SEPTAL DEVIATION

The nasal septum is rarely midline but marked degrees of deviation will cause nasal airway obstruction. In most cases it can be corrected by surgery, with excellent results.

AETIOLOGY

Most cases of deviated nasal septum (DNS) result from trauma, either recent or long forgotten, perhaps during birth. Buckling in children may become more pronounced as the septum grows.

SYMPTOMS

1 Nasal obstruction —may be unilateral or bilateral.

2 Recurrent sinus infection due to impairment of sinus ventilation by the displaced septum. Alternatively, the middle turbinate on the concave side of the septum may hypertrophy and interfere with sinus ventilation.

3 Recurrent serous otitis media. It has been shown that DNS may impair the ability to equalize middle-ear pressure, especially in divers.

SIGNS Two main deformities occur and may coexist;

 First, the caudal end of the septum may be dislocated laterally from the columella, narrowing one nos- tril, while the septal cartilage lies obliquely in the nose causing narrowing of the opposite side.

Second, the septum may be convex to one side, often associated with inferior dislocation of the cartilage from the maxillary crest to cause a visible spur. The changes present in the nasal septum are easily seen on examination of the nose with a nasal speculum. It is helpful to try to recognize the anatomical deformation that has occurred .

TREATMENT If symptoms are minimal and only a minor degree of deviation is present, no treatment is necessary other than treatment of coexisting conditions, such as nasal allergy Where more severe symptoms are present, correction of the septal deformity is justified (though never essential).

Submucous resection (SMR)

SMR  is the operation of choice for mid-septal deformity when the caudal septum is in a normal position. It is to be avoided in children, because interference with nasal growth will occur, leading, in turn, to collapse of the nasal dorsum. Under local or general anaesthetic, an incision is made 1cm back from the front edge of the cartilage through the muco-perichondrium, which is elevated from the cartilage. The incision is then deepened through the cartilage and the muco-perichondrium on the other side is elevated. Deflected cartilage and bone are removed with punch forceps and the two mucosal flaps are allowed to fall back into the midline. The nose is packed gently for 24 h to maintain apposition of the flaps and the patient may go home after 2 days.

Septoplasty

Septoplasty is the operation of choice (i) in children, (ii) when combined with rhinoplasty, and (iii) when there is dislocation of the caudal end of the septal cartilage. The essential features of septoplasty are a minimum of cartilage removal and careful repositioning of the septal skeleton in the midline after straightening or removing spurs and convexities. It may be performed in conjunction with mid- or posterior-septal resection. It avoids the drooping tip and supra-tip depression seen sometimes after SMR and causes less interference with facial growth in children.

Complications of septal surgery

1 Post-operative haemorrhage, which may be severe.

2 Septal haematoma, which may require drainage.

3 Septal perforation —see below.

4 External deformity —owing to excessive removal of septal cartilage, allowing the nasal dorsum to collapse from lack of support. It can be very difficult to correct. 5 Anosmia —fortunately rare, but untreatable when it occurs.

SEPTAL PERFORATION

AETIOLOGY

Perforation of the nasal septum is most common in its anterior cartilagi- nous part and may result from the following conditions:

1 postoperative (particularly SMR);

2 nose-picking (ulceration occurs first, perforation later);

3 trauma;

4 Wegener’s granuloma;

5 inhalation of fumes of chrome salts;

6 cocaine addiction;

7 rodent ulcer (basal cell carcinoma);

8 lupus;

9 syphilis (the gumma affects the entire septum and nasal bones, with resulting deformity).

SYMPTOMS

Symptoms consist of epistaxis and crusting, which may cause considerable obstruction. Occasionally, whistling on inspiration or expiration is present. Frequently, the subject is symptom-free.

SIGNS

A perforation is readily seen and often has unhealthy edges covered with large crusts.

INVESTIGATIONS

In any case where the cause is not clear, the following should be carried out:

1 full blood count and ESR to exclude Wegener’s granuloma;

2 urinalysis, especially for haematuria;

3 chest X-ray;

4 serology for syphilis;

5 if doubt remains, a biopsy from the edge of the perforation is taken.

TREATMENT

Septal perforations are almost impossible to repair. If whistling is a problem, enlargement of the perforation relieves the patient’s embarrassment. Nasal douching with saline or bicarbonate solution reduces crusting around the edge of the defect, and antiseptic cream will control infection. If crusting and bleeding remain a problem, the perforation can be closed using a silastic double-flanged button.