Nasal septum & its diseases

NASAL SEPTUM & ITS DISEASES

NAVAS SHAREEF .P .P

KMCT MED COLLEGE ; CALICUT ; INDIA

Email:[email protected]

Nasal septum

Anatomy

3 parts

1)Columellar septum

2)Membranous septum

3)Septum proper

Nasal septum

1.Columellar septum

Formed of columella containing the

medial crura of alar cartilage united

together by fibrous tissue and covered

on either side by skin

2.Membranous Septum

Double layer of skin

No bony or cartilaginous support

Lies b/w columella & caudal border of septal

cartilage.

Both columella & membranous parts are freely

movable from side to side

3.Septum proper

Osteocartilagenous frame work

Covered with nasal mucous membrane

1.Perpendicular plate of ethmoid

2.The vomer

3.Large septal cartilage

Minor contributions from

-Crest of nasal bone

-Nasal spine of frontal bone

-Rostrum of sphenoid

-Crest of palatine bone

-Crest of maxilla

-Anterior nasal spine of maxilla

Septal cartilage

Partition b/w right&left nasal cavities.

Provides support to the tip & dorsum of cartilaginous part

of nose.

Its destruction ( in Septal abscess, injuries, tuberculosis,

excessive removal during septal surgery ) causes

depression of lower part of nose &drooping of nasal tip

Blood supply of nasal septum

Little’s area/Kiesselbach’s plexus

Vascular area in the anteroinferior part of nasal septum.

-Anterior ethmoidal artery

-Spheno palatine

-Greater palatine

-Septal branch of superior labial

+corresponding veins

Commonest site for epistaxis

Site for origin of “Bleeding polypus”(Hemangioma) of nasal

septum

Nerve supply

1)Nerves of common sensation

Anterior ethmoidal nerve.

Branches of sphenopalatine ganglion.

Branches of infra orbital nerve

2)Olfactory nerves.

3)Autonomic nerves.

Nerve supply

Fractures of nasal

septumAetiopathogenesis

Trauma

Fracture of septal cartilage or its

dislocation from vomerine groove

Septal injuries

with mucosal tear-profuse epistaxis

with intact mucosa-hematoma.

“ Jarjaway” fractures of nasal septum-

Blows from front.

Starts just above the antarior

nasal spine of maxilla &runs

horizontally backwards just

above the jn of septal cartilage

with vomer

“Chevallet” fractures of septal cartilage

Blows from below.

Runs vertically from antarior

nasal spine of maxilla upwards

to the jn of bony and

cartilaginous dorsum of nose.

Treatment of Fractures of nasal

septum

Hematoma should be drained

Dislocated or fractured septal fragments

should be repositioned& supported.

Complications of Fractures of nasal

septum

If injuries are ignored ,they would result in

deviation of cartilaginous nose

assymetry of nasal tip,columella

or the nostril.

DNS

DEVIATED NASAL SEPTUMAetiology

1)Trauma

Lateral blow on nose:-displacement of septal

cartilage from the vomerine groove&maxillary

crest

Crushing blow from the front:-buckling or

twisting fractures

Trauma at birth during passage thru birth canal.

2)Developmental error

3)Racial factors

Caucasians affected more than negroes

4)Hereditary factors

Several members of the same family may have

deviated nasal septum.

Types of DNS

1)Anterior dislocation

Nasal septum dislocated to one of

the nasal chambers.

2)C-shaped deformity

Septum is deviated in a single curve to one

side.

Nasal chamber on the concave side will be

wider &may show compensatory

hypertrophy of turbinates.

3)S-shaped deformity

Septum may show an S-shaped

curve either in vertical or

anteroposterior plane.

Causes bilateral nasal

obstruction.

4)Spurs

Shelf like projection often found at the jn of

bone and cartilage.

A spur may press on the lateral wall& give rise

to headache.

It may also predispose to repeated epistaxis

from the vessels stretched on its convex

surface.

5)Thickening

Due to organised hematoma or

Overriding of dislocated septal

fragments.

Clinical features :DNS DNS can involve any age and sex

Males are affected more than females

1)Nasal obstruction Unilateral/bilateral

Site of obstuction

i. Vestibular

ii. At the nasal valve

iii. Attic

iv. Turbinal

v. Choanal

COTTLE TEST

Used to know whether nasal obstruction is due to

septal abnormality or not?

Cheek is drawn laterally while the patient breathes

quietly

If the nasal airway improves on the test side,test is +

ve

Indicates abnormality vestibular component of nasal

valve

COTTLE TEST

2)Headache

Deviated septum,esp. a spur may press on

lateral wall of nose giving rise to pressure

headache

3)Sinusitis

Deviated septum may obstruct sinus ostia

poor ventillation of sinus predispose or

perpetuate sinus infection.

4)Epistaxis

Mucosa over the deviated parts of

septum exposed to drying effects of

air currents formation of crusts which

when removed causes bleeding

Bleeding may occur from vessels over a

nasal spur

5)Anosmia

Failure of inspired air to reach the

olfactory region may result in total or

partial loss of sense of smell.

6)External deformity

7)Middle ear infection

Septal hematoma

Collection of blood under of perichondrium/

periosteum of nasal septum.

Often results from nasal trauma or septal

surgery.

It may occur spontaneously in bleeding

disorders .

Clinical features :Septal hematoma

Bilateral nasal obstruction.

Frontal headache & sense of pressure over

nasal bridge.

Examn –smooth rounded swelling of the

septum in both the nasal fossa.

Palpation-mass soft & fluctuant.

Treatment :Septal hematoma

Small hematomas aspirated with a wide

bore sterile needle.

Large hematomas incised and drained.

Following drainage nose is packed on

both sides to prevent reaccumulation.

Systemic antibiotics should be given to

prevent septal abscess.

Complications :Septal hematoma

Septal hematoma if not

drainedorganise into fibrous tissue

leading to permanantly thickened septum

Secondary infection results in septal

abscess with necrosis of

cartilage&depression of nasal septum.

Septal abscess

Aetiology

Mostly from secondary infection of septal

hematoma.

Occassionally it follows furuncle of the nose or

upper lip.

It may follow a/c infection such typhoid or measles

Complications Septal abscess

Necrosis of septal cartilagedepression of

the cartilaginous dorsum.

Necrosis of septal flapsseptal

perforation.

Meningitis&cavernous sinus thrombosis-

rare &serious complication

Perforation of nasal septum

Aetiology

1)Traumatic perforation

Most common cause.

Common forms of trauma-injury to mucosal flaps during

SMR,cauterisation of septum with chemicals/galvanocautery

for epistaxis,habitual nose pricking.

2)Pathologic perforation

Septal abscess

Nasal myiasis

Rhinolith/neglected foreign body causing pressure

necrosis.

c/c granulomatous condn

lupus,TB,leprosy (perforation in cart. Part)

Syphilis (bony part)

Wegener’s granuloma-midline destructive lesion-

cause total septal perforation.

3)Drugs & chemicals

i. Prolonged use of steroid sprays in nasal allergy.

ii. Coccaine addicts.

iii. Workers in certain occupations,eg.Cr plating,dichromate/soda

ash(sod.carbonate) manufacture or those exposed to As.

4)Idiopathic

No h/o trauma,previous disease or Pt. may be unaware of

existence of perforation.

Clinical features:Perforation

Small ant.perforation-whistling sound

during inspiration/expiration.

Larger perforation-develop crusts

which obstruct the nose or may cause

severe epistaxis when removed

Treatment of septal perforation

Find the cause of perforation first

Inactive small perforation can be surgically closed by

plastic flaps.

Larger perforation difficult to close.

Their t/t is aimed to keep the nose crust free by alkaline

nasal douches&application of a bland oinment.

Thin sialistic button worn to get relief

from symptoms.

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