Dr. Sudeep K.C.

 Columellar septum -formed of columella containing the medial crura of alar cartilages united together by fibrous tissue and covered on either side by skin.  Membranous septum- it consists of double layer of skin with no bony or cartilaginous support. It lies between the columella and the caudal border of septal cartilage. Both columellar and membranous parts are freely movable from side to side.

 Septum proper- it consists of osetocartilaginous framework,covered with nasal mucos membrane.It consists of ◦ The perpendicular plate of ethmoid ◦ The vomer and ◦ A large septal cartilage wedged between the above two bones anteriorly.  other bones which make minor contributions at the periphery are : crest of nasal bones, nasal spine of frontal bone, rostrum of sphenoid, crest of palatine bones and the crest maxilla, and the anterior nasal spine of maxilla.

 Septal cartilage not only forms a partition between the right and left nasal cavities but also provides support to the tip & left nasal cavities but also provides support to the tip and dorsum of cartilaginous part of nose. Its destruction eg. In septal abscess, injuries, tuberculosis or excessive removal during septal surgery, leads to depression of lower part of nose and drooping of nasal tip.

 INTERNAL CAROTID SYSTEM ◦ Anterior ethmoidal artery ◦ Posterior ethmoidal artery  EXTERNAL CAROTID SYSTEM ◦ Sphenopalatine artery(branch of maxillary artery), gives nasopalatine and posterior nasal septal branches. ◦ Septal branch of greater palatine artery (branch of maxillary artery)\ ◦ Septal branch of superior labial artery( br of facial artery) Branches of opthalmic artery.

 LITTLE’S AREA OR KIESSELBACH’S PLEXUS

 Trauma on the nose from front, side or below can result in injuries to nasal septum. Fracture of septal cartilage or its dislocation from vomerine groove can result from trauma to lower nose.  Septal injuries with mucosal tear  profuse epistaxis.  While with intact mucosa result in septal haematoma.

 “jarjaway” fracture  blows from front it starts just above anterior nasal spine and runs horizontally backwards.  “chevallet” fracture results from blows from below ; it runs vertically from anterior nasal spine upwards to junction of bony and cartilaginous dorsum of nose.

 Early recognition and treatment of septal injuries is essential.  Haematomas should be drained.  Discolated or fractured septal fragments repositioned and supported between mucoperichondrial flaps with sutures and nasal packing. COMPLICATIONS  Deviation of cartilaginous nose, or asymmetry of nasal tip, columella or nostril.

AETIOLOGY:  1) Trauma: A lateral blow on nose may cause displacement of septal cartilage. A crushing blow from front may cause buckling twisting fractures and duplication of nasal septum.  2)Racial factors:  3)Hereditary factors:

4) Developmental error: Nasal septum descends to meet the two halves of developing palate in midline. Unequal growth between palate and base of skull may cause buckling of nasal septum. TYPES OF DNS: 1) Anterior dislocation : 2) C-shaped deformity: 3) S-shaped deformity: 4) Spurs: 5) Thickening:

 1) Nasal obstruction: may be unilateral or bilateral.  Cottle test: is used in nasal obstruction due to abnormality of nasal valve.  2)Headache: deviated septum specially spur may press on lateral wall of nose causing headache.  3)Sinusitis: deviated septum may obstruct sinus ostia resulting in poor ventilation.  4)Epistaxis : Mucosa over deviated part is exposed to drying effect of air currents that forms crust which when removed will cause bleeding.

5)Anosmia :failure of inspired air to reach the olfactory region may result in total or partial loss of sense of smell. 6)External deformity: 7) Middle ear infection: TREATMENT:  Submucous resection operation(SMR):it consists of elevating mucoperichondrial and mucoperiosteal flaps on either side of septum, removing deflected parts of bony and cartilaginous septum, then repositioning the flaps.

Septoplasty: It is conservative approach. Much more septal framework is preserved and only most deviated parts is removed. Mucoperichondrial/periosteal flap is raised only on one side of septum retaining the attachment and blood supply on the other.

 It is collection of blood under perichondrium or periosteum of nasal septum. often results from nasal trauma or septal surgery or in bleeding disorders. CLINICAL FEATURES:  Bilateral nasal obstruction.  Associated frontal headache.  Sense of pressure over nasal bridge.

EXAMINATION:  It reveals smooth rounded swelling of septum in both side. on palpation mass to be soft and fluctuant. TREATMENT:  Small haematoma  aspirated with wide bore needle.  Larger haematoma  incised and drained. following drainage nasal packing to be done both sides to prevent reaccumulation.  Antibiotics to prevent septal abscess.

COMPLICATIONS:  If not drained,may organise into fibrous tissue leading to permanently thickened septum.  If secondary infection occurs, it results in septal abscess with necrosis of cartilage and depression of nasal dorsum.

 Aetiology:  Mostly by secondary infection of septal haematoma.  Occasionally by furuncle of nose.  CLINICAL FEATURES:  Severe B/L nasal obstruction with pain and tenderness over the bridge of nose.  Fever with chills and frontal headache.  Skin over nose may be red and swollen.

It reveals -smooth B/L swelling of nasal septum. -septal mucosa is often congested. - submandibular lymphnodes may also be enlarged and tender. TREATMENT: Abscess should be drained by giving inscion on most dependent part.pus and necrosed pieces of cartilage are removed.antibiotics given for 10 days.

 COMPLICATIONS:  Necrosis of septal cartilage results in depression of cartilaginous dorsum.  Necrosis of septal flaps may lead to sepatal perforation.

AETIOLOGY: 1) Traumatic perforations: it is most common cause. 2)Pathological perforations : it can be caused by septal abscess, rhinolith or neglected foreign body causing pressure necrosis, tuberculosis, leprosy, syphillis and wegener’s granuloma. 3) Idiopathic:

CLINICAL FEATURES:  Small anterior perforations cause whistling sound during inspiration and expiration.  Larger perforation develop crust which obstruct nose or cause severe epistaxis when removed.

TREATMENT:  Small perforations can be surgically closed by flaps.  Larger perforations are difficult to close.  Their treatment is aimed to keep nose crust free, by alkaline nasal douches and application of ointment.