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
5. Hereditary: in posterior D.N.S.

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

Anterior / caudal dislocation

C - shaped

S - shaped

Nasal septal spur

Thickened & impacted

nasal septum

C-shaped DNS not touching

lateral nasal wall

C-shaped DNS touching

lateral nasal wall

Compensatory turbinate
hypertrophy

Clinical features
1. 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
(Sluders neuralgia), sinusitis

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

Sequelae
Sinusitis
Mouth breathing snoring, pharyngitis
Atrophic rhinitis & myiasis
Otitis media

History of septal
surgeries

 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.

Edwin Smith Papyrus

 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

Gustav Killian

Maurice Cottle

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

Septoplasty

Freers Incision

Cottles 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.

Muco-perichondrial flap
elevation on right side

Anterior + Inferior tunnels

Inferior cartilage strip removal

Dislocation of bony
cartilaginous junction

Muco-periosteal flap
elevation on both sides

Cartilage + Bone removed

Scoring & cross-hatching

Wedge excision & shaving

Anterior nasal packing

Outer nasal packing

Submucosal
Resection

Killians incision

Muco-perichondrial flap
elevation on right side

Cutting of cartilage &

elevation of opposite flap

Excision of septal cartilage

Excision of septal cartilage

Cartilage + Bone removed

Anterior nasal packing

S.M.R.

Septoplasty

Radical surgery

Conservative

Not done below 17 yr

Done after 4 yr

Killians incision

Freers incision

Cannot correct anterior DNS

Can correct

B/L mucoperichondrium elevated

One side only

Radical removal of cartilage

Only inferior strip

Rhinoplasty incision cant combine Can

Revision surgery difficult

Relatively easy

Cartilage graft can be harvested

No

Complications common

Rare

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

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

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.

Septal Haematoma

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

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

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

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

Septal Abscess

Septal abscess

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

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

Saddle nose

Nasal synechia

Perforated
nasal septum

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

7. Idiopathic

Clinical features
Small perforation: whistling sound

during respiration
Large perforation: nasal crusting
nasal obstruction
epistaxis on crust removal

Perforated nasal septum

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.

Nasal mucosal flaps

Nasal mucosal flaps

Sublabial flap

Silastic obturator

Thank You