Discuss the clinical features and management of deviated nasal septum.
Clinical features septal deviation:
Nasal obstruction - This is always found on the side of the deviation, and can also be present on the opposite side as a result of hypertrophic changes of the turbinates.
Mucosal changes - The inspiratory air currents are abnormally displaced and frequently gets concentrated on small areas of nasal mucosa, producing excessive drying effect. Crusting will occur and the separation of the crusts often produces ulceration and bleeding. Since the protective mucous layer is lost the resistance to infection is reduced. The mucosa around a septal deviation may become oedematous as a result of Bernouilli's phenomenon. This oedema further increases nasal obstruction.
Neurological changes - Pressure may be exerted by septal deviations on adjacent sensory nerves can produce pain. This was first explained by Sluder and the resultant condition became known as 'the anterior ethmoidal nerve syndrome'.
Sluders neuralgia can be differentiated from head ache due to sinusitis by packing the affected nasal cavity with a roller gauze dipped in 4% xylocaine. Pain
due to sluder's neuralgia gets releived, whereas pain due to sinus infection remains the same.
In addition to these direct neurological effects, reflex changes perhaps may result from septal deformities which affect the nasopulmonary and nasal reflexes.
Symptoms :
The symptoms caused by septal deviations are entirely the result of their effects on nasal function. The dominent symptom being nasal obstruction, but this is rarely severe enough to cause anosmia.
Signs :
Septal deviations are evident on anterior rhinoscopy. This should be done without the use of nasal speculum because the insertion of speculum is sufficient to straighten the nasal septum. When the tip of the nose is lifted septal deviation become evident. Nasal obstruction may also be present on the opposite side (paradoxical nasal obstruction). This is due to the presence of hypertrophied turbinates. If the hypertrophy is limited to turbinate mucosa alone then it will shrink when decongestant drugs are used in the nasal cavity. If the hypertrophy is bony then deconstant drops is useless.
Septal deviations in the region of the nasal valve area cause the greatest obstruction, since this is the narrowest part of the nasal cavity. This can be identified by the cottle test. A positive cottle test will confirm the fact that narrowing is present in the nasal valve area. This is done by asking the patient to pull the cheek outwards and this manuver is supposed to open up the area thus reducing the block. The septum should not be considered in isolation and it is necessary to do a careful examination of the lateral wall of the nasal cavity. When ever sinus complications like sinusitis is suspected due to obstruction to the drainage channel of the sinuses by the deviation xray sinus must be taken.
Septal deviation in new born is associated with asymmetry of the nostrils, an oblique columella and tip which points in the direction which is opposite to the deviation. Most of these patients are diagnosed by the use of Gray's struts. These struts are 4mm wide and 2mm thick and after lubrication, are inserted into the nostrils and then gently pushed backwards along the floor of the nasal cavity, hugging the nasal septum. Normally these struts can be introduced for a distance of 4 - 5 cms, but in cases of septal deviation a frank obstruction is encountered, usually 1 - 2 cms from the nostril.
Cottle has classified septal deviations into three types :
Simple deviations: Here there is mild deviation of nasal septum, there is no nasal obstruction. This is the commonest condition encountered. It needs no treatment.
Obstruction: There is more severe deviation of the nasal septum, which may touch the lateral wall of the nose, but on vasoconstriction the turbinates shrink away from the septum. Hence surgery is not indicated even in these cases.
Impaction: There is marked angulation of the septum with a spur which lies in contact with lateral nasal wall. The space is not increased even on vasoconstriction. Surgery is indicated in these patients.
Management:
If the symptoms caused by deviated nasal septum is causing problems to the patient then it needs to be managed.
Medical management: This is indicated in patients with sinusitis due to deviated nasal septum. Acute sinus
infections and acute exacerbation of chronic sinusitis should be managed by:
Antibiotics: Oral amoxycillin is the drug of choice
Antihistamines: The role of antihisamines is to reduce the secretions from the nasal and sinus mucosal lining,
and reduction of allergic response
Antiinflammatory drug: Ibuprofen in combination with paracetomol is the drug of choice
Nasal decongestant drops: Xylometazoline, or oxymetazoline nasal drops can be used to decongest the
nasal mucosa. These drugs should be administered only for a week otherwise patient is likely to
develop dependence to the drug.
Surgical management: The type of surgery used depends on the type of deviation.
If the deviation lies anterior to the cottle's line (vertical line between the nasal processes of frontal and maxillary bones)
then septoplasty is preferred.
If the deviation lies posterior to the cottle's line then submucosal resection
of septum is preferred. If the septal deviation is associated with external
deviation of the nose, then septorhinoplasty is the treatment of choice.
Anesthesia: Septoplasty / SMR can be performed either under local or general anesthesia.
Local anesthesia:
4% xylocaine is used as topical anesthesia
2% xylocaine is used as infiltration anesthesia
4% xylocaine admixed with 1 in 10,000 units of adrenaline is used.The total amount of 4% xylocaine
used should not exceed 7ml, as this is the highest dose of xylocaine an adult can tolerate without
complications.
Cotton pledgets soaked in 4% xylocaine with adrenaline mixture is used
to pack the nasal cavity. Three packs are used in all.
The first pack is left in the superior meatus to block the anterior ethmoidal nerve
The second pack is placed lateral to the middle turbinate in the middle meatus close
to the posterior end of the middle turbinate to block the sphenopalatine ganglion
The third pack is placed in the floor of the nasal cavity. This blocks the nerves
exiting through the incisive canal.
These packs are left in place atleast for 15 minutes. It causes
1. Anesthesia of the nasal mucosa
2. Shrinks the nasal mucosa
Premedication:
Fortwin and Phenargan are used for premedicating the patient.
The role of premedication is to:
1. To reduce the anxiety level of the patient
2. To reduce pain
3. To dry up the upper airway secretions
4. To cause amnesia
Infiltration:
2% xylocaine with 1 in 80,000 units adrenaline is used. A total of
5 ml of the solution is used.
The nasal septum is infiltrated from its inferior portion on both sides,
The floor of the nasal cavity is also infiltrated on both sides.
The infiltration serves to elevate the septal flap on both sides, reduce bleeding
during surgery, and anesthetizes the surgical area.
Septoplasty:This procedure is preferred to treat anterior deviations of nasal septum.
A Freer's incision is made on the concave side close to the lower border of nasal septum.
Elevation of mucoperichondrium and periosteum is performed, developing anterior and inferior
tunnel on one side. The mucoperichondrium is left attached on one side. Inferior tunnel
is created on the opposite side. The anterior tunnel and the inferior tunnels are connected, thus
freeing the septum. Incision through the periosteum is made over the crest of the maxilla and
vomer. The septal cartilage is separated from the bone, deviated piece of cartialge excised, and
flaps repositioned and sutured.
SMR: is performed to correct posterior deviations. The entire nasal septum is exposed using Killian's incision.
It is made about 5mm above the caudal border of nasal septum. Septal flaps are elevated on both sides. Septal
cartialge is incised to reach the opposite side. The whole septum is exposed and is removed using a Ballanger's swiwel knife.
Flaps are repositioned and sutured using chromic catgut.
These surgical procedures can also be performed under general anesthesia.
Clinical features septal deviation:
Nasal obstruction - This is always found on the side of the deviation, and can also be present on the opposite side as a result of hypertrophic changes of the turbinates.
Mucosal changes - The inspiratory air currents are abnormally displaced and frequently gets concentrated on small areas of nasal mucosa, producing excessive drying effect. Crusting will occur and the separation of the crusts often produces ulceration and bleeding. Since the protective mucous layer is lost the resistance to infection is reduced. The mucosa around a septal deviation may become oedematous as a result of Bernouilli's phenomenon. This oedema further increases nasal obstruction.
Neurological changes - Pressure may be exerted by septal deviations on adjacent sensory nerves can produce pain. This was first explained by Sluder and the resultant condition became known as 'the anterior ethmoidal nerve syndrome'.
Sluders neuralgia can be differentiated from head ache due to sinusitis by packing the affected nasal cavity with a roller gauze dipped in 4% xylocaine. Pain
due to sluder's neuralgia gets releived, whereas pain due to sinus infection remains the same.
In addition to these direct neurological effects, reflex changes perhaps may result from septal deformities which affect the nasopulmonary and nasal reflexes.
Symptoms :
The symptoms caused by septal deviations are entirely the result of their effects on nasal function. The dominent symptom being nasal obstruction, but this is rarely severe enough to cause anosmia.
Signs :
Septal deviations are evident on anterior rhinoscopy. This should be done without the use of nasal speculum because the insertion of speculum is sufficient to straighten the nasal septum. When the tip of the nose is lifted septal deviation become evident. Nasal obstruction may also be present on the opposite side (paradoxical nasal obstruction). This is due to the presence of hypertrophied turbinates. If the hypertrophy is limited to turbinate mucosa alone then it will shrink when decongestant drugs are used in the nasal cavity. If the hypertrophy is bony then deconstant drops is useless.
Septal deviations in the region of the nasal valve area cause the greatest obstruction, since this is the narrowest part of the nasal cavity. This can be identified by the cottle test. A positive cottle test will confirm the fact that narrowing is present in the nasal valve area. This is done by asking the patient to pull the cheek outwards and this manuver is supposed to open up the area thus reducing the block. The septum should not be considered in isolation and it is necessary to do a careful examination of the lateral wall of the nasal cavity. When ever sinus complications like sinusitis is suspected due to obstruction to the drainage channel of the sinuses by the deviation xray sinus must be taken.
Septal deviation in new born is associated with asymmetry of the nostrils, an oblique columella and tip which points in the direction which is opposite to the deviation. Most of these patients are diagnosed by the use of Gray's struts. These struts are 4mm wide and 2mm thick and after lubrication, are inserted into the nostrils and then gently pushed backwards along the floor of the nasal cavity, hugging the nasal septum. Normally these struts can be introduced for a distance of 4 - 5 cms, but in cases of septal deviation a frank obstruction is encountered, usually 1 - 2 cms from the nostril.
Cottle has classified septal deviations into three types :
Simple deviations: Here there is mild deviation of nasal septum, there is no nasal obstruction. This is the commonest condition encountered. It needs no treatment.
Obstruction: There is more severe deviation of the nasal septum, which may touch the lateral wall of the nose, but on vasoconstriction the turbinates shrink away from the septum. Hence surgery is not indicated even in these cases.
Impaction: There is marked angulation of the septum with a spur which lies in contact with lateral nasal wall. The space is not increased even on vasoconstriction. Surgery is indicated in these patients.
Management:
If the symptoms caused by deviated nasal septum is causing problems to the patient then it needs to be managed.
Medical management: This is indicated in patients with sinusitis due to deviated nasal septum. Acute sinus
infections and acute exacerbation of chronic sinusitis should be managed by:
Antibiotics: Oral amoxycillin is the drug of choice
Antihistamines: The role of antihisamines is to reduce the secretions from the nasal and sinus mucosal lining,
and reduction of allergic response
Antiinflammatory drug: Ibuprofen in combination with paracetomol is the drug of choice
Nasal decongestant drops: Xylometazoline, or oxymetazoline nasal drops can be used to decongest the
nasal mucosa. These drugs should be administered only for a week otherwise patient is likely to
develop dependence to the drug.
Surgical management: The type of surgery used depends on the type of deviation.
If the deviation lies anterior to the cottle's line (vertical line between the nasal processes of frontal and maxillary bones)
then septoplasty is preferred.
If the deviation lies posterior to the cottle's line then submucosal resection
of septum is preferred. If the septal deviation is associated with external
deviation of the nose, then septorhinoplasty is the treatment of choice.
Anesthesia: Septoplasty / SMR can be performed either under local or general anesthesia.
Local anesthesia:
4% xylocaine is used as topical anesthesia
2% xylocaine is used as infiltration anesthesia
4% xylocaine admixed with 1 in 10,000 units of adrenaline is used.The total amount of 4% xylocaine
used should not exceed 7ml, as this is the highest dose of xylocaine an adult can tolerate without
complications.
Cotton pledgets soaked in 4% xylocaine with adrenaline mixture is used
to pack the nasal cavity. Three packs are used in all.
The first pack is left in the superior meatus to block the anterior ethmoidal nerve
The second pack is placed lateral to the middle turbinate in the middle meatus close
to the posterior end of the middle turbinate to block the sphenopalatine ganglion
The third pack is placed in the floor of the nasal cavity. This blocks the nerves
exiting through the incisive canal.
These packs are left in place atleast for 15 minutes. It causes
1. Anesthesia of the nasal mucosa
2. Shrinks the nasal mucosa
Premedication:
Fortwin and Phenargan are used for premedicating the patient.
The role of premedication is to:
1. To reduce the anxiety level of the patient
2. To reduce pain
3. To dry up the upper airway secretions
4. To cause amnesia
Infiltration:
2% xylocaine with 1 in 80,000 units adrenaline is used. A total of
5 ml of the solution is used.
The nasal septum is infiltrated from its inferior portion on both sides,
The floor of the nasal cavity is also infiltrated on both sides.
The infiltration serves to elevate the septal flap on both sides, reduce bleeding
during surgery, and anesthetizes the surgical area.
Septoplasty:This procedure is preferred to treat anterior deviations of nasal septum.
A Freer's incision is made on the concave side close to the lower border of nasal septum.
Elevation of mucoperichondrium and periosteum is performed, developing anterior and inferior
tunnel on one side. The mucoperichondrium is left attached on one side. Inferior tunnel
is created on the opposite side. The anterior tunnel and the inferior tunnels are connected, thus
freeing the septum. Incision through the periosteum is made over the crest of the maxilla and
vomer. The septal cartilage is separated from the bone, deviated piece of cartialge excised, and
flaps repositioned and sutured.
SMR: is performed to correct posterior deviations. The entire nasal septum is exposed using Killian's incision.
It is made about 5mm above the caudal border of nasal septum. Septal flaps are elevated on both sides. Septal
cartialge is incised to reach the opposite side. The whole septum is exposed and is removed using a Ballanger's swiwel knife.
Flaps are repositioned and sutured using chromic catgut.
These surgical procedures can also be performed under general anesthesia.
Last modified: Sunday, 6 January 2008, 03:57 AM