The Nasal Septum
Pane
‘The nasal septum is rarely midline but marked degrees of deviation will
cause nasal airway obstruction Inmost easesitean be correctedby surgery,
with excellentresuts.
AETIOLOGY
Most cases of deviated nasal septum (ONS) result from trauma, either
recent er long forgotten, perhaps during birth. Buckling in children may
become more pronounced s the septum grows
SYMPTOMS
| Nasal obstruction —may be uniateral or blateral
2 Recurrent sinus infection cue co impairment of sinus ventilation by the
displaced septum. Alernatvely themideleturbinate onthe concaveside of
‘the septum may hypertrophy and interfere with sinus venation
3 Recurrent serous otis medi. Ichas been shown that DNS may impair
‘the ability to equalize middle-ear pressure, expecially n divers.
SIGNS
“Two main deformities occur and may coexist. First, the caudal end of the
septum maybe dislocateé laterally from the columella, narrowing onenos-
‘ri, while tne septal eartlage lies obliquely in the nose causing narrowing of
the opposite side Fg-2I. |). Second, che septum maybe convexto one side,
often associated wit inferior dislocation ofthe carslage‘rom themaxilary
reset cause visible spur.
‘The changes presentin the naal septum are eal seen on examination
fof the nose with a nasal speculum. Ie is helpful to try to recognize the
anatomical deformation that has occurree (Fig. 21.2)
‘TREATMENT
Irsymptoms are minimal and onlya miner degree of deviations present.no
‘treatment is necessary other than treatment of coexisting conditions such
senasalallergy.2 (Chapter 21: The Nasal Septum
Paine od
Fig 21.4 ‘S-shaped deviation
ofthenasel seprum with
Inypertophy oftheright
middle urbinate
Fig.212 Thedorsallineof
thenasalseptumhasbeen
marked ands displacedo
‘thelets.causing extemal
nasal deformity in addition
tonasal obstruction.‘The Nasal Septum 83
SUBMUCOUS RESECTION OF THE SEPTUM
Fig.215 Submucous resection of the septum (Incision through the muco
perichondrium.) Elevation of muce-perchondrial aps oneither side ofthe
apt skeleton (The dzplacedcardlageandbonehas been recected,
allowing the septum toresumea midline pesitcn
Where more severe symptoms are presene, correction of the septal
deformity is justifies (though never essential
‘Submucous resection (SMR)
‘SMR (Fig 21.3) isthe operation of choicefor mi-septal deformity when the
‘caudal sepeum isin anormal postion. leis tabeavaided in ciléren because
incerference with nasal growth will cur leading. in turn, ta collapse ofthe
pasal dorsum.
Under local or general anaesthetic. an incision is made I em back from
the fronc edge ofthe cartlage through the muce-perichonérium, which is
The incision is then deepened through the
cartilage and the muco-perichondrium on the other side elevated
Deflectedcarclage and bone are remaved with punch forceps and the
‘wo mucosal ape are allowed to fll backineo the midi,
‘Thenoseispacked gently for 24h comaintain apposition oftheflaps and
the patentmay go home after 2 days.
elevated from the carcla
Septoplasty
‘Septoplaty isthe operation of choice (i) n children i) when combined
with rhinephscy,an¢ (ii) when there ie dislocation ofthe caudal end of the4 (Chapter 21: The Nasal Septum
septal carhge, The essential features of septoplasty are a minimum of
caruhge removal and carefl repositioning ofthe septal skeleton in the
rmicline after straightening or removing spurs and convexities.
le may be performed in conjunction with mid- oF posteriorseptal
resection. Ie avoids the drooping tp and supra-tip depression seen
sometimes ater SMR and causes leze interference with facil growth in
children,
Complications of septal surgery
1 Postoperativehaemorrhage, which maybe severe,
2. Septalhaematoma, which may requir drainage.
3 Septalpertoration—see below.
4. Excernal deformity—ewing to excessive removal of septal eartlage
allowing the nasal dorsum to collapse from lack of support. It can be very
cific to correct.
5 Anosmia—fortunately rae, butuntreatable when ic occurs
Paeakd
AETIOLOGY
Perforation of the nasal septum is most comman in its anterior cartlag-
nous part and may result from the following conditions:
postoperative (particularly SMR);
‘nose-picking (ulceration occurs frst perforation later):
Wegener: granuloma:
inhalation of fumes of chrome salts;
‘cocaine addiction;
7 rodentuleer (basal call carcinoma}:
8 lupus:
9 syphilis (the gumma affects the entire septum and nasal bones, with
resulting deformity),
SYMPTOMS
Symptoms consist of epistanis and crusting, which may cause considerable
‘obstruction. Occasionally, whistling on inspiration or expiration ispresent.
Frequently the subjectis symptom-free.
SIGNS
{A perforation i readily seen and often has unhealthy edges covered with
barge crusts‘TheNasal Septum 85
INVESTIGATION
Inany caze where the cause isnot clear, the following shouldbe carried out
fullblood count and ESR to exclude Wegener's granuloma:
urinalysis, expecially for hematuria
chest Xn
serology or syphilis
if doubt remains, a biopsy from the edge of the perforation is taken.
‘TREATMENT
Septal perforations arealmostimpossible to repai If whistling sa problem,
tenkirgement of the perforation relieves the patient: embarrassment
[Nasal douching with saline or bicarbonate solution reduces crusting
around the edge ofthe defect and antiseptic cream will contra infection
rusting andbleeding remain a problem, the perforation canbe closed
Using slnstic ouble-fanged button,