Nasal septum

The nasal septum consists of the quadrilateral cartilage ante­riorly and the bony perpendicular plate of the ethmoid and vomer posteriorly. Few, if any, people are born with an entirely straight septum and symmetrical nasal airways. In some individuals a naturally occurring deviated nasal septum gives rise to significant nasal obstruction. In others minor nasal trauma is responsible for displacement of the septum and restriction of the nasal airway (Fig. 39.12). Further encroachment of the anterior nasal airway can occur if the ventral edge of the septal cartilage is dislocated from the columella and projects into the nasal vestibule. Inferior turbinate hypertrophy is frequently seen on the concave side of a deviated nasal septum. This is particularly likely to occur after nasal injury. The physical obstruction of the nasal airway by a deviated septum is readily apparent on anterior rhinoscopy.

Septal deformity can be corrected by means of a septo­plasty procedure or by a submucus resection of the septum (SMR). In the former procedure the septal cartilage is preserved but the anatomical abnormalities giving rise to its deformity such as a twisted maxillary crest or inclination of the bony septum are corrected, permitting the septal cartilage to be repositioned in the midline with the restoration of nasal airway patency. In the SMR procedure the deformed septal cartilage is excised, while preserving a dorsal strut along with the anterior 5 mm of septal cartilage in order to support and maintain the normal shape of the nasal tip. Both operations are performed through a vertical incision of the septal mucosa with elevation of mucoperichondrial flaps.

Postoperatively, the nose is packed for 24—48 hours to prevent haematoma formation. Complications of septal surgery include septal perforation giving rise to excessive crusting within the nose, nasal obstruction and epistaxis. If too much cartilage is excised in the SMR procedure the loss of support to the dorsum of the nose may result in a saddle deformity or drooping of the tip of the nose.

Septal perforation

The causes of septal perforation are listed in Table 39.1. The commonest cause is a complication of septal surgery. Septal perforations seldom heal spontaneously. They give rise to extensive crusting at the margins of the perforation, often with mucosal bleeding. If situated towards the front of the septum embarrassing whistling can occur. Patients also often complain of a sensation of nasal obstruction.

Crusting can be controlled to a degree with nasal douches or the use of topical antiseptic creams to minimise mucosal drying. A great variety of operations has been described to close septal perforations but none of them has met with universal success. A more certain option is to occlude the perforation by inserting a sialastic biflanged prosthesis (Fig. 39.13).