Back

Haematoma | Diseases of Nasal Septum | Nose | Otorhinolaryngology (Ear Nose Throat / E.N.T) | 4th Year (Fourth Year) | MBBS | Detailed Free Notes

Views 0

1. DEFINITION

  • Structural displacement of nasal septum from the midline.

  • May involve cartilage, bone, or both.

  • Can produce airflow obstruction, turbulence, contact points, and sinus drainage impairment.

  • Deviation may be C-shaped, S-shaped, spur formation, tilt, or dislocation.

2. EMBRYOLOGY & DEVELOPMENTAL BASIS

2.1 Embryological Origin

  • Septum formed from frontonasal process.

  • Composed of:

    • Quadrilateral cartilage (anterior)

    • Perpendicular plate of ethmoid (superior)

    • Vomer (posteroinferior)

2.2 Growth Influence

  • Post-natal growth causes:

    • Disproportion between ethmoid and vomer growth

    • Tension on septal cartilage

    • Natural tendency toward mild deviation

2.3 Developmental Deviations

  • Occur in utero or during birth canal compression.

  • Newborns delivered in difficult labor or with molding can present with deviation.

3. APPLIED ANATOMY

3.1 Components of Nasal Septum

  • Cartilaginous part

    • Quadrilateral cartilage

    • Key functional segment

  • Bony part

    • Perpendicular plate of ethmoid

    • Vomer

    • Maxillary crest

    • Palatine crest

3.2 Mucosal Lining

  • Respiratory epithelium: pseudostratified ciliated columnar

  • Highly vascular → explains bleeding risk in septal surgery.

3.3 Areas Important in DNS

  • Little’s area (Kiesselbach’s plexus) — bleeding with spur trauma

  • Internal nasal valve — most important area for resistance

  • Septal spur contact with turbinate → headache (contact point headache)

4. CLASSIFICATION OF DNS

4.1 Based on Shape

  • C-shaped deviation

    • Bowing to one side

    • Commonest type

  • S-shaped deviation

    • Double curvature

    • Causes bilateral obstruction

  • Septal tilt

    • Septum straight but tilted off midline

  • Septal dislocation

    • Cartilage knocked off maxillary crest

  • Septal spur

    • Sharp projection into airway

  • High deviation

    • Involving superior septum

  • Low deviation

    • Causing airway blockage at valve level

4.2 Mladina Classification (Most ENT-accurate)

(High yield for exams)

  • Type 1: Vertical septal ridge in nasal valve

  • Type 2: Anterior vertical deviation obstructing the valve

  • Type 3: C-shaped in deeper cartilaginous septum

  • Type 4: S-shaped

  • Type 5: Spur touching lateral wall

  • Type 6: Massive bony spur with deep groove

  • Type 7: Combination of above

5. ETIOLOGY

5.1 Developmental Causes

  • Disproportionate growth of septal components

  • Intrauterine pressure

  • Birth trauma

5.2 Traumatic Causes

  • Falls, sports injuries, road traffic accidents

  • Septal hematoma → cartilage necrosis → deviation

  • Minor repeated trauma (nose picking, blows during childhood)

5.3 Racial & Genetic Factors

  • Certain populations have higher deviation prevalence

  • Familial tendency

  • Cartilage structural variations

5.4 Compensatory Causes

  • Compensatory septal deviation due to:

    • Chronic turbinate hypertrophy

    • Polyp mass in one side pushing septum

5.5 Post-surgical Causes

  • Incorrect reduction after septal hematoma drainage

  • Collapse after septoplasty

6. PATHOPHYSIOLOGY

6.1 Airflow Dynamics

  • Airflow must be laminar for optimal humidification & filtration

  • Deviation → turbulent flow

  • Leads to:

    • Dryness

    • Crusting

    • Epistaxis

6.2 Nasal Valve Narrowing

  • Internal nasal valve most important resistance site

  • Minor deviations here cause major obstruction

6.3 Mucosal Changes

  • Opposite side (wider side) undergoes:

    • Turbinate hypertrophy

    • Congestion

    • Paradoxical obstruction

6.4 Sinus Drainage Disturbance

  • DNS blocks:

    • Osteomeatal complex

    • Frontal recess

    • Sphenoethmoidal recess

→ Predisposes to sinusitis.

6.5 Contact Point Headache

  • Spur touching inferior turbinate

  • Stimulation of trigeminal nerve endings → headache

7. CLINICAL FEATURES

7.1 Symptoms

A. Nasal Obstruction

  • Most common

  • Unilateral or bilateral (S-shaped)

  • Worse during:

    • Upper respiratory infections

    • Allergy

    • Sleeping on affected side

B. Mouth Breathing

  • Particularly during sleep

  • Daytime dryness

C. Snoring

  • Due to altered airflow resistance

D. Epistaxis

  • Spur trauma → mucosal ulceration

E. Headache

  • Due to contact point

  • Deep, aching, radiating around eyes

F. Postnasal Drip

  • Due to rhinitis changes

G. Recurrent Sinusitis

  • DNS causes blockage of sinus ostia

H. Hyposmia or Anosmia

  • Reduced airflow to olfactory cleft

7.2 Signs

A. External Deviation

  • Nasal dorsum deviated visibly

  • C-shaped or S-shaped external deformity

B. Anterior Rhinoscopy Findings

  • Septum deviated to one side

  • Spur formation

  • Mucosal crusting

  • Opposite side turbinate hypertrophy

C. Cottle’s Test

  • Lateral traction on cheek improves airflow → valve area narrowing

D. Modified Cottle’s Test

  • Probe lifts upper lateral cartilage

  • Improvement indicates nasal valve collapse

8. EXAMINATION

8.1 Inspection

  • External deformity

  • Mouth breathing

  • Alar collapse

8.2 Anterior Rhinoscopy

  • Septal deviation pattern

  • Spur location

  • Crusting or ulcer

  • Turbinate size

8.3 Nasal Endoscopy

Most accurate method.
Shows:

  • Exact deviation site

  • Spur contact points

  • Osteomeatal obstruction

  • Mucosal disease

8.4 Examination of Related Systems

  • Throat for postnasal drip

  • Ear for ET dysfunction

  • Sinus tenderness

Written And Compiled By Sir Hunain Zia (AYLOTI), World Record Holder With 154 Total A Grades, 7 Distinctions And 11 World Records For Educate A Change MBBS 4th Year (Fourth Professional) Otorhinolaryngology (ENT) Free Material

9. INVESTIGATIONS

9.1 Clinical Diagnosis

  • DNS is primarily a clinical diagnosis

  • No imaging required in simple cases

9.2 Diagnostic Nasal Endoscopy

  • Gold standard

  • Demonstrates airflow obstruction

  • Identifies additional pathology

9.3 Imaging (Only when indicated)

A. X-ray PNS

  • Rarely useful

  • Shows sinusitis secondary to DNS

B. CT Scan (PNS)

Indicated when:

  • Chronic rhinosinusitis

  • Pre-operative planning

  • Polyps or mass present

  • Trauma cases

Findings:

  • Deviated septum pattern

  • Spur projection

  • Sinus blockage

  • Turbinate hypertrophy

10. DIFFERENTIAL DIAGNOSIS

Conditions producing nasal obstruction similar to DNS:

  • Inferior turbinate hypertrophy

  • Nasal polyps

  • Allergic rhinitis

  • Rhinosinusitis

  • Choanal atresia

  • Nasal tumors

  • Adenoid hypertrophy (children)

  • Nasal valve collapse

  • Foreign body (unilateral obstruction in child)

11. COMPLICATIONS OF DNS

Local Complications

  • Recurrent epistaxis

  • Contact point headache

  • Recurrent sinusitis

  • External deformity progression

  • Septal ulcer

  • Crusting

Functional Complications

  • Mouth breathing → dry throat

  • Sleep disturbance → snoring, apnea risk

  • Hyposmia

Ear & Throat Complications

  • Eustachian tube dysfunction

  • Otitis media with effusion

  • Postnasal drip

12. MANAGEMENT OF DNS

12.1 Principles of Management

  • Main goal: restore normal nasal airflow.

  • Treat associated issues:

    • Allergic rhinitis

    • Sinusitis

    • Turbinate hypertrophy

  • DNS correction is surgical, not medical.

  • Medications help symptoms but cannot straighten a deviated septum.

13. INDICATIONS FOR SURGERY (VERY IMPORTANT FOR VIVA)

A. Absolute Indications

  • Severe nasal obstruction due to DNS

  • Recurrent epistaxis due to septal spur

  • Recurrent sinusitis secondary to DNS

  • Septal deviation causing sleep disturbance/snoring

  • Septal spur causing contact point headache

  • DNS obstructing nasal endoscopy/other surgeries

  • DNS causing external nasal deformity (functional rhinoplasty)

B. Relative Indications

  • Chronic rhinitis resistant to treatment

  • Hyposmia/anosmia due to airflow limitation

  • Mouth breathing habit

  • Post-trauma cosmetic concerns (with rhinoplasty)

14. CONTRAINDICATIONS FOR SURGERY

Absolute Contraindications

  • Children < 16 years (growth disturbance risk)

    • Exception: severe obstruction or cleft palate surgery

  • Active infection

  • Uncontrolled hypertension

  • Coagulopathies

  • Atrophic rhinitis

Relative Contraindications

  • Elderly with poor general health

  • Uncontrolled diabetes

  • Severe deviated external nose requiring rhinoplasty instead

15. TYPES OF SURGERY FOR DNS

15.1 Submucous Resection (SMR)

(Traditional method)

Characteristics

  • Removes deviated septal parts extensively

  • Preserves mucosa

  • More aggressive vs septoplasty

  • Not preferred today unless septum severely deformed

Advantages

  • Effective in severe deviations

  • Removes spurs thoroughly

Disadvantages

  • Risk of perforation

  • Loss of structural support → saddle nose deformity

15.2 Septoplasty

(Modern, preferred procedure)

Characteristics

  • Conservative

  • Corrects deviation by repositioning, not removing

  • Preserves quadrilateral cartilage

  • Better functional outcome

Steps

  • Elevation of mucoperichondrial flap

  • Correction of deviation

  • Scoring, suturing, or repositioning cartilage

  • Removal of minimal bone if required

  • Closure and nasal splints

Advantages

  • Preserves support

  • Lower risk of complications

  • Best for valve area deviations

15.3 Endoscopic Septoplasty

Indications

  • Posterior deviations

  • Spur obstructing sinus ostia

  • Coexisting sinus surgery

Advantages

  • Direct visualization

  • Precise correction

  • Minimal trauma

15.4 Septorhinoplasty

Indications

  • DNS with external nasal deformity

  • Cosmetic + functional correction required

Written And Compiled By Sir Hunain Zia (AYLOTI), World Record Holder With 154 Total A Grades, 7 Distinctions And 11 World Records For Educate A Change MBBS 4th Year (Fourth Professional) Otorhinolaryngology (ENT) Free Material

16. DETAILED SURGICAL STEPS (SEPTOPLASTY)

(High-yield stepwise ENT surgical description)

Step 1: Anesthesia

  • Local or general

  • Local infiltration with:

    • Lignocaine + adrenaline (1:100,000)

  • Vasoconstriction reduces bleeding

Step 2: Incision

  • Freer’s hemitransfixion incision at caudal end

  • Alternative: Killian incision (older style)

Step 3: Elevation of Mucoperichondrial Flap

  • Critical step

  • Should be:

    • Atraumatic

    • Bloodless

    • Continuous plane

Step 4: Identification of Deformed Area

  • C-shaped bend

  • S-shaped deformity

  • Spur

  • Bony thickening

Step 5: Correction Techniques

  • Scoring of cartilage to weaken bend

  • Removal of minimal deviated cartilage

  • Repositioning onto midline

  • Shaving of bony spur

  • Removal of vomer/perpendicular plate segments if needed

Step 6: Reapproximation

  • Replace flap

  • Quilting sutures to prevent hematoma

Step 7: Splinting

  • Use silastic splints or nasal packs

  • Packs removed after 24–48 hours

17. COMPLICATIONS OF SEPTOPLASTY

Early Complications

  • Bleeding

  • Septal hematoma

  • Infection

  • Pain

  • Mucosal tear

Late Complications

  • Septal perforation

  • Saddle nose deformity

  • Persistence of deviation

  • Synechiae (adhesions)

  • Hyposmia

Serious but Rare

  • CSF rhinorrhea (if skull base injured)

  • Orbital injury (extremely rare)

18. POSTOPERATIVE CARE

Immediate

  • Head elevated

  • Ice packs

  • Antibiotics

  • Analgesics

After Pack Removal

  • Nasal saline irrigation

  • Avoid nose blowing

  • Avoid trauma

  • Follow-up for crust removal

19. SPECIAL SITUATIONS

DNS in Children

  • Avoid surgery before age 16

  • Indications for early surgery:

    • Severe obstruction

    • Obstructive sleep apnea

    • Syndromic anomalies

    • Cleft palate reconstruction

DNS in Trauma

  • Septal hematoma must be drained immediately

  • Untreated → cartilage necrosis → severe future DNS

20. VIVA QUESTIONS (HIGH YIELD)

  • Define DNS.

  • Types of DNS.

  • Causes of DNS.

  • What is a septal spur?

  • Symptoms of DNS.

  • What is the internal nasal valve?

  • What are the indications for septoplasty?

  • Septoplasty vs SMR.

  • Complications of septal hematoma.

  • Cottle’s test significance.

  • Why is septoplasty avoided in children?

21. SHORT CLINICAL CASE SCENARIO (Exam Style)

A 22-year-old male presents with unilateral nasal obstruction and recurrent epistaxis. Examination reveals a sharp septal spur touching the inferior turbinate.

Diagnosis:

  • DNS with septal spur causing contact point headache and trauma-induced bleeding.

Management:

  • Endoscopic septoplasty with spur removal.

22. SUMMARY TABLE (SEO-Friendly)

Feature DNS
Etiology Developmental, traumatic, racial, compensatory
Symptoms Obstruction, headache, epistaxis, hyposmia
Signs Spur, tilt, turbinate hypertrophy
Investigation Nasal endoscopy
Treatment Septoplasty / SMR
Complications Hematoma, perforation, saddle nose
Hunain Zia

Hunain Zia has previously achieved considerable success in the high-school educational stream, gaining a massive 154 Total A Grades and 7 Major Distinctions, a process in which he broke/ set 11 different world records, including the most A grades ever achieved, most subjects ever appeared in, most distinctions, gaining distinctions across two separate boards (Pearson Edexcel and CAIE) within the same year/ ever, and even 19 hours of constant examination. All records stand intact today. Hunain pursued his Honors Accounting Degree from the prestigious Bentley University, and then completed an LLB (in Honors) from University of London. Currently, he manages multiple social and commercial projects, has founded digital streams and works tirelessly in the education sector.

Educate A Change focuses on truly bringing change in the educational sector worldwide. All our courses are designed to ensure success, and provide complete preparation without requiring any other external material. Therefore, it takes away the expense of academies, books, past paper compilations and other miscellaneous items. Instead, by just the courses we offer, the student can prepare fully for the best grades in their CAIEs, Edexcel and other high-school exams. The earnings from our course-sales are invested in social projects and growing the free educational activities of Educate A Change.