this seminar is regarding the anatomy of nasal septum its importance , and surgeries used to correct deviated septum.

1. NASAL SEPTUM
By-Dr soumya singh

9. Embyology of nasal septum
5 facial prominences form the nose
• 1-frontal prominence
• Paired medial prominence
• Paired lateral prominence
Septum begins as a downward growth of frontal
prominence,as primary n secondary shelves
join in ,descending septum fuses with the
palate to separate the nasal cavity into 2
distinct nasal passages

10. Nasal septum
Anatomy of nasal septum:
Nasal septum consists of three parts:
1. Columellar septum
2. Membranous septum
3. Septum proper: principle constituents of septum proper
are
a)perpendicular plate of ethmoid
b)vomer
c)septal(quadrilateral cartilage)
minor contributions from crest of nasal bone,nasal spine
of frontal bone,rostrum of sphenoid,crest of palatine and
maxilla and anterior nasal spine of maxilla.

11. Nasal septum
o Mucosa :pseudostratified columnar epithelium
o along inferior two-thirds
o olfactory epithelium along superior one third
o forms a partition between right and left nasal cavities and
provides support to tip and dorsum of cartilagenous part of
nose.
o Septal cartilage lies in a groove in the anterior edge of vomer
and rests anteriorly on anterior nasal spine. during trauma, it
may get dislocated from nasal spine or vomer causing caudal
septal deviation and spur respectively.

14. BLOOD SUPPLY-NASAL SEPTUM

15. • FROM ICA >ophthalmic artery >ant. and post.
Ethmoidal arteies
• FROM ECA- sphenopalantine artery br of int.
maxillary artery
Superior labial br of facial artery

17. NERVE SUPPLY-NASAL SEPTUM

19. LITTLE’S AREA (KIESSEL BACH’S PLEXUS)
 Anterior ethmoidal
 Septal branch of supeior labial
Septal branch of sphenopalotine
Septal branch of greater palatine

21. Vomeronasal organ
 Vomeronasal organ for
olfaction (primordial)
 Aka Jacoben’s organ
 Located on anterior septum
 Found with endoscopy 76%
of the time
 Don’t biopsy but recognize
as normal anatomic
structure

22. Factors affecting shape and position of
nasal tip
• Lateral crural complex
• Thickness of the overlying skin
• Ligaments and fibrous attachments of nasal
tip structures

24. DOME
 Anatmic dome :
Junction of middle and lateral crura
 clinical dome:
The most anterior projecting portion of lower
lateral cartilage
Tip defining point:
The external projection of dome

28. Nasal valve
• Narrowest point of upper airway
• Small changes in nasal septal structure can have
significant effects of airflow resistance n
sensation of obstruction
• Boumdaries – 2dimensional plane slicing through
caudal end of upper lateral cartilage superiorly
Alae – laterally
Bony nasal floor inferiorly
Septum medially

30. Fractures of nasal septum
• 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.
septal injuries with mucosal tears cause profuse epistaxis
while with intact mucosa result in septal hematoma.

31. Fractures of nasal septum
Types :
1} Jarjaway fracture: result from blow from front.
fracture line starts just above the anterior nasal spine and
runs horizontally backwards just above the junction of septal
cartilage with the vomer.
2} Chevallet fracture: results from blow from below.
runs vertically from anterior nasal spine upwards to the
junction of bony and cartilaginous dorsum of nose.

32. Fractures of nasal septum

33. Fractures of nasal septum
Treatment: -early recognition and treatment of septal injuries is
essential.
-dislocated or fractured fragments should be repositioned and
supported between mucoperichondrial flaps.
-haematomas should be drained.
Complications: a) deviation of cartilagenous nose.
b) asymmetry of nasal tip,columella,or
nostril.

34. DEVIATED NASAL SEPTUM
AETIOLOGY:
1) Trauma:
lateral blow-displacement of septal cartilage from vomer.
blow from front-buckling, fracture, duplication of septum with
telescoping of fragments.
2) Developmental: the septum should grow at the same rate as that of
face. if septum grows at faster rate it becomes buckled. unequal
growth between palate and base of skull may also cause buckling
(high arched palate)
3) Congenital: abnormal intrauterine posture cause compressing
forces acting on nose and upper jaw.
4) Hereditary
5) Racial: Caucasians are more affected
6) Secondary: to a tumour, mass or polyp.

35. DEVIATED NASAL SEPTUM
Types:
1) Deviations: upper or lower, anterior or posterior, C
shaped, S shaped. nasal cavity on the concave side of
the septum will be wider and may show compensatory
hypertrophy of turbinates.
2) Anterior Dislocation: seen on tilting the patients head
backwards.
3) Spurs: shelf like projection at the junction of bone and
cartilage. may predispose for epistaxis and headache.
4) Thickening: it may be due to organized haematoma or
over-riding of dislocated septal fragments
5) impacted septum-despite decongestants

36. DEVIATED NASAL SEPTUM-types

37. Mladina classification for nasal septal
deviation
• Type 1- U/L vertical ridge in the valve region
• Type 2- same as type 1 but more severe obstrution n disturbance of
nasal valve
• Type3- U/L vertical ridge at d level of head of middle turbinate
• Type 4- combination of type3 wid either type ½
• Type 5- HZ septal crest in contrast wid lateral nasal wall
• Type 6- prominent maxillary crest C/L to deviation wid a septal crest
on d deviated side
• Type 7- combination of previously described septal deformity types

38. Clinical features
• Nasal obstruction: the most common symptom mainly on side
of DNS,C/L paradoxical nasal obstruction due to turbinate
hypertrophy may be seen
• Headache-contact with lateral wall sluders neuralgia,sinusitis
• Recurrent attacks of cold due to sinusitis
• Epistaxis-stretched mucosa on DNS-dry crusting n bleeding on
removal-stretched blood vessels over spur
• Anosmia/hyposmia-in high DNS
• External deformity
• Middle ear infection

39. Clinical features
• Cottle’s test: used in nasal obstruction due to
abnormality of nasal valve. In this test cheek is
drawn laterally while the patient breathes
quietly. If the nasal airway improves on test
side the test is positive and indicates
abnormality of nasal valve

40. Cottle’s test

41. SEQUELAE
• SINUSITIS
• MOUTH BREATHING
• ATROPHIC RHINITIS AND MYIASIS
• OTITIS MEDIA

42. Differential diagnosis
• Polyps
• Septal haematoma
• Hypertrophied turbinates

43. History of septoplasty
• Edwin smith papyrus
treating broken nose by placing 2 plugs of linen coated wid grease& ext packing
wid stiff rolls of linen
• Bosworth opeartion (late 19th)
deviated part of septum amputed wid mucosa on convex side
• Asch (1899)- full thickness cruciate incision on septal cartilage
• Freer (1902) -SMR of total septal cartilage
• Killian (1904) -SMR wid preservation of dorsal&caudal portion of cartilage
• Metzenbaum (1929)-swinging door technique for caudal dislocation
• Peer (1937)-removal of caudal septum n replacement after its alterartion
• Cottle (1948)-maxilla –premaxilla septoplasty

44. Preoperative assessment
 History
1. Allergies
2. Nasal obstruction (unilateral/bilateral, constant/intermittent, seasonal)
3. Bilateral symptoms that change in severity (mucosal disease)
4. Constant obstruction (fixed structural abnormality)
5. Presence of epistaxis or rhinorrhea
6. Prior nasal surgery
7. Medication history (especially vasoconstrictive sprays, OC’s)
8. Trauma
9. Symptoms (crusting, dry mouth, frequent sore throats, sinus problems)

45. Anosmia/hyposmia
 University of Pennsylvania Smell Identification
Test (UPSIT)
 Help identify malingering and gross degree of
impairment
 34% of patients scored lower postoperatively after
septal surgery
 66% improved or were unchanged

46. Rhinomanometry
 Anterior rhinomanometry
 Posterior rhinomanometry
 Pernasal rhinomanometry
 Objective information regarding respiratory
function
 Quantifies nasal air flow and pressure
 Nasal resistance (pressure/flow)

47. Acoustic rhinomanometry
 Measures the cross-
sectional area of the
nasal cavity as a
function of distance
from the nostril
 Sound generator, wave
tube, microphone, and
a computer

48. Optimizing acoustic rhinomanometry
 Must form an acoustic seal with wave tube
without distorting the nasal tip
 Results represent cross sectional area as a
function of distance (cm) from end of
nosepiece
 Does not detail shape of the airway, cannot
provide information on nasal airway resistance

49. Physical exam
• External appearance of nose
• Mouth breather
• Adenoid facies (maxillary hypoplasia)
• Location of deviation
• Tip support
• Nasal valve
• Remove all crusts (? Underlying perforation,
exophytic lesion, etc)
• Any abnormal crusts, ulcerations, or polypoid
changes should delay elective surgery for
possible underlying systemic condition
• Examine with vasoconstrictor, endoscope

50. Goals of surgery
 Exposure of the pathologic portion of septum
 Removal or reconstruction of the defective
portions
 Preserve nasal mucosa and lining
 Prevent external deformity of patient

51. Anaesthesia
• Lignocaine 2% wid epinephrine 1/100,000
• Solution injected subperichondrially (not used only as a hemostatic
agent but for hydrodissection-with pressure lifting the mucosa and
perichondrium from cartilage
• Performed in anterior to posterior direction and d mucosa should
blanch as injection proceeds
• Injected bilaterally
• more the time taken for infillteration less is the time rqrd for Sx

52.  You inject lidocaine with epinephrine and the patient becomes
tachycardic, hypotensive, and syncope…
 Vasovagal?, Allergic Reaction to PABA?, Intravascular Injection of
Epinephrine?
 Vasovagal-Bradycardic, Cool skin, Hypotensive, Impending sense of doom
 Allergic Reaction-Tachycardic, Hypotensive, Flushed and warm skin
 Intravascular Epinephrine-Tachycardic (from epinephrine), Hypotensive
from impaired ventricular filling of heart, Peripheral Vasodilation
(depending on the dose) can occur

53. Incisions
 Kilian incision
 Preserves projection the best
 Should not be too far posterior (difficult to close)
 Hemitransfixion incision
 Full transfixion incision
 High and Low transfixion incision
 Open rhinoplasty incision

55. Technique
 Classic Submucosal Technique
 Scoring
 Morselization
 Sutures
 Swinging door
 Removal and replacement

56. Treatment- surgery
• Submucous resection of nasal septum (SMR)
It is generally done in adults
It consists of elevating mucoperichondrial and
mucoperiosteal flap on either side of the
septum, removing the deflected parts of bony
and cartilagenous septum and then
repositioning the flaps

57. SMR
• Indications
 Deviated nasal septum causing nasal obstruction and
recurrent headaches
 Deviated nasal septum causing obstruction to ventilation of
paranasal sinuses and middle ear resulting in recurrent
infections
 Recurrent epistaxis from septal spur
 As a part of septorhinoplasty
 Harvesting cartilage graft for tympanoplasty and
rhinoplasty
 As an approach to surgeries of sphenoidal sinus, vidian
nerve and pituitary gland

58. SMR
• Contraindications
Acute URTI
Patient below 17 yrs of age
Bleeding disorders
Uncontrolled hypertension and diabetes
mellitus

59. SMR
• Anesthesia - Local anesthesia/ general
anesthesia
• Positioning: reclining position with head end of
the table raised

60. SMR - STEPS
• 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

61. SMR – STEPS (cont…)
• 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 ( L-struts)
• Nasal packing

62. SMR – STEPS

63. Keystone areas
 Preserve along bony
cartilaginous junction
 Preserve along nasal floor
 Diagram showing area of L
SHAPED STRUT cartilage
preserved

64. Submucous resection limitations
and comlications
 Caudal end deformities are not addressed
 Poor access to nasal spine
 Dorsal deformities not addressed
 Saddle back defomity
 Septal hematoma
 Collopse of nasal tip n columella
 Nasal obstruction
 Mucosal tear
 TSS
 Septal perforation
 Cartilage n bone may have memory to return to original
deformed position

65. Reconstitution
 Morselized cartilage replaced between flaps
 Less risk of septal perforation
 Future source of cartilage for rhinoplasty and
easier dissection

66. Scoring the cartilage
 Which side do you score
the cartilage on,
concave or convex?

67. Deviated caudal septum

69. Eliminate all posterior
bony attachments to
mobilize the anterior
septum

70. Shift caudal margin
& inferior margin to
opposite side of the
Maxillary spine

71. Caudal margin &
Inferior margin
to the left of the
maxillary spine

72. Eliminate all posterior
bony attachments to
mobilize the anterior
septum

73. Shift caudal margin
& inferior margin to
opposite side of the
Maxillary spine

74. CONSIDER RELAXING
INCISIONS ON CAUDAL
MARGIN

75. 1.Anterior septum
separated from
Vomer and Ethmoid

76. Maxillary Spine
1.Anterior septum
separated from
Vomer and Ethmoid

77. Maxillary Spine
1.
2.
Anterior septum
separated from
Vomer and Ethmoid

78. Maxillary Spine
1.
2. 3.
Anterior septum
separated from
Vomer and Ethmoid

79. Maxillary Spine
1.
2. 3.
Anterior septum
separated from
Vomer and Ethmoid Anterior septum
to midline

80. complications
• Bleeding
• Septal haematoma
• Damage to surrounding structures
• Septal abscess
• Septal Perforation
• Depression of bridge
• Retraction of columella
• Synichae
• Flapping septum
• Infection- sinus and middle ear
• CSF rhinorrhoea

81. Cottle’s line
• A vertical line between the
nasal process of frontal
bone and nasal spine of
maxillary crest. it divides
septum into anterior and
posterior segments

82. Septoplasty
• It is a conservative approach to septal surgery as much of the septal
framework is retained
• Indications:
 Deviated nasal septum causing nasal obstruction and recurrent
headaches
 Deviated nasal septum causing obstruction to ventilation of
paranasal sinuses and middle ear resulting in recurrent infections
 Recurrent epistaxis from septal spur
 As a part of septorhinoplasty
 As an approach to surgeries of sphenoidal sinus, vidian nerve and
pituitary gland

83. Septoplasty (cont…)
• Contraindications
Acute URTI
Bleeding disorders
Uncontrolled hypertension and diabetes
mellitus

84. Septoplasty (cont…)
• Anesthesia: local or general anesthesia
• Position: same as SMR
• Steps :
 Infiltration
 Incision: Freer’s incision– a unilateral hemitransfixation
incision at the caudal border of the septum
 Exposure: the mucoperichondrial and mucoperiosteal
flap is elevated on only one side

85. Septoplasty (cont…)
Separate septal cartilage from vomer and ethmoid
plate
Inferior strip of cartilage is removed
Correct the bony septum by removing deformed parts
Minor deviations of cartilage are corrected by criss
cross incision which breaks spring action of cartilage
Nasal packing

86. Post-operative complications
• Bleeding
• Septal haematoma
• Saddle nose
• Damage to surrounding structures
• Septal abscess
• Septal Perforation
• Depression of bridge
• Retraction of columella
• Synechiae
• Persistent deviation
• Infection- sinus and middle ear
• CSF rhinorrhoea
• Toxic shock syndrome

87. Differences between SMR and septoplasty
SMR
1. Radical surgery
2. Not done in children
3. Killian’s incision
4. Flaps elevated on both sides
5. Most of cartilage removed
6. Caudal dislocation not corrected
7. Perforation chance higher
8. Post operative saddling may be
present
9. Revision surgery difficult
10. Rhinoplasty incision cant combine
11. Cartilage graft can be harvested
Septoplasty
1. Conservative surgery
2. Can be done in children
3. Freer’s incision
4. Flap elevated on concave side only
5. Most of cartilage preserved
6. Caudal dislocation corrected
7. Perforation rare
8. Post operative deformity absent
9. Revision surgery easier
10. Can combine
11. Cannot be harvested

88. ENDOSCOPIC SEPTOPLASTY
• Described by LANZA and STAMMBERGER
ADVANTAGES :
• Minimally invasive
• Better for treatment of isolated spurs
• Improved access to deviation posterior to septal perforation
• Better assessment of relationship b/w septum n middle turbinate
• Possible to see d separation of collagenous fibres connecting the
perichondrium and periosteum to underlying bone and cartilage
• Can be used as a teaching tool for residents
• mucosal disruptions are recognized immediately

89. Procedure
• Infilteration is given
• The nasal cavity is examined with a 0 degree
endoscope to see location of deviation and spur
• Rest of the steps are same as conventional
septoplasty

90. Directed septoplasty
• This approach is useful for managing isolated spurs in
absence of larger septal deviations
• HZ incision is made over the apex of spur,mucosal
flaps elevated in superior and inferior direction
• Spur incised using microdebrider or by traditional
septal transfixion with resection of spurring
cartilage/bone.
• Flaps redrapped to minimize exposure of raw mucosa
• Advantage :limited dissection and quicker post op
healing

91. Complications
• Major complications are rare
• Minor complications include epistaxis. Septal
hematoma, injury to nasopalantine nerve wid dental
numbness, scarring,perforation and CSF leak are rare
complications.

92. Paediatric septoplasy
Absolute indications:
• Septal abscess
• Septal haematoma
• Severe deformity secondary to acute nasal fracture
• Dermoid cyst
• Cleft lip nose

93. • A child coming wid nasal obstructions should be properly evaluated
very rarely cause will be septal deviation alone
Factors contributing are:
• Congenital nasal mass(dermoid,encephalocele,glioma)
• Nasal polyp
• Choanal atresia
• Foreign body
• Septal hematoma
• Adenoid hypertrophy
• Reversible obstruction (acut URTI,chronic sinusitis,allergic
inflammation)
• Isolated spur
• Turbinate hypertrophy
• Deviated septum
• Midface hypoplasia

94. Nasal septal perforation
Etiology :
 Traumatic - post surgical, habitual nose picking, cauterization of septum with
chemicals or galvano-cautery for epistaxis
 Pathological perforation
a) Septal abscess
b) Nasal myasis
c) Rhinolith or neglected foreign body
d) Chronic granulomatous conditions like TB, lupus, leprosy, syphilis, wegener’s
 Inhalant irritants- snuff and cocaine irritant, industrial toxins
 Malignancy
 idiopathic

95. Septal Perforation
 History
 Crusting, bleeding, whistling
if perforation is small
 Rhinorrhea and disruption
of lamellar flow if
perforation is large
 Pain signifies chondritis
 More anterior the
perforation the more likely
the patient will become
occult

96. Septal Perforation
 Must rule out a chronic inflammatory disease
process, cocaine abuse, granulomatous
process in face of granulation tissue on
perforation

97. Physical Exam
 Crusting on mucosa due to dry
nonlaminar flow, not
necessarily at site of
perforation
 Bleeding at edge of
perforation
 Picture with endoscope and
ruler to assess size of
perforation

98. What tests do I order?
 Nasal cultures for fungal
and bacterial infections
 Skin testing for TB, fungi
and anergy
 VDRL, FTA-Abs, C-ANCA
 Biopsy to rule out
autoimmune process

99. Principle
 Perforation is unlikely to
heal on its own
 More likely to contract
and create a larger
opening

100. Medical Therapy
 Petroleum based ointments
 Antiseptic wash per
Fairbanks (1 teaspoon salt
in warm water delivered by
Water-Pik device +/-
glycerin to moisturize +
boric acid or vinegar)
 Medical button

101. Surgical therapy
 Endonasal repair
 Small perforations
 External approach
 Most perforations less than 2cm
 Tissue expander
 Free flap

103. Nasal septal perforation
• Clinical features
• Whistling sound
• Irritation and crusting
• Epistaxis
• Nasal obstruction

104. Nasal septal perforation
Treatment :
Treat the root cause
Inactive small perforation can be surgically closed
by plastic flaps or septal mucosal flaps
Larger perforations are difficult to close: their
treatment is aimed to keep the nose crust free by
alkaline nasal douch and application of lubricants,
silastic obturator may also be used