NASAL SEPTAL ANATOMY AND

SMR

Col Dr Anwar ul Haq ENT Consultant +923018513303

ANATOMY OF NASAL SEPTUM

Columellar septum

It is formed of columella Containing the medial crura of alar cartilages united together by fibrous tissue Covered on either side by skin

MEMBRANOUS SEPTUM

It lies b/w columella and caudal border of septal cartilage

No bony or cartilaginous support

Above two parts freely movable from side to side

SEPTUM PROPER

Consist of osteocortilaginous frame work

Its main Constitutes are

Perpendicular plate of ethmoid vomer bone Large septal cartilage (quadrilateral) wedged

between the above two bones anteriorly

SEPTUM PROPER

Minor contributions Crest of nasal bone Nasal spine of frontal bone Rostum of spnenoid Crest of palatine bone Crest of maxilla and anterior nasal spine of

maxilla

BLOOD SUPPLY OF NASAL SEPTUM

Internal carotid system

Anterior ethmoidal artery Branches of Post ethmoidal artery opthalmic

artery

EXTERNAL CAROTID SYSTEM

Spheno palatine artery (maxillary)

Nasopalotine branches Post nasal septal branches

Septal branch of great palatine artery (maxillary) Septal branch of superior labial artery (Facial)

LITTLE’S AREA (KIESSEL BACH’S PLEXUS)

Anterior ethmoidal

Septal branch of supeior labial

Septal branch of sphenopalotine

Septal branch of greater palatine

VENOUS DRAINAGE

Posteriorly through sephenopalatine veins into pterygoid venous plexus Anteriorly drain into facial veins Superiorly in ethmoidal veins

NERVE SOPPLY OF NASAL SEPTUM

Olfactory nerves Carry sense of smell Supply olfactory region of nose Can Carry sheath of dura, archnoid and pia

matter

NERVE SUPPLY

Nerves of common sensation

Anterior ethmoidal nerve Branches of nasopalatine nerve Branches of infra orbital nerve

AUTONOMIC NERVES

Parasympathetic nerve fibers supply nasal glands and control nasal secretions

Greater superfacial petrosal nerve.

Sympathetic nerve fibers Upper two thoracic segments Deep petrosal nerve

LYMPHATIC DRAINAGE Submandibular lymph nodes Rest of nasal cavity drain into upper jugular nodes directly or through retropharyngeal nodes

SUBMUCOUS RESECTION OF NASAL SEPTUM

• INDICATIONS– DNS causing symptoms of nasal obstruction and

recurrent headache. – DNS causing obstruction of paranasal sinuses and

middle ear. – Recurrent epistaxis from septal spur – As a part of septorhinoplasty – As a preliminary step in Hypophsectomy (Trans septal trans sphenoidal

approach) Vidian neurectomy (Trans septal apprach)

CONTRA INDICATIONS

• Pt’s below 17 years age

• Acute respiratory infection

• Bleeding diathesis

• Untreated diabetes or hypertension

ANASTHESIA

• LA is preffered

• GA is used in children and apprehensive adults

POSITION

• Reclining position with head-end of the table raised

STEPS OF OPERATION

• Infiltration of nasal septum

• Incision – A curvilinear incision with forward convexity is

made at 5mm behind the mucocutaneous junction on the deviated side of septum

STPES OF OPERATION

• Elevation of mucopeichondrial and periosteal flap.

• Incision of the cartilage

• Elevation of opposite mucopeichondrium and periostium.

STEPS OF OPERATION

• Removal of cartilage & bone– Preserve a strip of cartilage about 1cm along

the dorsal and caudal border of the septum to prevent collapse of the nasal bridge.

• Stiching– One or two catgut or silk stitches are applied

• Packing – Ribbon gauze, smeared with furacin oinment

or liquid paraffin

POST OPERATIVE CARE

• Semi sitting position

• Soft diet

• Analgesics

• Antibiotic cover for 5-6 days.

• Nasal pack removed after 24 hours

• Decongestant and steam inhalation

• Avoid nasal trauma

COMPLICATIONS

• Bleeding • Septal haematoma • Septal abscess • Perforation • Depression of nasal bridge • Retraction of columella• Flapping of nasal septum • Toxic shock syndrome

SEPTOPLASTY

• Septoplasty is a conservative approch to septal surgery as much of the septal framework as possible is retained

• Mucoperichondrial / periosteal flap is generally raised only one side.

STEPS OF OPERATION

• Infiltrate the septum with 1% lignocaine with adrenaline

• In case of deviated septum make a slightly curveline incision 2-3 mm above the caudal end of septal cartiflage on the concave side in case of caudal dislocation a transfixition or hemi transfixition incision is made

• Raise mucoperichondrial / mucoperiosteal flap on one side only

• Seprate septal cartilage from the vomer and ethmoid plate and raise mucoperiosteal flap on the apposite side of septum.

• Remove maxillary crest to realign the septal cartilage

• Correct the bony septum by removing the deformed parts

• Deformed septal cartilage is corrected by various methods such as – Scoring on the concave side – Cross hatching – Shaving – Wedge excision – Trans septal sutures are put to coapt

mucoperichondrial flaps– Nasal pack