NASAL SEPTUM NASAL SEPTUM AND ITS AND ITS

DISEASESDISEASESMUNEERMUNEER

NASAL SEPTUM NASAL SEPTUM AND ITS AND ITS

DISEASESDISEASESMUNEERMUNEER

ANATOMYNasal septum consists of 3 parts 1. Columellar septum- formed of

columella, containing medial crura of alar cartilage.

2. Membranous septum- consists of double layer of skin, no bony supports.

3. Septum proper- consists of osteocartilaginous framework covered with nasal mucus membrane.

Constituents of septum proper

Perpendicular plate of ethmoidVomerLarge septal cartilage wedged between the

above two bones anteriorlyMinor contributions at periphery- crest of nasal bone nasal spine of frontal bone rostrum of sphenoid crest of palatine bone and maxilla

Septal cartilage not only forms a partition between right and left nasal cavity but also provides support to tip and dorsum of cartilaginous part of nose.

Its destruction, Eg:- in Septal abscess, injuries, Tb leads to depression of lower part of nose and drooping of nasal tip.

Septal cartilage lies in the vomerine groove and during trauma it may get dislocated causing caudal Septal deviation.

LITTLE’S AREA / KIESSELBACH’S PLEXUS

Vascular area in the anteroinferior part of nasal septum just above the vestibule.

Arteries forming the plexus include septal branch of sphenopalatine septal branch of greater palatine septal branch of superior labialAnd their corresponding veins form an

anastmosis at this site.Common site for epistaxis, also a site for

origin of ‘bleeding polyps’

FRACTURES OF NASAL SEPTUM

Etiopathogenesis : trauma to nose may cause the septum to buckle on itself, fracture vertically, horizontally or be crushed to pieces.

The fractural pieces may overlap on each other or project into the cavity through mucosal tears.

Septal injuries with mucosal tears can cause profuse epistaxis while those with intact mucosa results in septal haematoma which when prolonged can lead to septal cartilege absorption and saddle nose deformity.

JARJAWAY FRACTURE-fracture of nasal septum resulting from blows from front; start just above ANS and runs horizontally backwards.

CHEVALLET FRACTURE- resulting from blows from below.

TREATMENTEarly recognition and treatment

of septal injuries is essential.Hematomas should be drained.Dislocated or fractured septal

fragments should be repositioned and supported with mattress sutures and nasal packings.

COMPLICATIONSSeptum is important in

supporting the lower part of external nose.

If injuries are ignored they would result in deviation of the cartilaginous nose.

DEVIATED NASAL SEPTUM

AETIOLOGY• TRAUMA.• DEVELOPMENTAL ERROR• RACIAL FACTOR• HEREDITARY FACTORS

TRAUMAA lateral blow on nose –

displacement of Septal cartilage from vomerine groove and maxillary crest..

Blow from front –fracture, buckling, twisting, fractures…

Trauma during birth

Developmental error

Nasal septum is formed by two tectoseptal process and descent to meet

Uneqal growth blw palate and base of skull may cause buckling of nasal septum

In mouth breathers and adenoid hypertrophy, the palate is often highly arched and septum is deviated

Also seen in cleft palate and lip

• RACIAL FACTORS- negros rarely affected

• HERIDITARY FACTORS- several members of same family

TYPES OF DNSANTERIOR DISLOCATION- Septal

cartilage may dislocated into one nasal chamber, better appreciated by looking at the base of nose

C –SHAPED DEFORMITY- septum deviated in a simple curve to one side. Nasal chamber on the concave side of ns will be wider and show hypertrophy

S –SHAPED DEFORMITY- S shaped curve and may causes bilateral nasal obstruction

SPURS-shelf like projection found at the junction of bone and cartilage.. A spur may press on lateral wall and give rise to headache, and cause repeated epistaxis from stretched vessels

THICKENING-due to organized haematoma

CLINICAL FEATURES1. NASAL OBSRTUCTION-depending on the

type of septal deformity, obstruction may be unilateral or bilateral

High septal deviation cause nasal obstruction more than lower ones

• COTTLE TEST• HEAD ACHE.• SINUSITIS• EPISTAXIS• ANOSMIA• EXTERNAL DEFORMITY• MIDDLE EAR INFECTION

TREATMENTSubmucous resection operation- generally

done in adults under LA, elevation of mucoperichondreal and mucoperiosteal flaps on either side of septum.

Septoplasty-conservative approach to septal surgery.Most deviated parts are removed and retain the attachment and blood supply.

Septal surgery is usually done after the age 17.

SEPTAL HAEMATOMAAETIOLOGY-IT is the collection of blood

under perichondrium or periosteum of the nasal septum. It often results from nasal trauma or septal surgery. Spontaneously occurs in bleeding disorders

CLINICAL FEATURES-bilateral nasal obstruction , associated with frontal headache and a sense of pressure over the nasal bridge.

Examination reveals smooth rounded swelling of the septum.. Palpation show the mass to be soft

TREATMENTSmall haematomas can be

aspiratedLarger heamatomas are incised

and drainedSystemic antibiotics

COMPLICATIONS• Septal haematoma , if not

drained may organise into fibrous tissue leading to permanently thickened septum

• If secondary infection occurs-result in septal abscess with necrosis of cartilage

SEPTAL ABSCESSAETIOLOGY-Result from secondary

infection of Septal haematoma…it follows furuncle of the nose

CLINICAL FEATURES- Severe bilateral nasal obstruction with pain and tenderness over the bridge of nose ,fever ,frontal headache, skin over the nose may be red or swollen enlarged Submandibular lymph nodes.

TREATMENTAbscess should be drainedPus and necrosed tissue should

be removed by suctionSystemic antibiotics for at least

10 days

COMPLICATIONS•septal perforation•meningitis•cavernous sinus thrombosis

PERFORATION OF NASAL SEPTUM

Traumatic perforationPathological perforatuon- 1.septal abscess 2.nasal myiasis 3.rhinolith 4. chronic granulomatous condition Idiopathic

CLINICAL FEATURES

Whistling sound during inspiration and expiration

Obstruction and epistaxis

TRATMENTFind the cause and treatBiopsy from granulation tissueSmall perforation closed

surgical by plastic flaps

EPISTAXIS

Bleeding from inside the nose is called epistaxis

Fairly common & seen in all age groups

Presents as an emergencyEpistaxis is a sign & not a disease

per se and an attempt should always be made to find any local or constitutional cause

BLOOD SUPPLY OF NOSENASAL SEPTUM Internal carotid system a) Anterior ethmoid artery

b) Posterior ethmoid artery -branches of ophthalmic artery

External carotid system a) Sphenopalatine artery (branch of maxillary

artery) gives nasopalatine & posterior medial nasal branches

b)Septal branch of greater palatine artery(Br. ofmaxillary artery)

c)Septal brnch of superior labial artery(Br. Of facial artery)

LATERAL WALL Internal carotid system a)Anterior ethmoidal

b)Posterior ethmoidal -branches of ophthalmic artery

External carotid system a)Posterior lateral nasal branches →from

sphenopalatine artery b)Greater palatine artery →from maxillary artery c)Nasal branch of anterior superior dental→frm

maxillary artery d)Branches of facial artery to nasal vestibule

LITTLE’S AREA Situated in the anterior inferior part of nasal

septum,just above vestibule Four arteries-ant. Ethmoidal,septal brnch of

sphenopalatine,septal brnch of superior labial&greater palatine anastomose to form vascular plexus –Kiesselbach’s plexus

Exposed to drying effect of inspiratory current and to finger nail trauma

Usual site for epistaxis in children &young adultsRetrocolumellar vein –runs vertically downwards

behind the columella,crosses floor of nose& joins venous plexus on lateral nasal wall

-is a common site of venous bleeding in young people

WOODRUFF’S AREAVascular area situated under the posterior

end of inferior turbinate where sphenopalatine artery anastomoses with posterior pharyngeal artery

Posterior epistaxis may occur in this area

CAUSES OF EPISTAXIS May be divided into a)Local,in the nose or nasopharynx b)General c)Idiopathic

a)LOCALCAUSES1.NOSE 1.Trauma:Fingernail trauma,injuries to

nose,intranasal surgery,fractures ofmiddlethird of face& base of skull,hard blowing of nose , violent sneeze

2.Infections: Acute – viral rhinitis,nasal diphtheria,acute sinusitis Chronic –All crust forming diseases e.g. atrophic

rhinitis,rhinitis sicca.tuberculosis,syphilisseptal perforation,granlomatouslesion of the nose e.g. rhinosporidiosis

3.Foreign bodies: Nonliving-any neglected foreign body,rhinolith Living-maggots leeches 4.Neoplasms of nose& paranasal sinuses Benign : Hemangioma,papilloma Malignant :Carcinoma or sarcoma5 Atmospheric changes : high altitude,sudden

decompression(Caisson’s disease)6. Deviated nasal septum

2.NASOPHARYNX

1.Adenoiditis 2.Juvenile angiofibroma 3.Malignant tumoursb)GENERAL CAUSES 1.Cardiovascular system –

Hypertension,arteriosclerosis,mitral stenosis 2.Disorders of blood & bld vessels – Aplastic

anaemia ,leukaemia,thrombocytopenic & vascular purpura,haemophilia,Christmasdisease,Scurvy,vitamin k deficiency

3.Liver disease -Hepatic cirrhosis 4.Kidney disease – chronic nephritis5.Drugs –excessive use of salicylates &other

analgesics,anticoagulant therapy (for heart disease)6.Mediastenal compression -tumours of

mediastinum(raised venous presure in nose)7.Acute general infection - measles ,infuenza,chicken

pox,rheumatic fever,pneumonia,IMN,typhoid,malaria8Vicarious menstruation (epistaxis occuring at the time of

menstruation)

c)IDIOPATHIC – cause not clearSITES OF EPISTAXIS 1.Little’s area –in 90%of cases 2.Above the level of middle turbinate –bleeding

often from anterior & posterior ethmoidal vessels3.Below the level of middle turbinate –bleeding

is from branches of sphenopalatine artery.it may be hidden,lying lateral to middle or inferior turbinate

4.Posterior part of nasal cavity –here blood flows directly into the pharynx

5.Diffuse –both from septum &lateral nasal wall.Often seen in general systemic disorders &blood dyscracias

6.Nasopharynx

CLASSIFICATION OF EPISTAXIS Anterior Epistaxis When blood flows out from the front

of the nose with patient in sitting position

Posterior Epistaxis Mainly the blood flows backwardsinto

the throat.patient may swallow it-”coffee coloured vomitus”

Differences between anterior & posterior epistaxis

Anterior epistaxisAnterior epistaxis Posterior epistaxisPosterior epistaxis

IncidencIncidencee

More commonMore common Less commonLess common

SiteSite Mostly from Little’s Mostly from Little’s area or anterior part of area or anterior part of lateral walllateral wall

Mostly frm Mostly frm posterosuperior part posterosuperior part of nasal cavity; often of nasal cavity; often difficult to localise difficult to localise bleeding pointbleeding point

AgeAge Mostly occurs in Mostly occurs in children or young children or young adultsadults

After 40 yrs of ageAfter 40 yrs of age

CauseCause Mostly traumaMostly trauma Spontaneous;often Spontaneous;often due to hypertension due to hypertension or arteriosclerosisor arteriosclerosis

BleedinBleedingg

Usually mild,can be Usually mild,can be easily controlled by easily controlled by local pressure or local pressure or anterior packanterior pack

Bleeding is Bleeding is severe,requires severe,requires hospitalisation;post hospitalisation;post nasal pack often nasal pack often requiredrequired

MANAGEMENT

In any case of epistaxis it is important to know; 1. Mode of onset – spontaneous or fingernail trauma 2. Duration & frequency of bleeding 3. Amount of blood loss 4.Side of nose from where bleeding is occuring 5.Whether bleeding is of anterior or posterior type 6.History of known medical ailment like hypertension 7.Any known bleeding tendency in patient or family 8.History of drug intake(analgesics , anticoagulants )

FIRST AIDMostly Bleeding occurs from Little’s area &

can be controlled by pinching the nose with thumb and index finger for 5 minutes

In Trotter’s method patient is made to sit,leaning forward over a basin to spit any blood& breathe quietly from mouth. Cold compress should be applied to nose to cause reflex vasoconstriction

CAUTERISATIONUseful in anterior epistaxis wherebleeding

point can be located.Area is anaesthetised & bleeding point is

cauterised with a bead of silvernitrate or coagulated with electrocautery

ANTERIOR NASAL PACKINGIn cases of active anteriorepistaxis,nose is first cleared

of blood clots by suction&attempts are made to localise the bleeding site

If bleeding is profuse and/or site of bleeding is difficult to localise, anterior packing should be done

Ribbon gauze soaked with liquid paraffin is used 1 metre gauze (2.5cm wide in adults &12mm in children)

is required in each nasal cavityFirst,few cm of gauze are folded upon itself and inserted

along the floor& then whole nasal cavity is packed tightly by layering from floor to roof& from before backwards

Packing can be done in vertical layers or horrizontal layers

Pack can be removed after 24hrs if bleeding has stoppedIn some cases ,it has to be kept for 2-3days,then

systemic antibiotics should be given to prevent sinus infection &TSS

POSTNASAL PACKINGIn case of bleeding posteriorly into throatPostnasal pack is first prepared by tying three silk ties to a

piece of gauze rolled into the shape of a coneA rubber catheter is passed through nose &its end brought

out from mouthEnds of silk threads are tied to it and catheter is withdrawn

from nose.Pack which follows silk thread is guided to nasopharynx

with index finger.Anterior nasal cavity is now packed& silk threads are tied over a dental roll.third silk thread is cut short & allowed to hang from oropharynx (for easy removal of pack later)

Patients requiring postnasal pack should always be hospitalised

Foley’s catheter can also be used instead of postnasal packNasal balloons are also available

ENDOSCOPIC CAUTERYPosterior bleeding ponit can sometimes be better

located with an endoscopeCan be coagulated with suction cauteryLocal anaesthesia with sedation may be requiredELEVATION OF MUCOPERICHONDRIAL FLAP

& SMR OPERATIONIn case of persistent or recurrent bleeds from the

septum,just elevation of mucoperichondrial flap &then repositioning it backhelps to cause fibrosis &constrict blood vessels

SMR operation can be done to achieve the same result or remove any septal spur (can be a cause of epistaxis)

LIGATION OF VESSELSa)External carotid –when conservative measures have

failed,ligation of external carotid artery can be done above the origin of superior thyroid artery.

It is avoided these days in favourof embolisation or ligation of more peripheral branches

b)Maxillary artery –in cases of uncontrollable posterior epistaxis.

Approach is via Caldwell-Luc operation Posterior wall of maxillary sinus is removed &maxillary

artery or its branches are blocked by applying clips Endoscopic ligation of maxillary artery can also be done

through nosec)Ethmoidal arteries –In anterosuperior bleeding,above

middle turbinate(if not controlled by packing)anterior &posterior ethmoidal arteries can be ligated

Vessels are exposed in the medial wall of orbit by an external ethmoid incision

GENERAL MEASURES IN EPISTAXISMake the patient sit up with a backrest&record

any bloodloss taking place through spiting or vomitting

Reassure the patient.Mild sedation should be given

Keep check on pulse,BP&respirationMaintain haemodynamics.Blood transfusion may

be requiredAntibiotics may be given to prevent sinusitis,if

pack is to be kept beyond 24 hrs Intermittent oxygen may be required in patients

with bilateral packs because of increased pulmonary resistence from nasopulmonary reflex

Investigate &treat the patient for any underlying local or general cause

HEREDITARY HAEMORRHAGIC TELANGECTASIA

Occurs on anterior part of nasal septum & is the cause of recurrent bleeding

Can be treated using laserProcedure maybe repeated ,as telangectasia

recurs in surrounding mucosaSome cases require septodermoplasty where

anterior part of septal mucosa is excised and replaced by a split skin graft

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