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
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.