OtoRhinoLaryngology Portal

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The Nasal Septum

Deviation of Nasal Septum

This figure shows a deviated nasal septum towards left

and compensatory right inferior turbinate hypertrophy.

                Right nasal cavity.                                     Left nasal cavity.

          Star- maxillary crest area.                  Convexity of septum towards left.

Hypertrophied inferior turbinate (IT) with C-shaped convexity of septal deviation to the left.  [V - vestibule, S - nasal septum, (+) - middle turbinate]

S-shaped deviated nasal septum made obvious after decongestion spray (dashed line).  S - nasal septum, IT - inferior turbinate (right). 

Deviated Nasal Septum: The Nasal Valve & Cottle's Manoueuvre

These figures show a significant nasal septum deviation with co-existing allergy rhinitis. The convex surface to the right had caused narrowing at nasal valve area and on the opposite site there was compensatory inferior turbinate hypertrophy. Patient should be advised to performed Cottle's manoeuvre prior to topical corticosteroid spray actuation. This manouevre involves pulling the skin of the cheek in an upward and outward direction. By doing so, the nasal valve becomes wider, thus optimal delivery of the nasal spray mist to the inferior turbinate 

can be achieved (right side in this case).

[V- vestibule, S- septum, IT- inferior turbinate,

yellow dots- mucocutaneus junction]

Septal Spur

Spur is a sharp projection involving either the cartilaginous or bony septum of the nose.  It can occur in isolation or combined with deviated nasal septum.  Most the patient has no significant symptom and the finding is usually incidental.  Epistaxis, nasal blockage, or facial pain can occur in those who are symptomatic.

     Another example of septal spur (SS).        An obvious spur pricking left inferior

              [IT - inferior turbinate].                      turbinate (circle).  [S - nasal septum

                                                                                  IT - inferior turbinate]

Septal spur in contact with right middle turbinate.  This phenomena was implicated in Sluder's neuralgia (other causes of facial pain been ruled out).

 

Watch video of septal spur @ YouTube

Septal Spur Granuloma

MT - middle turbinate, S - nasal septum, ss - septal spur, arrow - granuloma 

 

 

 

Septal Turbinate

 

N- nasopharynx, S- nasal septum, MT- middle turbinate,

ST- superior turbinate. Star- septal turbinate.

V- vomer, 1- middle turbinates, 2- middle turbinates,

Arrows- septal turbinates bilaterally

Nasal Septum:Mucous Glands Secretion

Little's Area Prominent Blood Vessels

 

 An established vascular ectasia of left Little's area as seen on anterior rhinoscopy using headlight.

 

Prominent vessels of nasal septum over left Little's area

(circle) which can potentially cause epistaxis.

A florid and established vascular ectasia of left Little's area with bleeding occuring almost everyday for a week before consultation.  Bipolar cautery vessels ablation was then performed under general anaesthesia.

Anterior nasal endoscopy without using nasal speculum.  Note vibrissae

coming into view if untrimmed which may potentially smear the endoscope tip.

Aural speculum being used to protect surrounding structures

prior to cauterization of abnormal vessel seen in view.

Abnormal septal capillaries of Little's area as seen under microscope view.

Right Little's area abnormal vessels made prominent after topical co-phenylcaine spray, thus making targeted cauterization easier and more accurate.

 

Watch video of abnormal blood vessels at Little's area @ YouTube

Epistaxis from Little's Area

The commonest site of epistaxis is from Little's area which is the confluent of capillaries of the Kiesselbach's plexus (ellipse).  First aid measures include bilateral press of the alar cartilage (soft part of the nose) firmly for a few minutes (for tamponade effect) while breathing through the mouth, and sucking small ice cube in the mouth (for vasoconstrictive effect).

Spontaneous epistaxis from left Little's area in a Dengue Fever patient with platelet count of 11 x 109/L.

Retrograde haemotympanum in a patient who had violent coughs following gag reflex and retching during a severe epistaxis from left Little's area.

 

Anterior Septal Granulation

Endoscopic image pre-removal.

(X - granulation, V - vestibule, IT - inferior turbinate, S - nasal septum)

Endoscopic view post-removal.

(V - vestibule, IT - inferior turbinate, S - nasal septum)

Septal Haemangioma

Histologically-confirmed early septal haemangioma (ellipse) involving right Little's are just beyond the mucocutaneous junction (dashed line).  (S - superior, I - inferior, L - Little's area, IT - inferior turbinate, arrow - septal spur)

Immediate post-excision image.  The perichondrium was well-preserved with re-epithelialization expected to occur readily.

Septal Abscess

Broad & swollen nasal dorsum and tip with bilateral eyelid oedema in established septal abscess. 

 

 Indurated and severely swollen septum due to formed septal abscess which had caused bilateral nasal obstuction.  Incision & drainage with systemic intravenous antibiotic was given.  Cavernous sinus thrombosis and saddle nose formation are few possible complications.

Synechiae- Left Inferior Turbinate to Nasal Septum

This image shows a synechiea or adhesion band involving left inferior turbinate and the nasal septum.  It complicates septoplasty and mucosal cautery of the inferior turbinate as part of management of deviated nasal septum and persistent hypertrophy.  It is important not to cause opposing raw surfaces

to come into contact during healing phase. 

In selected cases, silastic intranasal splint can be inserted temporarily.

 

Watch video of adhesion bands after sinus surgery @ YouTube

Septal Perforation: Clinical Assessment

 

As seen externally using 0 degree endoscope over left nasal introitus.

As seen internally using 0 degree endoscope passed through right nasal cavity. 

 

Watch video of large nasal septum perforation @ YouTube

Septal Perforation: The Impact of Size & Site of Involvement

 Small

 Large

 

Septal perforation may involve its cartilaginous or bony part.  These images showed the difference between a small and large septal perforation involving its cartilaginous segment.  Small hole may cause whistling sound while bigger size may not.  However, the latter can present with crustings or epistaxis.  Septal button can be used for small to medium size perforation.  Reconstructive septal surgery may have role in bigger perforation but the success of surgery is small.

 

Disturbance of laminar flow may results in drying effect and crusts formation.

 

Watch video of septal perforation in HD @ YouTube

Watch video of small versus large septal perforation @ YouTube

Nasal Septum Fractures

CT-scan images show displaced traumatic fractures of cartilaginous nasal septum which had caused right anterior nasal cavity obstruction following trauma.  Fracture line involving the upper 1/3rd of bony septum is seen as well.  Septal exploration, removal of blood clots, debridement of fractured cartilage pieces, and temporary splinting of the septum need to be undertaken.  As much of normal cartilage must needs to be preserved.

Posterior Nasal Septal Cholesterol Cyst

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