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Deviated Nasal Septum Dr. Vishal Sharma.

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Presentation on theme: "Deviated Nasal Septum Dr. Vishal Sharma."— Presentation transcript:

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 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

44 Complications of septal surgery
1. Haemorrhage Septal haematoma 3. Septal abscess Septal perforation 5. Saddle nose Columellar retraction 7. Flapping septum Persistent deviation 9. Nasal synechia C.S.F. rhinorrhoea 11. Infection Toxic shock syndrome

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

46 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.

47 Septal Haematoma

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

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

50 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

51 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

52 Septal Abscess

53 Septal abscess

54 Treatment Abscess drained immediately
Incision made on most dependent part Pus & necrosed cartilage removed Nasal packing done Systemic antibiotics for 10 days

55 Complications Necrosis of septal cartilage Saddle nose
Supra-tip deformity Septal perforation Meningitis Cavernous sinus thrombosis

56 Saddle nose

57 Nasal synechia

58 Perforated nasal septum

59 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 Idiopathic

60 Clinical features Small perforation: whistling sound
during respiration Large perforation: nasal crusting  nasal obstruction  epistaxis on crust removal

61 Perforated nasal septum

62 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.

63 Nasal mucosal flaps

64 Nasal mucosal flaps

65 Sublabial flap

66 Silastic obturator

67 Thank You

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