Deviated Nasal Septum Fracture Nasal Bone

Anatomy of Nasal Septum

►    Anatomically 3 parts:

1.       Columellar part

2.       Membranous part

3.       Septum proper

DNS

►    Aetiology:

1.       Traumatic

2.       Developmental

3.       Racial

4.       Hereditary

►    May involve the bony or cartilaginous part

►    Classified as:

1.       Spur

2.       Deviation

3.       Dislocation

►    Classification of Deformity of Septum.

►    Spur.  Sharp angulation  at the junction of vomer below with the septal cartilage  and or ethmoid , due to vertical compression force. # in the septal cartilage produces spur.

2.  Deviation : “C” or “S” , can be on vertical or horizontal  zone, may involve cartilage or bone or both.

3. Dislocation :  lower border of septal cartilage is displaced from its medial position ans projects into one of the nostril.Photo

DNS (spur)

►    Sharp projection at the junction of the cartilage and the bony part

DNS ( Deviation)

►    Bulging of the either the quadrilateral cartilage or bone.

►    ‘C’ or ‘S’ shaped.

DNS ( Dislocation)

1. The dislocation of the lower border of the septal cartilage from the maxillary crest. OR
2. Anterior columellar dislocation
3. Rarely posterior dislocation

Clinical features

1. Usually asymptomatic
2. Nasal obstruction
3. Dry nasal cavity
4. Recurrent rhinosinusitis
5. Headache
6. Epistaxis -rarely

Signs

1. Decrease nasal patency on the side of the DNS.
2. On anterior rhinoscopy

-          deviated septum

-          - maybe assoc. compensatory             hypertrophy of the middle or inferior turbinate on the opposite side.

3.     Maybe assoc. wt external nasal deformity.

4.     Investigations:

5.     Clinical diagnosis

Treatment:

•       Always Surgical

“As the septum goes, so goes the nose” Correct the septum first

1.  Treat the chronic sinusitis – Cap. Doxycyclin
2.  Treat the allergy – antihistamine, steroid spray

Treatment

1. Only for symptomatic DNS cases.
2. Surgical modality: Septoplasty OR Submucous resection of the septum (SMR operation)
3. Inferior turbinate reduction if needed. Collumelloplasty if ant. Collumellar dislocation.
4. Septoplasty:
1. Conservative operation where only the deviated part of the septum is removed.
5. SMR:
1. Radical operation where most of the bony and the cartilaginous part is excised leaving only ‘L’ shaped portion of the cartilage, superiorly and anteriorly.

Complications

Immediate:

1. Bleeding
2. Septal hematoma or abscess
3. Fever

Delayed:

1. Septal perforation
2. Nasal deformity
3. Nasal tip collapse
4. Synechiae
5. Depression of bridge
6. Columellar retraction
7. Papery thin septum
8. Parrot beak deformity

Fracture of the nasal bone

1.     After sports injury, RTA, blow etc.

2.     Maybe simple or complex

3.     Simple:

a.     With or without nasal deformity or septal deformity or septal displacement

1. Complex:
1. Assoc. with other facial skeletal fractures (naso-orbitoethmoid fractures)

Fracture nasal bone-clinical features

1. H/O trauma
2. Assoc. pain and swelling around the nose
3. epistaxis                                         
4. Nasal deformity                            
5. nasal obstruction (rule out septal hematoma)
6. Assoc. c/o facial deformity, diplopia, CSF rhinorrhea, proptosis, occlusal deformity
7. Maybe features of head injury, loss of consciousness

Signs:

1. Crooked nose
2. Tender swelling over the nasal bone
3. Epistaxis
4. Septal hematoma
5. DNS
6. Assoc. features of facial swelling, fracture zygoma, maxilla, orbital fracture, skull fracture etc

Fracture nasal bone-management

►    Investigations:

1.       X-ray of the nasal bone-lateral view

2.       CT scan in complex ones

Nasal injury (septal hematoma)

1. Early surgical drainage to prevent cartilage necrosis  and then packing of nose

Nasal bone fracture

1.Assess other facial injury

2. Pack if epistaxis
3. If grossly swollen fracture cant be assessed so wait for one week
4. If no immediate swelling then assess the grade of fracture

Nasal bone fracture (management)

►    Treatment:

1.       Undisplaced fractures- symptomatic treatment

2.       Simple fractures wt minimal displacement - ext. digital manipulation or intranasal fracture reduction in LA or GA. Either before edema develops or after the edema subsides( in 7-10 days). Delayed ones need rhinoplasty

3.       Complex ones – open surgical procedures. May need involvement of other faculties.