nasal septal diseases - app.svu.edu.eg
TRANSCRIPT
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NASAL
SEPTAL
DISEASES
VISHNU
NARAYANAN M.R
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ANATOMY OF NASAL SEPTUM
• Consists of three parts
1. Columellar septum
2.Membranous septum
3.Septum proper
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BLOOD SUPPLY OF NASAL SEPTUM
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NERVE SUPPLY OF NASAL SEPTUM
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NASAL SEPTAL DISEASES
Fracture of nasal
septum
Deviated nasal septum
Septalhaemato
ma
Septalabcess
Nasal synechia
Septalperforation
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1.FRACTURES OF NASAL SEPTUM
Aetiopathogenesis
• Trauma
• Fate of septum - buckling
vertical or horizontal fracture
crushed into pieces
• Septal injuries with mucosal tear profuse epistaxis
• Septal injuries without mucosal tear septal hematoma
• Types- 1.Jarjaway fracture
2.Chevallet fracture
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Treatment
• Early recognition and treatment of septal injuries is
essential.
• Haematoma is drained
• Dislocated or fractured septal fragments should be
repositioned and supported between mucoperichondrial
flaps with mattress sutures and nasal packing
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Complications
• deviation of cartilaginous nose
• asymmetry of nasal tip, columella or the nostril
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2.DEVIATED NASAL SEPTUM
Aetiology
1. Trauma
2. Developmental errors
3. Racial factors
4. Hereditary factors
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1. TRAUMA
• A lateral blow on the nose may cause displacement of
septal cartilage from the vomerine groove and maxillary
crest
• A crushing blow from the front may cause buckling ,
twisting ,fractures and crushing of nasal septum
• Trauma during delivery
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2 . DEVELOPMENTAL ERRORS
• Nasal septum is formed by the tectoseptal process which descends to meet the two halves of developing palate in the midline
• During primary and secondary dentition further developments takes place in palate
• Unequal growth between palate and base of skull may cause buckling of nasal septum
• In mouth breathers-high arched palate and DNS
• In cleft palate,cleft lip,dental abnormalities
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3. RACIAL FACTORS
Caucasians are more affected than negroes
4. HEREDITARY FACTORS
Members of same family may have deviated
septum
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Sites of DNS
• Cartilagenous/bony/both
• Anterior/posterior
• High/low
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Types of DNS
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ANTERIOR DISLOCATION
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SEPTAL SPUR
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Effects of DNS
1. Compensatory hypertrophy of turbinates of opposite
side
2. External deformity
3. Impairment of drainage to sinus
4. Secondary atrophic rhinits
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Clinical features
1 . NASAL OBSTRUCTION
• Sites
1. Vestibular
2. At the nasal valve
3. Attic
4. Turbinal
5. Choanal
• Bilateral/unilateral obstruction
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COTTLE TEST
• Used in nasal obstruction due to abnormality of nasal
valve
• In this test ,cheek is drawn laterally while patient
breathes quietly.If the nasal airway improves on test
side,the test is positive and indicates abnormality of
vestibular component of nasal valve
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2. HEADACHE
3. SINUSITIS
4. EPISTAXIS
5. ANOSMIA
6. EXTERNAL DEFORMITY
7. MIDDLE EAR INFECTION
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TREATMENT
• Minor degrees of septal deviation require no treatment
• If produces mechanical nasal obstruction or other
symptoms, an operation is indicated
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1.SUBMUCOUS RESECTION OPERATION
• Generally done in adults under local anaesthesia
• Elevating the mucoperichondrial and mucoperiosteal
flaps on either side of the septal framework by a single
incision made on one side of the septum
• Removing the deflected parts of bony and cartilaginous
septum
• Repositioning the flaps
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2.SEPTOPLASTY
• Conservative surgery
• Only most deviated parts are removed
• Rest of the septal framework is corrected and
repositioned by plastic means.
• Mucoperichondrial or mucoperiosteal flap is generally
raised only in one side of the septum retaining the
attachment and blood supply of the other
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SEPTAL HAEMATOMA
Definition
• Collection of blood under the perichondrium or
periosteum of nasal septum
Aetiology
1. nasal trauma
2. septal surgery
3. bleeding disorders
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Clinical features
• Bilateral nasal obstruction and mouth breathing
• Frontal headache
• Sense of pressure over nasal bridge
• Smooth rounded swelling of the septum in both nasal fossae
• Soft and fluctuant mass felt
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Treatment
• Small haematoma- Aspiration with a wide bore sterile
needle
• Large haematoma-Incised and drained by a small
anteroposterior incision parallel to the nasal floor
• Nose is packed on both sides to prevent reaccumulation
• Antibiotics
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Complications
• Permanently thickened septum
• Septal abscess with necrosis of cartilage and depression
of nasal dorsum
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SEPTAL ABSCESS
Aetiology
• Secondary infection from septal haematoma
• Furuncle of the nose or upper lip
• Acute infection such as typhoid or measles
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Clinical features
• Severe bilateral nasal obstruction with pain and
tenderness over the bridge of nose
• fever with chills and frontal headache
• Skin over the nose -- red and swollen
• smooth bilateral swelling of nasal septum
• Fluctuation elicited
• Septal mucosa -- congested
• Submandibular lymph nodes -- enlarged and tender
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Treatment
• Early drainage
• Incision made in the most dependent parts of the abscess
• A piece of septal mucosa is excised
• Pus and necrosed pieces of cartilages are removed by suction
• Incision reopened daily for 2-3 days
• Systemic antibiotics
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Complications
• Depression of the cartilaginous dorsum in the supratip area
• Septal perforation
• Meningitis and cavernous sinus thrombosis
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PERFORATION OF NASAL SEPTUM
Aetiology
1. Traumatic perforation
• Injury to mucosal flaps during SMR
• cauterization of septum with chemicals
• galvanocautery for epistaxis
• Habitual nose- picking
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2 . Pathologic perforations
• Septal abscess
• Nasal myiasis
• Rhinolith or neglected foreign body
• Chronic granulomatous conditions like Lupus,
tuberculosis, leprosy, syphilis
• Wegener’s granuloma
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3 . Drugs and chemicals
• Prolonged use of steroids in nasal allergy
• Cocaine addicts
• Workers in certain occupations. Eg .chromium
plating,dichromate or soda ash manufacture
or those exposed to arsenic or its compounds
4.Idiopathic
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Clinical features
• Small anterior perforation cause whistling
sound during inspiration or expiration
• Large perforations develop crusts which
obstruct the nose or cause epistaxis when
removed
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Treatment
• Based on cause and size of perforation
• Small perforation--closed by plastic flaps
• Larger perforations
treatment aim -- to keep the nose--crust free
By alkaline nasal douches and application of a
bland ointment
• A thin silastic button can be worn
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NASAL SYNECHIA
Aetiology
• Adhesions between septum and lateral wall
• Adhesions between middle turbinate and lateral wall
• Following nasal surgery and nasal packing
Clinical features
• Nasal obstruction
• Sinusitis and headache
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Treatment
• Excision and release of adhesion
• Dental wax plates/sialistic sheets between 2 surfaces
Prevention
• Proper perioperative cleaning
• Lubrication of nasal pack before insertion
• Use of septal splints following surgery
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