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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.
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.
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.
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
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
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
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
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
Posterior Epistaxis
Mainly the blood flows backwardsinto the throat.patient may swallow it-coffee coloured vomitus
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
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
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
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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