Deviated Nasal Septum
Dr. T. Balasubramanian
Septal deviations are pretty common occurrence. Infact a
dot central nasal septum is a clinical curiosity. Eventhough septal
deviations are common they are usually not severe enough to cause
Direct trauma - Many septal deviations are a result of
direct trauma and this is frequently associated with damage to other
parts of the nose such as fractures of nasal bone.
showing external deviation of nose caused by fracture nasal bone
associated with septal deviation
theory - Many patients with septal deviation do not give history of
trauma. Birth moulding theory was propounded by Gray. According to
him abonromal intrauterine posture may result in compression forces
acting 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
showing deviation of caudal portion of nasal
Differential growth between
nasal septum and palate - This is the most acceptable theory today.
When the nasal septum grows faster in certain individuals than the
palate then the nasal septum starts to buckle under
Fig showing unequal growth patterns between nasal
septum and palate
causing buckling of nasal
Deformity of nasal septum may be classified into:
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. 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.
showing septal spur
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.
Dislocations - In this the lower border of the septal
cartilageis displaced from its medial position and projects into one
of the nostrils.
In patients with septal deviation a compensatory
hypertrophy of the turbinates and bulla may occur on the side
opposite to the deviation. If compression forces are involved the
septal deviations are often asymmetrical and may also involve the
maxilla, producing flattenting of the cheek, elevation of the floor
of the affected nasal cavity, distortion of the palate and
associated orthodontic abnormalities. The maxillary sinus is usually
slightly smaller on the affected side.
Anterior septal deviations are often associated with
deviations in the external nasal pyramid. Deviations may affect any
of the three vertical components of the nose causing:
1. Cartilagenous deviations
2. The C deviation
3. The S deviation.
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:
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:
Here the deviation of the middle third (the upper
cartilagenous vault and associated septum) is opposite to that of
the upper and lower thirds. With deviations of the nose, the
dominant factor is the position of the nasal septum, hence the adage
'as the septum goes, so goes the nose'. The first step, therefore in
treating the twisted nose is to straighten the septum, and if this
objective is not achieved, there is no hope of successfully
straightening the external pyramid.
representation of various portions of nasal
shaped nasal septal deviated causing contour changes in the
shaped nasal septal deviation causing external deviation of
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 - 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. Since the protective mucous layer is lost the resistance
to infection is reduced. The mucosa around a septal deviation may
become oedematous as a result of Bernouilli's phenomenon. This
oedema further increases nasal obstruction.
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'. In addition to these
direct neurological effects, reflex changes perhaps may result from
septal deformities which affect the nasopulmonary and nasal
The symptoms caused by septal deviations are entirely the
result of their effects on nasal function. The dominent symptom
being nasal obstruction, but this is rarely severe enough to cause
Septal deviations are evident on anterior rhinoscopy.
This should be done without the use of nasal speculum because the
insertion of speculum is sufficient to straighten the nasal septum.
When the tip of the nose is lifted septal deviation become evident.
Nasal obstruction may also be present on the opposite side
(paradoxical nasal obstruction). This is due to the presence of
hypertrophied turbinates. If the hypertrophy is limited to turbinate
mucosa alone then it will shrink when decongestant drugs are used in
the nasal cavity. If the hypertrophy is bony then deconstant drops
Septal deviations in the region of the nasal valve area
cause the greatest obstruction, since this is the narrowest part of
the nasal cavity. This can be identified by the cottle test. A
positive cottle test will confirm the fact that narrowing is present
in the nasal valve area. This is done by asking the patient to pull
the cheek outwards and this manuver is supposed to open up the area
thus reducing the block. The septum should not be considered in
isolation and it is necessary to do a careful examination of the
lateral wall of the nasal cavity. When ever sinus complications like
sinusitis is suspected due to obstruction to the drainage channel of
the sinuses by the deviation xray sinus must be taken.
Septal deviation in new born is associated with asymmetry
of the nostrils, an oblique columella and tip which points in the
direction which is opposite to the deviation. Most of these patients
are diagnosed by the use of Gray's struts. These struts are 4mm wide
and 2mm thick and after lubrication, are inserted into the nostrils
and then gently pushed backwards along the floor of the nasal
cavity, hugging the nasal septum. Normally these struts can be
introduced for a distance of 4 - 5 cms, but in cases of septal
deviation a frank obstruction is encountered, usually 1 - 2 cms from
Cottle has classified septal deviations into three types
Simple deviations: Here there is mild deviation of nasal
septum, there is no nasal obstruction. This is the commonest
condition encountered. It needs no treatment.
Obstruction: There is more severe deviation of the nasal
septum, which may touch the lateral wall of the nose, but on
vasoconstriction the turbinates shrink away from the septum. Hence
surgery is not indicated even in these cases.
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
Indications for submucous resection of nasal
1. Marked septal deviation occurring behind the vertical
line passing between the nasal processes of the frontal and
maxillary bones. This deviation must be the cause for the patient's
2. Closure of septal perforations
3. Source of grafting material
4. To obtain surgical access in hypophysectomy, and
showing when Submucosal resection of septum should be
Surgically the septum
is divided into anterior and posterior segments by a
vertical line passing between the nasal processes of
frontal and maxillay bones
Submucosal resection of nasal septum is ideally performed
under local anaesthesia. 4% xylocaine is used as topical anesthetic
agent by nasal packing. 2% xylocaine is used as infiltrative
anesthetic agent. It is mixed with 1 in 1 lakh adrenaline.
Infiltration is done at the mucocutaneous junction on both sides
just behind the columella. The floor of the nasal cavity is also
infiltrated on the concave side. Killian's incision is preferred for
SMR operations. Killian's incision is the commonly used incision. It
is an oblique incision given about 5mm above the caudal border of
the septal cartilage.
illustrating the various incisions used in septal
The cartilagenous and bony
nasal septum is exposed by elevation of mucoperichondrial and
mucoperiosteal flaps on both sides. This is done by slicing the
septal cartilage just above the columella to access the opposite
side. Flaps are elevated on both sides of the nasal septum. the
cartialge is fully exposed from both sides and is remove using a
Luc's forceps or a Ballanger's swiwel knife. The flaps are allowed
to fall back in place and wound is closed with catgut. Bony
deviations along the floor of the nose if any are also chissled out
before wound closure.
SMR should not be performed in children because it may
Complications of SMR:
1. Septal hematoma
2. Septal abscess
3. Septal perforation
4. Nasal deformities due to excessive removal of dorsal
strut of the septum
5. Removal of the columella cartilage will cause pig
This is a more conservative procedure. The anesthesia is
the same as described for SMR operation. The incision is always
sited on the concave side of the septum. Freer's hemitransfixation
incision is preferred. This is made at the lower border of the
septal cartilage. A unilateral Freer's incision is sufficient for
septoplasty. Three tunnels are created as shown in the
showing the various tunnels raised in
Exposure: The cartilagenous and bony septum are exposed
by a complete elevation of a mucosal flap on one side only. Since
flap is retained on the opposite side the vascularity of the septum
is not compromised.
Mobilisation and straightening: The septal cartilage is
freed from all its attachments apart from the mucosal flap on the
convex side. Most of the deviations are maintained by extrinsic
factors such as caudal dislocation of cartilage from the vomerine
groove. Mobilisation alone will correct this problem. When
deviations are due to intrinsic causes like the presence of healed
fracture line then it must be excised along with a strip of
cartilage. Bony deviations are treated either by fracture and
repositioning or by resection of the fragment itself.
The septum is maintained in its new position by sutures
Advantages of Freer's incision:
1. The incision is cited over thick skin making elevation
of flap easy.
2. There is minimal risk of tearing the flap
3. The whole of the nasal septum is exposed.
4. If need arises Rhinoplasty can be done by extending
the same incision to a full transfixation one.
Advantages of Septoplasty:
1. More conservative procedure
2. Performed even in children
3. Less risk of septal perforation
4. Less risk of septal hematoma
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