The Nasal Septum Pane ‘The nasal septum is rarely midline but marked degrees of deviation will cause nasal airway obstruction Inmost easesitean be correctedby surgery, with excellentresuts. AETIOLOGY Most cases of deviated nasal septum (ONS) result from trauma, either recent er long forgotten, perhaps during birth. Buckling in children may become more pronounced s the septum grows SYMPTOMS | Nasal obstruction —may be uniateral or blateral 2 Recurrent sinus infection cue co impairment of sinus ventilation by the displaced septum. Alernatvely themideleturbinate onthe concaveside of ‘the septum may hypertrophy and interfere with sinus venation 3 Recurrent serous otis medi. Ichas been shown that DNS may impair ‘the ability to equalize middle-ear pressure, expecially n divers. SIGNS “Two main deformities occur and may coexist. First, the caudal end of the septum maybe dislocateé laterally from the columella, narrowing onenos- ‘ri, while tne septal eartlage lies obliquely in the nose causing narrowing of the opposite side Fg-2I. |). Second, che septum maybe convexto one side, often associated wit inferior dislocation ofthe carslage‘rom themaxilary reset cause visible spur. ‘The changes presentin the naal septum are eal seen on examination fof the nose with a nasal speculum. Ie is helpful to try to recognize the anatomical deformation that has occurree (Fig. 21.2) ‘TREATMENT Irsymptoms are minimal and onlya miner degree of deviations present.no ‘treatment is necessary other than treatment of coexisting conditions such senasalallergy.2 (Chapter 21: The Nasal Septum Paine od Fig 21.4 ‘S-shaped deviation ofthenasel seprum with Inypertophy oftheright middle urbinate Fig.212 Thedorsallineof thenasalseptumhasbeen marked ands displacedo ‘thelets.causing extemal nasal deformity in addition tonasal obstruction.‘The Nasal Septum 83 SUBMUCOUS RESECTION OF THE SEPTUM Fig.215 Submucous resection of the septum (Incision through the muco perichondrium.) Elevation of muce-perchondrial aps oneither side ofthe apt skeleton (The dzplacedcardlageandbonehas been recected, allowing the septum toresumea midline pesitcn Where more severe symptoms are presene, correction of the septal deformity is justifies (though never essential ‘Submucous resection (SMR) ‘SMR (Fig 21.3) isthe operation of choicefor mi-septal deformity when the ‘caudal sepeum isin anormal postion. leis tabeavaided in ciléren because incerference with nasal growth will cur leading. in turn, ta collapse ofthe pasal dorsum. Under local or general anaesthetic. an incision is made I em back from the fronc edge ofthe cartlage through the muce-perichonérium, which is The incision is then deepened through the cartilage and the muco-perichondrium on the other side elevated Deflectedcarclage and bone are remaved with punch forceps and the ‘wo mucosal ape are allowed to fll backineo the midi, ‘Thenoseispacked gently for 24h comaintain apposition oftheflaps and the patentmay go home after 2 days. elevated from the carcla Septoplasty ‘Septoplaty isthe operation of choice (i) n children i) when combined with rhinephscy,an¢ (ii) when there ie dislocation ofthe caudal end of the4 (Chapter 21: The Nasal Septum septal carhge, The essential features of septoplasty are a minimum of caruhge removal and carefl repositioning ofthe septal skeleton in the rmicline after straightening or removing spurs and convexities. le may be performed in conjunction with mid- oF posteriorseptal resection. Ie avoids the drooping tp and supra-tip depression seen sometimes ater SMR and causes leze interference with facil growth in children, Complications of septal surgery 1 Postoperativehaemorrhage, which maybe severe, 2. Septalhaematoma, which may requir drainage. 3 Septalpertoration—see below. 4. Excernal deformity—ewing to excessive removal of septal eartlage allowing the nasal dorsum to collapse from lack of support. It can be very cific to correct. 5 Anosmia—fortunately rae, butuntreatable when ic occurs Paeakd AETIOLOGY Perforation of the nasal septum is most comman in its anterior cartlag- nous part and may result from the following conditions: postoperative (particularly SMR); ‘nose-picking (ulceration occurs frst perforation later): Wegener: granuloma: inhalation of fumes of chrome salts; ‘cocaine addiction; 7 rodentuleer (basal call carcinoma}: 8 lupus: 9 syphilis (the gumma affects the entire septum and nasal bones, with resulting deformity), SYMPTOMS Symptoms consist of epistanis and crusting, which may cause considerable ‘obstruction. Occasionally, whistling on inspiration or expiration ispresent. Frequently the subjectis symptom-free. SIGNS {A perforation i readily seen and often has unhealthy edges covered with barge crusts‘TheNasal Septum 85 INVESTIGATION Inany caze where the cause isnot clear, the following shouldbe carried out fullblood count and ESR to exclude Wegener's granuloma: urinalysis, expecially for hematuria chest Xn serology or syphilis if doubt remains, a biopsy from the edge of the perforation is taken. ‘TREATMENT Septal perforations arealmostimpossible to repai If whistling sa problem, tenkirgement of the perforation relieves the patient: embarrassment [Nasal douching with saline or bicarbonate solution reduces crusting around the edge ofthe defect and antiseptic cream will contra infection rusting andbleeding remain a problem, the perforation canbe closed Using slnstic ouble-fanged button,