TREATMENT OF DEVIATED NOSE

TREATMENT OF DEVIATED NOSE Prof. Dr. Mirza Shehab Afzal Beg

ANATOMY

DEVIATED NOSE

Physical disorder of the nose involving a displacement of the nose off center(external deviation)
Causes;
- Deviated septum
- ULC-deforming forces
- Asymmetrical nasal bones

AETIOLOGY

1. Trauma
2. Developmental errors
3. Racial factors
4. Hereditary factors

TRAUMA

- A lateral blow on the nose may cause displacement of septal cartilage from the vomerine groove and maxillary crest
- A crushing blow from the front may cause buckling , twisting ,fractures and crushing of nasal septum
- Trauma during delivery

DEVELOPMENTAL ERRORS

Nasal septum is formed by the tectoseptal process which descends to meet the two halves of developing palate in the midline

Unequal growth between palate and base of skull may cause buckling of nasal septum

SEPTAL DEVIATION TYPES

EFFECTS OF DNS

Compensatory hypertrophy of turbinates of opposite side
External deformity
Impairment of drainage to sinus
Secondary atrophic rhinitis

CLINICAL FEATURES

Nasal obstruction
Headache
Sinusitis
Epistaxis
Anosmia
External deformity
Middle ear infection

COTTLE TEST

Used in nasal obstruction due to abnormality of nasal valve
If the nasal airway improves on test side, the test is positive
Indicates abnormality of internal nasal valve

TREATMENT OPTIONS

Submucous resection
Septoplasty
- Septum repositioning
- Septal resection
- Septal scoring
- Spreader graft/Batten grafts
- Supporting sutures

SUBMUCOUS RESECTION OPERATION

Anaesthesia

local anaesthesia or general anaesthesia

Positioning

reclining position with head end of the table raised

Infiltration

subperichondrial infiltration with xylocaine with adrenaline

Elevation of the mucoperichondrial and mucoperiosteal flaps on either side of the septal framework

SUBMUCOUS RESECTION INCISION

Dislocation of bony cartilaginous junction

Removing the deflected parts of bony and cartilaginous septum, leaving a 1cm l-strut dorsally and caudally
Repositioning the flaps

SEPTOPLASTY

Performed under general anaesthesia in supine position
Septal framework is corrected/resected and repositioned
Mucoperichondrial or mucoperiosteal flap is generally raised only in one side of the septum retaining the attachment and blood supply of the other

SEPTOPLASTY INCISIONS

Transcolumellar stairstep with intranasal marginal incisions: standard for open rhinoplasty
Cartilage-splitting incision: often used in
Intercartilaginous incision: often used in combination with marginal incision to “deliver” cartilage in closed rhinoplasty

EXPOSURE

Obtain wide exposure of the deviated structures
Release all of the mucoperichondrial attachments of the deviated septum
Release deforming forces, including the LLCs and ULCs from each other, and the ULCs from the septum

IDENTIFICATION OF PROBLEM

If deviation is caused by asymmetry of the ULCs, the septal deviation can be corrected by the release of the ULCs from the LLCs

If the deviation is result of septal deviation, the septum must be straightened

The caudal septum must be anatomically reduced onto the nasal spine

SEPTAL RESECTION

Resection of the posterocaudal segment of the septum
A minimum of 1 cm septal L strut (dorsal and caudal septum) must be preserved to prevent collapse of dorsum

SEPTAL TILT

The posteriocaudal portion of the septum is removed, leaving an L-strut septum anteriorly and caudally
The septum is repositioned after removal of a small segment of the overlapping cartilage and fixated in the midline with a figure-of-eight suture.

SWINGING DOOR TECHNIQUE

1.Excess septum above the maxillary crest is resected to permit repositioning in the midline

2.Caudal septum is be secured to the anterior nasal spine

Alternatively, the excess septal length can be swung over to the contralateral side of the maxillary crest,

which serves as a "doorstop" to straighten the septum

The caudal septum can be stabilized in the midline by its insertion into a small pocket created between the medial crura (arrowhead) in a "tongue-in-groove" fashion

WEDGE EXCISION AND SHAVING

Small wedges of cartilage can be excised from the convex side of the deviation

SCORING AND CROSS-HATCHING

Cartilage scoring on the concave side to destroy the cartilage memory and straighten the septum

CORRECTION OF C--SHAPED SEPTAL DEVIATIONS

Resection of the posteriocaudal portion of the septum, partial
disjunction of the perpendicular plate of the ethmoid and quadrangle cartilage and the scoring of the l-shaped frame in a cephalocaudal(a) and anteroposterior(b) direction on the concave surface
An anterior nasal spine osteotomy may also be used to correct deviation at this level

Creation of a new l-strut using bilateral extended spreader grafts that articulate with a caudal septal replacement graft.

SEPTAL BATTEN GRAFT

SPREADER GRAFT

High septal deviation: shaving the convex side of the deviation with addition of cartilage dorsal spreader grafts +/- scoring

Persisted dorsal deviation: a series of full-thickness cuts(only through the 50%) can be made through the deviated portion of the dorsal septum
If full-thickness cuts need to be made, then bilateral cartilage spreader grafts should be placed for support and better definition of the dorsal aesthetic line

EXTRACORPOREAL SEPTOPLASTY

Whole septum is removed, L-strut is constructed and placed back
The neo-septum is fixated to the upper lateral cartilages and keystone region dorsally and the lateral cartilages and nasal spine caudally

ADDITIONAL PROCEDURE FOR TURBINATES

Straightening of the septum narrows the nasal airway in patients with pre-existing inferior turbinate hypertrophy
Options:
- Out fracture of turbinate
- Submucous resection
- Destruction via cauterization
- Steroid injection

ADDRESSING THE NASAL BONE DEVIATION

Asymmetrical oblique rasping of the nasal bones
Osteotomies
- If the nasal bones are symmetrical, lateral osteotomies alone will be sufficient
- If the nasal bones are asymmetrical, then medial osteotomies may be required

OSTEOTOMIES

ANTERIOR NASAL PACKING

STERISTRIP APPLICATION

COMPLICATIONS OF SEPTAL SURGERY

Haemorrhage
Septal hematoma/ infection/ abscess /perforation
Saddle nose / supratip depression/ Columellar retraction
Collapsed septum
Persistent deviation
Nasal synechia
C.S.F. rhinorrhoea
Infection
Toxic shock syndrome

POSTOP CARE

Head elevation
Nasal normal saline drops starting in the evening of procedure day
Removal of nasal pack in 24-48 hours
Avoidance of strenuous activities, contact sports bending head, coughing and constipation in early post op period
Follow up in one week for ROS and steristrips, 2 weeks , 6 weeks and then in 3 months

DEVIATED NOSE TREATMENT ALGORITHM