NASAL SEPTUM AND ITS DISEASES

MUNEER

ANATOMY
Nasal 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 ethmoid Vomer Large septal cartilage wedged between the above two bones anteriorly Minor contributions at peripherycrest 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.

LITTLES AREA / KIESSELBACHS 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 labial And 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.

TREATMENT
Early 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.

COMPLICATIONS
Septum 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

TRAUMA
A 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 DNS
ANTERIOR 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 FEATURES
1. 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

TREATMENT
Submucous 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 HAEMATOMA
AETIOLOGY-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

TREATMENT
Small haematomas can be aspirated Larger heamatomas are incised and drained Systemic antibiotics

COMPLICATIONS
Septal haematoma , if not drained may organise into fibrous tissue leading to permanently thickened septum If secondary infection occursresult in septal abscess with necrosis of cartilage

SEPTAL ABSCESS
AETIOLOGY-Result from secondary
infection of Septal haematomait 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.

TREATMENT
Abscess should be drained Pus and necrosed tissue should be removed by suction Systemic antibiotics for at least 10 days

COMPLICATIONS
septal perforation meningitis cavernous sinus thrombosis

PERFORATION OF NASAL SEPTUM

Traumatic perforation Pathological perforatuon1.septal abscess 2.nasal myiasis 3.rhinolith 4. chronic granulomatous condition Idiopathic

CLINICAL FEATURES
Whistling sound during inspiration and expiration Obstruction and epistaxis

TRATMENT
Find the cause and treat Biopsy from granulation tissue Small perforation closed surgical by plastic flaps

PISTAXIS

 Bleeding from inside the nose is called epistaxis  Fairly common & seen in all age groups  Presents as an emergency  Epistaxis is a sign & not a disease per se and an attempt should always be made to find any local or constitutional cause

NASAL SEPTUM Internal carotid system a) Anterior ethmoid artery

BLOOD SUPPLY OF NOSE

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

LITTLES 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 Kiesselbachs plexus  Exposed to drying effect of inspiratory current and to finger nail trauma  Usual site for epistaxis in children &young adults Retrocolumellar vein runs vertically downwards behind the columella,crosses floor of nose& joins venous plexus on lateral nasal wall

WOODRUFFS AREA  Vascular 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)LOCALCAUSES

1.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 sarcoma 5 Atmospheric changes : high altitude,sudden decompression(Caissons disease) 6. Deviated nasal septum

2.NASOPHARYNX

1.Adenoiditis 2.Juvenile angiofibroma 3.Malignant tumours b)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 nephritis 5.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,malaria

c)IDIOPATHIC cause not clear SITES OF EPISTAXIS 1.Littles area in 90%of cases 2.Above the level of middle turbinate bleeding often from anterior & posterior ethmoidal vessels 3.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 epistaxis Incidence
Site

Posterior epistaxis Less common Mostly frm posterosuperior part of nasal cavity; often difficult to localise bleeding point After 40 yrs of age Spontaneous;often due to hypertension or arteriosclerosis

More common Mostly from Littles area or anterior part of lateral wall

Age Cause

Mostly occurs in children or young adults Mostly trauma

Bleeding

Usually mild,can be easily Bleeding is severe,requires controlled by local pressure or hospitalisation;post nasal anterior pack pack often required

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 ,

FIRST AID
 Mostly Bleeding occurs from Littles area & can be controlled by pinching the nose with thumb and index finger for 5 minutes  In Trotters 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 CAUTERISATION  Useful 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 PACKING

In 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 cavity First,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 stopped In some cases ,it has to be kept for 2-3days,then systemic antibiotics should be given to prevent sinus infection &TSS

POSTNASAL PACKING
In case of bleeding posteriorly into throat Postnasal pack is first prepared by tying three silk ties to a piece of gauze rolled into the shape of a cone A rubber catheter is passed through nose &its end brought out from mouth Ends 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 Foleys catheter can also be used instead of postnasal pack Nasal balloons are also available

ENDOSCOPIC CAUTERY Posterior bleeding ponit can sometimes be better located with an endoscope Can be coagulated with suction cautery Local anaesthesia with sedation may be required ELEVATION OF MUCOPERICHONDRIAL FLAP & SMR OPERATION In 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 VESSELS
a)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 nose c)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

 Make 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&respiration  Maintain haemodynamics.Blood transfusion may be required  Antibiotics 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

GENERAL MEASURES IN EPISTAXIS

HEREDITARY HAEMORRHAGIC TELANGECTASIA  Occurs on anterior part of nasal septum & is the cause of recurrent bleeding  Can be treated using laser  Procedure maybe repeated ,as telangectasia recurs in surrounding mucosa  Some cases require septodermoplasty where anterior part of septal mucosa is excised and replaced by a split skin graft

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