DEVIATED NASAL SEPTUM

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DEVIATED NASAL SEPTUM:

DEVIATED NASAL SEPTUM ENT II PROF.DR.G.GANANATHAN UNIT

DEVIATED NASAL SEPTUM:

DEVIATED NASAL SEPTUM Deviation of cartilage and or bony framework of the nasal septum from midline associated with nasal symptoms

AETIOLOGY:

AETIOLOGY DIRECT TRAUMA – This is frequently associated with damage to other parts of the nose such as fractures of nasal bone.

BIRTH MOULDING THEORY :

BIRTH MOULDING THEORY Abnomal intrauterine posture may result in compression forces on the nose and upper jaws. Displacement of septum can occur in these patients due to torsion forces that occur during parturition. Dislocations are more common in primipara and when the second stage of labour lasted for more than 15 minutes. Dislocations are generally to the right in the case of left occipitoanterior presentations and to the left with right occipitoanterior presentations. Subsequent growth of nose accentuates these asymmetries.

DIFFERENTIAL GROWTH BETWEEN NASAL SEPTUM AND PALATE :

DIFFERENTIAL GROWTH BETWEEN NASAL SEPTUM AND PALATE Most acceptable theory today When the nasal septum grows faster in certain individuals than the palate then the nasal septum starts to buckle under pressure.

TYPES OF DEFORMITIES:

TYPES OF DEFORMITIES DEFORMITY OF NASAL SEPTUM MAY BE CLASSIFIED 1. SPURS 2. DEVIATIONS 3. DISLOCATIONS

SPURS:

SPURS These are sharp angulations seen in the nasal septum occuring at the junction of the vomer below, with the septal cartilage and / or ethmoid bone above

PowerPoint Presentation:

This type of deformity is the result of vertical compression forces. Fractures that occur through nasal septum during injury to the nose may also produce sharp angulations . these fractures heal by fibrosis that extend to the adjacent mucoperichondrium . This increases the difficulty of flap elevation in this area.

DEVIATIONS :

DEVIATIONS May be c shaped or s shaped. These can occur in either vertical or horizontal plane. It may also involve both cartilage and bone. Deviations may affect any of the three vertical components of the nose causing 1. CARTILAGENOUS DEVIATIONS 2. THE C DEVIATION 3. THE S DEVIATION.

CARTILAGENOUS DEVIATIONS: :

CARTILAGENOUS DEVIATIONS: In these patients the upper bony septum and the bony pyramid are central, but there is a dislocation / deviation of the cartilagenous septum and vault.

The C deviation:

The C deviation Here there is displacement of the upper bony septum and the pyramid to one side and the whole of the cartilagenous septum and vault to the opposite side.

THE S DEVIATION:

THE S DEVIATION Here the deviation of the middle third (the upper cartilagenous vault and associated septum) is opposite to that of the upper and lower thirds.

DISLOCATIONS :

DISLOCATIONS In this the lower border of the septal cartilage is displaced from its medial position and projects into one of the nostrils.

CLASSIFICATION-COTTLES:

CLASSIFICATION-COTTLES COTTLE HAS CLASSIFIED SEPTAL DEVIATIONS INTO THREE TYPES : SIMPLE DEVIATIONS: - Here there is mild deviation of nasal septum - No nasal obstruction. -This is the commonest condition encountered. -It needs no treatment .

OBSTRUCTION:

OBSTRUCTION There is more severe deviation of the nasal septum, which may touch the lateral wall of the nose. On vasoconstriction the turbinates shrink away from the septum. Hence surgery is not indicated even in these cases.

IMPACTION:

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.

MLADINA CLASSIFICATION:

MLADINA CLASSIFICATION TYPE 1 Unilateral vertical ridge in the area of nasal valve does not disturb the function of nasal valve.

PowerPoint Presentation:

TYPE 2 Similar to type 1 but more severe obstruction and disturbance of nasal valve.

TYPE 3:

TYPE 3 Unilateral vertical ridge at the level of the head of the middle turbinate

TYPE 4:

TYPE 4 Defines two crest one at the level of the head of the middle turbinate Other on the opposite side in the valve area disturbing the functions

TYPE 5:

TYPE 5 Unilateral ridge on the base of the septum Other side of the septum is straight

TYPE 6:

TYPE 6 Unilateral sulcus running through the caudal ventral part of the septum Other side there is a ridge Accompanying asymmetry of the nasal cavity

TYPE 7:

TYPE 7 Mix of types from 1 to 6

MLADINA CLASSIFICATION:

MLADINA CLASSIFICATION

PETERMILLING CLASSIFICATION:

PETERMILLING CLASSIFICATION 1 anterior dislocation of septal cartilage 2 simple deviation with or without spur 3 spur or crest without deviation of the septum 4 sigmoid deviation in vertical or anteroposterior direction 5 combination of above

NEGUS CLASSIFICATION:

NEGUS CLASSIFICATION Negus defines spur as a spine which is chiefly made up of cartilage found at the junction of the bone and cartilage 1 diffuse 2 ‘ C’ shaped 3 ‘S’ shaped 4 angular deviation Too irregular to merit any term.

BALLENGER CLASSIFICATION:

BALLENGER CLASSIFICATION 1 deviation with or without crest ,spur and without external deformity 2 deviation associated with external nasal deformities 3 Isolated deformities( spur,ridge )

OSCAR AND BECKER CLASSIFICATION:

OSCAR AND BECKER CLASSIFICATION 1 DEVELOPMENTAL 2 TRAUMATIC A)DEPRESSED-CRUSHING FRONTAL FRACTURE B)LATERAL TYPE-LATERAL NASAL FRACTURE C)LATEROFRONTAL TYPE

EFFECTS OF SEPTAL DEVIATION:

EFFECTS OF 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 :

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.

PowerPoint Presentation:

Since the protective mucous layer is lost the resistance to infection is reduced. The mucosa around a septal deviation may become oedematous cause nasal obstruction.

NEUROLOGICAL CHANGES :

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 .

STRUCTURAL CHANGES:

STRUCTURAL CHANGES In patients with septal deviation, a compensatory hypertrophy of the turbinates and bulla occur on opposite side. If compression forces are involved ,the septal deviation are often asymmetrical and may involve maxilla, producing flattening of cheek, elevation of the floor of nasal cavity, distortion of the palate and associated orthodontic abnormalities.

CLINICAL PRESENTATION:

CLINICAL PRESENTATION SYMPTOMS NASAL OBSTRUCTION UNILATERAL/BILATERAL PARADOXICAL NASAL OBSTRUCTION HEADACHE EPISTAXIS ANOSMIA/HYPOSMIA EXTERNAL DEFORMITY MIDDLE EAR INFECTION

SIGNS:

SIGNS Inspect the nasal cavity before and after decongesion External nose deformity Side & type of septal deviation Compensatory hypertrophy of the turbinates Nasal mucosa-normal or congested

PowerPoint Presentation:

COLD SPATULA TEST COTTLES TEST Patient pulls the cheek outward and opens the internal nares . He will breathe normally if nasal valve area is obstructed

IMAGING STUDIES:

IMAGING STUDIES X-RAY PNS TO R/O SINUSITIS DIAGNOSTIC NASAL ENDOSCOPY CT-PNS

NASAL AIRWAY ASSESSMENT:

NASAL AIRWAY ASSESSMENT ACOUTIC RHINOMETRY - Minimal cross sectional area of the nose and the nasal airway resistance calculated - Used to determine whether valve surgery may be helpful for the correction of the pts c/o nasal airway obstruction

PowerPoint Presentation:

DISADVANTAGE - Variability associated with nostril opening and fit of measurement tip AIRFLOW RHINOMANOMETRY : Dynamic test of resistance to nasal airflow both before and after vasoconstriction. Can evaluate anatomic abnormalities and document surgical or medical management outcomes.

PowerPoint Presentation:

These studies are useful for research in nasal obstruction but provide little clinical value in decision making – surgery or medical management

THANK YOU:

THANK YOU

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