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Deviated Nasal Septum

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

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Deviated Nasal Septum

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  1. Deviated Nasal Septum Dr. Vishal Sharma

  2. 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.

  3. 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

  4. Anterior / caudal dislocation

  5. C - shaped

  6. S - shaped

  7. Nasal septal spur

  8. Thickened & impacted nasal septum

  9. C-shaped DNS not touching lateral nasal wall

  10. C-shaped DNS touching lateral nasal wall

  11. Compensatory turbinate hypertrophy

  12. 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

  13. 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

  14. Sequelae • Sinusitis • Mouth breathing snoring, pharyngitis • Atrophic rhinitis & myiasis • Otitis media

  15. History of septal surgeries

  16. 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.

  17. Edwin Smith Papyrus

  18. 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

  19. Gustav Killian

  20. Maurice Cottle

  21. 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

  22. Septoplasty

  23. Freer’s Incision

  24. 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.

  25. Muco-perichondrial flap elevation on right side

  26. Anterior + Inferior tunnels

  27. Inferior cartilage strip removal

  28. Dislocation of bony cartilaginous junction

  29. Muco-periosteal flap elevation on both sides

  30. Cartilage + Bone removed

  31. Scoring & cross-hatching

  32. Wedge excision & shaving

  33. Anterior nasal packing

  34. Outer nasal packing

  35. Submucosal Resection

  36. Killian’s incision

  37. Muco-perichondrial flap elevation on right side

  38. Cutting of cartilage & elevation of opposite flap

  39. Excision of septal cartilage

  40. Excision of septal cartilage

  41. Cartilage + Bone removed

  42. Anterior nasal packing

  43. 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

  44. Septal haematoma Collection of blood under perichondrium & periosteum of nasal septum. Aetiology: 1. Nasal trauma 2. Septal surgery 3. Bleeding disorders

  45. 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.

  46. Septal Haematoma

  47. Treatment 1. Small: wide bore needle aspiration 2. Large: a. incision & drainage b. nasal packing (prevent recurrence) c. systemic antibiotics (prevent abscess)

  48. Complications • Thickened nasal septum • Septal abscess with cartilage necrosis • Saddle nose • Supra-tip deformity • Septal perforation

  49. 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

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