nasal septum and its diseases[1]
TRANSCRIPT
DR PRIYANKA
Development Anatomy Septal diseases : deviated septum septal perforation septal fractures involvement in
systemic diseases
DEVELOPMENT Developin brain and pericardium forms two
prominent bulgings on the ventral aspect of embryo separated by stomatodaeum
Mesoderm covering the forebrain forms a downward projection : frontonasal process
Mandibular arch forms the lateral wall of the stomatodaeum which gives off a bud nd grows to form maxillary and mandibular process
Ectoderm in frontonasal process forms b/l localized thickenings to form nasal placodes.
These sink below the surface to form nasal pits.
Edges of the pit are raised to form the medial and lateral nasal process
Maxillary process grows medially fuses with the lateral nasal process and then with the medial nasal process
Medial and the lateral nasal process fuse
Nasal septum develops with the fusion of maxillary process and frontonasal process.
Initially its entirely cartilagenous, together with triangular cartilages forms a cartilagenous structure that supports the nose from the crista galli to the lower third of nose
A midline ridge develops from the posterior edge of frontonasal process in the roof of oral cavity and extends posteriorly to the opening of the rathkes pouch
This becomes the nasal septum which is continuous with the partition anteriorly between the primitive nasal cavities
On either side of the anterior septum, an invagination of ectoderm forms the vomeronasal organ : rudimentary in humans
Longitudinal strips of cartilage 7-15mm in length may be identified in embryos lyin adjacent to the vomeronasal organ on either side of the septal cartilage
Cephalic part of septum ossifies from the perpendicular plate of ethmoid bone.
Vomer develops in the tissues covering the posteroinferior part of septal cartilage
Two ossification centres appear for vomer at 8th week on eithr side of cartilage uniting to form a deep groove in which the cartilage sits
Nasal bones arise during 10th and 11th weeks
ANATOMY NASAL SEPTUM HAS 3 PARTS : COLUMELLAR : Columellar septum. It is
formed of columellaContaining the medial crura of alar cartilages united together by fibrous tissue and covered on either side by skin.
Membranous septum. It consists of double layer of skin with no bony or cartilaginous support. It lies between the columella and the caudal border of septal Cartilage. Both columellar and membranous parts are freely movable from side to side.
Septum proper. It consists of osteocartilaginousframework, covered with nasal mucous membrane.
Cartilagenous portion composed of quadrilateral cartliage, contributions from lower and upper lateral cartilages.
Quadrilatral cartilage(Septal cartilage) not only forms a partition between the right and left nasal cavities but also provides support to the tip and dorsum of cartilaginous part of nose.
Septal cartilage lies in a groove in the anterior edge ofvomer and rests anteriorly on anterior nasal spine
Its destruction leads to drooping of nasal tip and depression of nose
is 3-4 mm thick in its centre and increases to 4-8 mm anteroinferiorly, this is called the footplate
Similar expansion of cartilage can be seen posteriorly known as lateral posterior process at the junction of lateral nasal cartilage
Anteroinferior edge lies free in the columellar septum
It sits inferiorly in the nasal crest of the palatine process of maxilla
Its anterosuperior margin is connected to the posterior border of the internasal suture
Distal end of superior margin is connected by fibrous tissue on each side to the medial crurae of the major alar cartilage
Posterosuperior border is continuous with the perpendicular plate of ethmoid
Posterior septal angle formed where septum articulates with the nasal spine anteroinferiorly
A : Anterior septal angle
B mid septal angle C : posterior septal
angle
Bony septum : mainly by perpendicular plate of ethmoid and vomer
Minor contributions : crest of nasal bone
nasal spine of frontal bone
rostrum of sphenoid
crest of palatine bone
crest of maxilla
anterior nasal spine of maxilla
Bony septum: perpendicular plate of ethmoid forms the superior and anterior bony septum, which is continuous above with the cribriform plate and crista galli.
Vomer defined as keel shaped bone, extends anteriorly from spenoid and superiorly from nasal crest of maxilla and palatine bone.
forms the posterior and inferior nasal septum and articulates by its two alae with the rostrum of sphenoid creating vomerinovaginal canals which transmit pharyngeal branches of maxillary artery.
Inferior border of vomer articulates with nasal crest formed by maxillae and palatine bones.
Anterior border articulates with perpendicular plate of ethmoid and septal cartilage inferiorly.
Posterior border forms the free edge
ARTERIAL SUPPLY Internal and external carotid system Sphenopalatine artery : posteroinferior septum Greater palatine artery anteroinferior part of
septum Superior labial artery branch of facial artery anterior and posterior ethmoid arteries
Sphenopalatine artery : enters through the sphenopalatine foramen and immediately divides into posterior septal and posterior lateral rami
Posterior septal branch runs medially across the sphenoid to the posterior part of septum
Takes course anteroinferiorly in mucoperichondrium
Terminal branches anastomose in littles area
Anterior ethmoid artery traverses the anterior ethmoid canal, descends into cavity through slit by the side of crista galli, runs along inner surface of nasal bone and supplies the nasal septum
Usually in a mesentry just below skull base between ethmoid fovea and lamina papyracea
Posterior ethmoid artery enters posterior ethmoid foramen situated 5mm anterior to optic canal,
Gives nasal branches which enters nasal cavity through the cribriform plate apertures and anstomoses with sphenopalatine artery br.
Nerve supply Maxillary division of trigeminal nerve Nasopalatine nerves supplies bulk of nasal
septum Enters via SPF passing medially across the roof
of upper septum and runs down and forwards to incisive canal
Anterosup part is supplied by the anterior ethmoidal branch of nasociliary nerve
Anteroinferior portion : anterior superior alveolar nerve
Posteroinf : nerve from pterygoid canal and posteroinferior branch of anterior palatine nerve
Aetiopathogenisis:
-Trauma inflicted from front, side or below.the septum may buckle on itself, fracture vertically, horizontally or get crushed.
-fracture of septal cartilage or its dislocation can occur without nasal bones fracture in cases of trauma to lower nose.
Classification Nature of injury Extent of deformity Pattern of fracture
Extent of deformity Grade 0 : bones perfectly straight Grade 1 : boones deviated less than half the
width of bridge of nose Grade 2: deviated half to full width Grade 3: deviated greater than one full width Grade 4: bones almost touching cheek
Pattern of fracture Class 1: chevallet Low or moderate degrees of force Extent of deformity is less Simplest form is a depressed nasal bone Fractured segment is in position due to its inferior
attachment to upper lateral cartilages Nasal septum is not involved, except for in severe
injuries
Fracture line runs parallel to nasomaxillary suture, then connects across to contralateral side runs paralleljust below the dorsum
Cartilagenous septum is fractures 0.5 cm below the dorsum may extend posteriorly into bony septum through the perpndicular plate of ethmoid
Children : greenstick fracture
Class 2 : jarjavay Significant cosmetic
deformity Fracture nasal bones with
frontal process of maxilla and septum
Grade 2 Fracture begins just beneath
the nasal tip in quadrilateral cartilage, extends posteriorly through perp plate of ethmoid to the anterior border of vomer
And runs forward through lower part of perpendicular plate of ethmoid into inferior part of quadrilateral cartialge
Frontal impact can cause gross flattening and widening of dorsum
Lateral blow can cause a high deviation of nasal skeleton
Perpendicular plate of ethmoid inevitably involved
Correction of both septum and nasal bones for proper cosmetic results
Class 3 : high velocity trauma Naso orbital ethmoid fractures Ass with # of maxilla Quadrilateral cartilage falls back Saddled nose, nostrils facing more anteriorly
like the snout of a pig
Sypmtoms : nose bleed Nasal obstruction Diplopia, epiphora Watery rhinorrhea Hyposmia
Signs : External deformity difficult to examine in acute condition,
Better seen after the edema has reduced Look for movements of eye Palpate the nose to look for : deformity,
deviation, crepitus, mobility, any tenderness Look for septal hematoma, abscess Investigation : xray nasal bone In severe facial injury : ct pns to be done
Treatment Most patients don’t need any active treatment Reduction of fracture : under GA or LA Principle for reduction : mobilize the fragments
first by increasing and then decreasing the degree of deformity
An initial slight increase away from the side of impact, followed by steady movement back and then across the midline towards the side of blow
Instruments : freer hiller ashe walsham forcepsSplints may be necessary
Open reduction : b/l fractures with dislocation of nasal dorsum and significant septal deformity
Fractures of cartilagenous pyramid Infraction of nasal dorsum
Complications Residual deformity Nasal obstruction : septal deviation, collapse of
upper lateral cartilages, depressed nasal bones Septal complications : septal hematoma, septal
abscess Septal perforation
DEVIATED NASAL SEPTUM Extremly common May be present at birth Etiology : trauma with or without nasal bone fractures Birth mouldin theory given by Gray Abnormal intrauterine postures with compression
forces acting on the nose and upper jaws Post natal trauma Childs nose is cartilagenous, any trauma can cause
irreversible deviation of cartilage
Types : Spurs : sharp angulations occuring at the junction of
vomer below with the septal cartilage or ethmoid bone above.
Usually a result of vertical forces Fracture through the septal cartilage may also produce
spurs
Deviations Cartilagenous, C or s
shaped deviations either in vertical or horizontal plane
Cartilagenous deviations : upper bony septum and bony pyramid is central, deviation of the cartilagenous part
C shaped: displacement of upper bony septum to one side and whole of cartilagenous septum and vault to opposite side
S shaped : deviation of middle third is opposite to that of lower and upper one third
Disclocations : lower border ofseptal cartilage displaced from its median position and projects into one of the nostrils
Symptoms : nasal obstruction Can be on the same side of the deviation or opposite
side because of the hypertrophic changes in turbinate Snoring Mucosal changes : dryness, crusting Neurologic pain : pressure exerted by septal deviations
on adjacent sensory nerves Anterior ethmoidal nerve syndrome Deviations in region of nasal valve cause greatest
obstruction : cottle test
History of septal surgery 19th century : dns was identified and treated Acute spurs and angulations were removed by shaving
down convexities Langenbeck 1843 Dieffenbach 1845 Chassaignac 1851 Or complete removal of deviation with punch forceps Rubrent 1868 Resulted : perforations
Development of Submucus resection ( SMR ) 1881 Ingalls : earliest Refined by freers and killian Freers 1902 : radical approach Septal cartilage did not contribute to support of nasal
pyramid Septal cartilage culd be completely removed Saddling of dorsum in supratip region
Killian 1904 described technique of retention of both dorsal and caudal struts of cartilage
Prevents any external change in shape Septum is divided by a vertical line drawn from the
nasal process of frontal bone to nasal process of maxilla, any deviations posterior to this corrected by smr and anterior ones by septoplasty
Even then surgeries were followed by supra tip depression and columellar retraction
To minimize : killians technique was followed. Deviations in dorsal and caudal areas could not be
corrected
COTTLES LINE
Significant change brought about by Metzenbaum 1929
Avoided producing a large defect in cartilagenous septum by mobilizing and repositioning spetum in central position
Applicable to caudal dislocation of septum Compared the principle to a swinging door Incision given at the level of the deviation Free inferior border Posterior free border created by separating the septal
cartilage from the vomer
No anterior free border, septum tethered to displaced upper cartilage resulting in recurrence ofdeviation
Peer 1937 completely excised deviated caudal segment of cartilage
Reinserted as free graft
Galloway 1946 Removed the entire septal
cartilage and replaced it with single autograft cut from the excised cartilage
Graft was held in place with mattress sutures nd later suture removed
Problems with this method : unequal scar contraction : recurrence
Absorption of autograft : saddling of supratip Alternative solution : mobilization and
repositioning of septal cartilage : Cottle and then advocated by Rubin
INDICATIONSDNS causing symptoms of nasal obstruction and
recurrent headache. DNS causing obstruction of paranasal sinuses and
middle ear. Recurrent epistaxis from septal spur As a part of septorhinoplasty As a preliminary step in Hypophsectomy (Trans septal trans sphenoidal
approach) Vidian neurectomy (Trans septal apprach)
SMR Infiltration: subperichondrial infiltration with 2%
xylocaine with adrenaline Incision: killian’s incision- curvilinear incision 2-3mm
behind the anterior end of septal cartilage Elevation of flaps: the mucoperichondrial and
mucoperiosteal flap is elevated Incision of the cartilage- cartilage is incised just posterior
to the first incision Elevation of opposite mucoperichondrial and
mucoperiosteal flap
Removal of cartilage and bone - cartilage can be removed with Ballinger swivel knife or luc’s forceps. Bony spur is removed using gouge and hammer
Preserve a strip of 1cm wide cartilage along the dorsal and caudal borders (struts)
Complications Bleeding Septal haematoma Damage to surrounding structures Septal abscess Septal Perforation Depression of bridge Retraction of columella Synichae Flapping septum
Septoplasty Incisions / approaches to
septum Killians : vertical incision in
septal mucoperichondrium 1.5 cm cranially from the caudal septal border
Mucoperichondrium is relatively easily elevated from this part of the septum and incision gives good access to all parts of septum except for the caudal most cartilagenous portion
Total transfixion incision Verticular vestibular skin incision caudally
from the caudal septal margin through the membranous septum
Good exposure of nasal valve area and dorsum Attachments of medial crura to the caudal
septum is sacrificed
Rethi incision Horizontal midcolumellar incision Used in rhinoplasty Elevation of skin from the nasal tip and
dorssum, medial crura of alar cartilages divided, membranous septum divided and then caudal border is exposed.
May also be used in septoplasty
Hemitransfixation incision
Also known as freers Vertical vestibular skin
incision at the level of caudal septal cartilage, mucocutaneous junction
Good access to entire septum
Steps : Infiltration Incision: Freer’s incision– a unilateral
hemitransfixation incision at the caudal border of the septum
Advantages of this incision : incision is in relatively avascular zone
Decreased risk of mucosal tears Easy access to whole septum including he caudal septal
bborder To combine with rhinoplasty it can be easily extended
to the opposite side and produce a transfixion incision
Exposure : usually best to expose the cartilagenous and bony septum by elevating the mucosal flap on concave side
Difficulty in flap elevation occurs mainly at the junction of septal cartilage above, with the anterior nasal spine and vomer below
Perichondrium encloses the septal cartilage in a complete envelope which does not fuse with the periosteum
Periosteum forms another envelope over adjacent bony septum
Anterior tunnel created between the cartilage and perichondrium from the freers incision
The periosteum over the anterior nasal spine incised and elevated backwards on both sides over premaxillary crest then vomer keeping below the chondrovomerine suture. This forms the inferior tunnel
Unite the anterior and the inferior tunnels using a knife : maxilla premaxilla approach
Inferior part of the septum separated from its osseous base, anterior nasal spine, premaxillary and maxillary crest
Incsion made between posterior part of septal cartilage and bony septum : posterior chondrotomy
Straightening Require removal of a stirp of cartilage, 3-4mm wide
from the lower border, and placed in saline during the procedure for later use
Straighten the vomerine crest to accommodate the septal cartilage
Anterior spine is deviated, can be fractured and repositioned.
Angulated spurs at junction between ethmoid and vomer, vertical incision is made just behind the cottles line
Mucosal flap is elevated and deviated portion of bone and cartilage removed.
While making the vertical incision careful not to make it too anteriorly
Reconstruction of septum Once the cartilage has been freed attempt made to
reposition it back in midline. Require removal of a stirp of cartilage, 3-4mm wide
from the lower border, and placed in saline during the procedure for later use
Pts own cartilage or ear or rib cartilage as substitutes
Stabilizing the septum Nasal packing Sutures Internal nasal splints
SMR1. Radical surgery2. Not done in children3. Killian’s incision4. Flaps elevated on both
sides5. Most of cartilage
removed6. Caudal dislocation not
corrected7. Perforation chance
higher8. Post operative saddling
may be present9. Revision surgery
difficult
Septoplasty1. Conservative surgery2. Can be done in children3. Freer’s incision4. Flap elevated on concave
side only5. Most of cartilage
preserved6. Caudal dislocation
corrected7. Perforation rare8. Post operative deformity
absent9. Revision surgery easier
SEPTAL PERFORATION Majority involves septal cartilage Most common cause : trauma with or without
secondary infection Iatrogenic : septoplasty, mainly during smr ( killians
incision ) Tight nasal packing b/l cauterizations for nose bleed Inadequately treated septal hematoma/ abscess Foreign bodies intubation
Surface irritants Cocaine sufuric acid, chromic Decongestant nasal sprays phosphorus Arsenicals, mercury copper smelting fumes Hydrofluric acid, calcium nitrate
Infections:
Syphilis ( bony perforation ) rhinoscleroma
Wegners granulomatosis mucor
Leprosy rhinosporidiosis
Diphtheria histoplasmosis
Symptoms Mainly asymptomatic Size and site of perforation Anterior and large perforations symptomatic Drying, crusting Recurrent epistaxis Nasal obstruction Whisting sounds Saddling of nose
Management Nonsurgical and surgical No specific treatment for asymptomatic perforations Reducing the dryness, crusting Nasal douching, petroleum based ointments Cure the causative causes
Obturators Cover the inflamed mucosal
margin Usually silastic Prevent drying and encourage
epithelialization over the cartilage, bony septum.
Major disadvantage :cleaned or replaced regularly, can increase blockage
granuloma formation
SURGICAL Vertical height of perforation more critical than the ap
dia Approximation of mucoperichondrial edges from the
floor of nose to the dorsum of septum causes greatest tension
Extremely difficult to close perforations larger than 2cm in dia
Free grafts : simple or composite grafts allograftPedicled flaps : local nasal mucosal buccal mucosal composite septal cartilage composite skin / cartilage Rotation or advancement of mucoperichondrial or
mucoperiosteal flaps b/l mucosal flaps with main blood supply from
sphenopalatine vessels form the basis of most techniques
Grafts used temporalis fascia, mastoid periosteum, septal/ auricular cartilage
Small defects can be closed with bipedicled flaps Larger perforations require larger flaps which are
pedicled posteriorly based on sphenopalatine vessels Amount of mucosa available for closure is inversely
proportional to the dia of perforation Endonasl : broad based elevations via hemitransfixion
incisions and bipedicled flaps preserving anterior and posterior blood supplies
With horizontal relieving incisions and interposition grafts gives good results for perforations < 0.5cm
External rhinoplasty approach via trans columella approach or a columella – philtrum incision
Sectioning of columella below the medial crural footplates and connecting to transfixion and intercartilagenous incisions provides excellent exposure of septum and lower dorsum.
Alar crease incisions limited access not to be combined with transcolummellar approach
MIDFACE DEGLOVING APPROACH Extensive dissection of face for >2cm perforations Used with rotation transposition mucosal flaps
Septal hematoma It is collection of blood under the perichondrium or
periosteum of nasal septum When septum is subjected to a sharp buckling stress,
submucosal blood vesels are torn if mucosa remains intact this will result in hematoma
If severe injury , septal fracture, blood will flow to opp side and cause b/l hematoma
Blood accumulates in subperichondrial layer : interferes with vitality of cartilage
Cartilage can remain viable for 3 days, absorption follows
Symptom : nasal obstruction Examination will reveal smooth rounded b/l septal
swelling which often extends upto the lateral nasal wall
Treatment : early surgical drainage Long hemitransfixation incision made, blood
aspirated. If there is a defect in the cartilage, supported with a
homograft Complications : external deformity Septal abscess
Septal abscess Etiology Secondary infection of septal haematoma Furuncle of the nasal vestibule Clinical features Severe bilateral nasal obstruction with pain and
tenderness over bridge of nose Fever with chills Frontal headache Skin over the nose may be red and swollen Smooth bilateral swelling of the nasal septum Congested septal mucosa
Treatment Abscess should be drained as early as possible Pus and necrosed cartilage removed by suction Incision may required to be re-opened daily for 2-3
days to drain any pus or remove any necrosed piece of cartilage
Systemic antibiotics to be started as soon as possible and continued for two weeks
Complications Depression of the cartilagenous dorsum Septal perforation Meningitis and cavernous sinus thrombosis
(rare)
Involvement of septum in systemic disorders Infectious diseases : tb, syphilis, leprosy,
diphtheria Autoimmune : wegners granulomatosis, lupus
erythematosus, sarcoidosis Vascular disorders : arteriosclerosis, osler weber
rendu
WEGNERS GRANULOMATOSIS Autoimmune disorder, necrotizing granulomatous
lesion of respiratory tract, vasculitis of small and medium arteries and glomerulonephritis
M:F 1:1, 20 – 40yrs Constitutional symptoms of fever, night sweats, wt
loss, malaise, weakness Nose : nose and pns r most frequently affected in head
and neck Foul smelling rhinorrhea, recurrent epistaxis Nasal obstruction, hyposmia or anosmia Nasal crusting, eythematous tissue, granulation tissue
Perforation in septum Chronic sinusitis Diagnosis : ANCA + Biopsy : pns tissue offers most favourable results Treatment : corticosteroids, immunosuppresive
therapy, cytotoxic drugs : cyclophosphamide, chlorambucil or azathioprine may b used
SYPHILIS Sexually transmitted disease, cause by spirochete,
treponema pallidum Primary syphilis presence of a chancre at the site of
treponemal inoculation Secondary syphilis represents hematogenous
dissemination followed by a latent or asymptomatic phase
This might progress into tertiary syphilis Congenital syphilis : early and late stages
Early congenital syphilisPurulent nasal dischargeFissuring and excoriation of nasal vestibule
Late congenital syphilisGummatous lesion destroy the nasal structureCorneal opacityDeafnessHutchinson’s teeth
Primary sysphilis of nose is rare, but occurs at the mucocutaneous junction
Secondary ssyphilis manifests as rhinitis with scant thick discharge and irritation of anterior nares
Tertiary : gummata of nose Septum is commonly involved and eventually
destroyed Diagnosis VDRL, FTA – ABS, TPHA TREATMENT : Benzathine penicillin 2.4 million units
i.m weekly x 3week
TUBERCULOSIS Primary nasal infection is rare Secondary to pulmonary T.B. Nodular infiltration of anterior part Ulceration and perforation of the cartilaginous part of
the septum Diagnosis by Biopsy Anti tubercular drug is the t/t
LUPUS VULGARIS Low grade tubercular infection Commonly involve the nasal vestibule and skin
of the face Characteristic feature is “apple-jelly nodules”
brown, gelatinous nodules Perforation of the cartilaginous septum Biopsy is diagnostic Anti-Tubercular t/t.
LEPROSY Caused by M.leprae Mostly by Lepromatous leprosy Starts from the nasal vestibule and involve the
septum and inf turbinate Nodular lesion Ulcers Perforation
Atrophic rhinitis Retraction of collumela Diagnosis by Biopsy Anti-leprotic therapy
SARCOIDOSIS Unknown etiology, mutiorgan disorder Young and middle aged Presents with b/l hilar lymphadenopathy, pulmonary
infiltration, ocular and skin lesions Formation of epitheloid granuloma, noncaseating Nose – obstruction, postnasal drip, headache, recurrent
sinus infections, purulent nasal discharge Dry friable lesions involving septum and inferior
turbinates with thick discharge and crusting Granulomatous inflammation result in subcutaneous
yellowish nodules Polypoid tissue and spetal perforations can occur
Diagnosis Clinical and radigraphic findings Histological finding of non caseating granuloma Exclusion of other diseases Biopsy : transbronchial lung biopsy, bronchoalveolar
lavage : cd 4/ cd 8 ratio increased Treatment : systemic corticosteroids
Mucormycosis Found in uncontrolled diabetics and pt with
immunosuppressive therapy Rapidly fatal condition Affinity of the fungus to artery ,causes thrombosis Black necrotic mass eroding the septum and hard palate T/t – Surgical debridement, amphotericin B ,control of
underlying cause.
Believe to be a type of Lymphoma, t cell / nk cell lymphoma
Stewart granuloma Destructive disease in the nose and mid facial
region Common in males, 5-6th decade Differentiated from Wegener's granulomatosis
by absence of pulmonary and renal involvement.
Purulent nasal discharge, persistent rhinorrhea with nasal obstruction,
Nasal crusting, necrosis Progressive destruction of nasal framework Gross mutilation of face Metastasis Diagnosis : biopsy Necrotic area with atypical cellular infiltrate Immunohistochemistry using monoclonal
antibodies against t cell differentiation antigen can b used for diagnosis
Tratment : radiotherapy