Resection Killian’s incision Muco-perichondrial flap elevation on right side Cutting of cartilage & elevation of opposite flap Excision of septal cartilage Excision of septal cartilage Cartilage + Bone removed Anterior nasal packing S.M.R. Septoplasty Radical surgery Conservative Not done below 17 yr Done after 4 yr Killian’s incision Freer’s incision Cannot correct anterior DNS Can correct B/L mucoperichondrium elevated One side only Radical removal of cartilage Only inferior strip Rhinoplasty incision can’t combine Can Revision surgery difficult Relatively easy Cartilage graft can be harvested No Complications common Rare 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. Septal Haematoma 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 Clinical Features • Bilateral nasal obstruction with fever • Skin over nose shows raised temperature, erythema, swelling & tenderness • B/L smooth, soft, fluctuant septal swelling • Septal mucosa congested • Submandibular node enlarged & tender Septal Abscess Septal abscess Treatment • Abscess drained immediately • Incision made on most dependent part • Pus & necrosed cartilage removed • Nasal packing done • Systemic antibiotics for 10 days Complications • Necrosis of septal cartilage • Saddle nose • Supra-tip deformity • Septal perforation • Meningitis • Cavernous sinus thrombosis Saddle nose Nasal synechia Perforated nasal septum Aetiology 1. Trauma: septal surgery, nose picking, septal cautery, ornamentation 2. Infection: septal abscess 3. Nasal Irritants: snuff, cocaine 4. Foreign body, Rhinolith, Nasal myiasis 5. Granuloma: TB, leprosy, syphilis, Wegener 6. Malignancy 7. Idiopathic Clinical features Small perforation: whistling sound during respiration Large perforation: nasal crusting nasal obstruction epistaxis on crust removal Perforated nasal septum Treatment • Treat cause of septal perforation • Alkaline nasal douche for crusting • Small perforation: closed by mucosal advancement flaps • Large perforation: Silastic obturator, Alloderm. Results of surgery are poor. Nasal mucosal flaps Nasal mucosal flaps Sublabial flap Silastic obturator Thank You