​DEVIATED NASAL SEPTUM - Causes and Risk Factors, pathophysiology, clinical manifestations, diagnostic evaluations, medical management, surgical management and prevention

Nasal septum deviation is a common physical disorder of the nose, involving a displacement of the nasal septum. A deviated septum occurs when the thin wall (nasal septum) inside the nose is displaced to one side. Septum separates right and left nasal cavities and ideally is situated in the center of the nose, equally separating the two sides. In about 80 percent of people, however, the nasal septum is displaced, making one nasal passage smaller.

Normally, the septum lies centrally, and thus the nasal passages are symmetrical. Deviated septum is an abnormal condition in which the top of the cartilaginous ridge leans to the left or the right, causing obstruction of the affected nasal passage. The condition can result in poor drainage of the sinuses. Patients can also complain of difficulty breathing easily headaches, nasal congestion, nosebleeds, and frequent sinus infections or of sleeping disorder such as snoring or sleep apnea.

Causes and Risk Factors

A deviated septum occurs when nasal septum – the thin wall that separates right and left nasal passages – is displaced to one side.

Most cases of deviated nasal septum result from impact trauma; approximately 5% are from birth defects or congenital disorder, caused by compression of the nose during childbirth. Trauma to the nose most commonly occurs during contact sports, active play or roughhousing, or automobile accidents. Deviated septum is associated with Marfan syndrome

PATHOPHYSIOLOGY

Deformity of nasal septum may be classified into: spur, deviation and dislocation

1. Spurs: These are sharp angulations seen in the nasal septum occurring 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 extends to the adjacent mucoperichondrium. This increases the difficulty of flap elevation in this area.

2. 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.

3. Dislocations: In this the lower border of the septal cartilages displaced from its medial position and projects into one of the nostrils.

 

Deviations may affect any of the three vertical components of the nose causing: cartilaginous deviations, C deviations and S deviation.

1. Cartilaginous deviations: In these patients the upper bony septum and the bony pyramid are central, but there is a dislocation/deviation of the cartilaginous septum and vault. 

2. The C Deviation: Here there is displacement of the upper bony septum and the pyramid to one side and the whole of the cartilaginous septum and vault to the opposite side.

3.The S Deviation: Here the deviation of the middle third (the upper cartilaginous 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.

 

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 these patients.

 

CLINICAL MANIFESTATIONS

If a deviation in nasal septum is minor, patient may have no symptoms. If the deviation is severe, however, it may  cause the following signs and symptoms:

• Obstruction of one or both nostrils: This obstruction can make it difficult to breathe through the nostril or nostrils. This may be more noticeable when patient have a cold (upper respiratory tract infection) or allergies that cause your nasal passages to swell and narrow.
• Nasal congestion: As a result of nasal congestion, postnatal drip also is common. Postnatal drip occurs when mucus is blocked from flowing out of nose, causing it to drip into and linger in the back of throat.
  
• Nosebleeds: The surface of nasal septum may become dry, increasing risk of nosebleeds
  
• Frequent or recurring sinus infections: Sinus infections can result from blocked mucus and are often marked by facial pain and headaches
  
• Noisy breathing during sleep: There is more common in infants and young children with deviated septums
  

DIAGNOSTIC EVALUATIONS

Diagnosis can usually be made by the physician or specialist simply examining the nasal passages and finding an inequality in the size of the nostrils and a deformity of the septum. During a physical exam doctor will ask about symptoms – such as nosebleeds or nasal congestion – and ask whether you have had any trauma to your nose. Using a bright light and an instrument (nasal speculum) designed to spread open nostrils; doctor will examine the inside of the nose. Based on this exam, he or she should be able to diagnose deviated septum and determine the seriousness of condition. Septal deviations are evident on anterior rhinoscopy.

MEDICAL MANAGEMENT

Mild forms of nasal septum deviation require no medical intervention other than treatment of occasional nasal congestion, sinusitis or allergy symptoms. Initial treatment of deviated septum may be directed at managing the symptoms of the condition, such as nasal congestion and postnatal drip. The doctor may prescribe:

• Decongestants: Decongestants are medications that reduce nasal congestion, helping to keep the airways on both sides of your nose open. Decongestants are available as a pill or as a nasal spray. Use nasal sprays with caution, however. Frequent use can create dependency and cause symptoms to be worse (rebound) after you stop using them.
• Antihistamines: Antihistamines are medications that help prevent many cold and allergy symptoms, including runny nose. Avoiding a runny nose is important when you have a deviated septum because the mucus can become blocked in your narrow nasal passage, causing discomfort, postnatal drip or, ultimately, a sinus infection.
  
• Nasal cortisone sprays: Prescription nasal cortisone sprays can reduce inflammation in your nasal passage and help prevent runny nose – thus reducing your risk of nasal blockage and sinus infection.
  

 

SURGICAL MANAGEMENT

When the deviation is more severe and obstructs breathing, surgical intervention is necessary.

1. Septoplasty: A surgical procedure called septoplasty is performed under local or general anesthesia. With an endoscope, the surgeon makes an incision inside the nose, lifts up the lining of the septum, and removes and realigns the deviated portions of the septal bone and cartilage. The septum is maintained in its new position by sutures and splints inside the nostrils. In some cases, surgery to reshape the nose (rhinoplasty) is performed at the same time as septoplasty. Rhinoplasty involves readjusting the bone and cartilage of nose to change its shape or size or both.

2. Submucous Resection (SMR): This operation is usually done under general anesthesia and involves peeling back the lining of the nose from the septum and removing the cartilage and bone from the deviated area. The lining is then replaced. The nose is gently packed for about 24 hours to maintain the correct position and usually the patient is allowed home after a day or two

 

Post-Operative Care

1. After the procedure individual will go home the same day. There will be mild discomfort to the nasal area for one or two days afterward.
2. In reducing postoperative discomfort oral pain medications are generally effective. Apply cold compresses or ice packs for 24 hours to reduce edema and discoloration and to promote comfort. Keep the head elevated day and night to reduce swelling.
   
3. Considerable swelling and bruising can be expected. The nasal cavities may or may not be packed, and a piece of gauze is taped underneath the nose to absorb blood
   
4. Postoperative care includes frequent changing of this gauze (roughly every hour or so) and after 1 to 2 days, the excess bleeding normally stops and the inner nasal packing may be removed
   
5. Saline irrigations of the nasal cavities are often advised, and it is only then that is patient is allowed to gently blow his/her nose.
   
6. Encourage the use of humidifier to relieve crusting of nasal mucosa and prevent irritation from dryness in the nose and throat.
   
7. Patients are sometimes instructed not to blow their nose for a week or two to allow the septum to heal up in the correct position. After 1 to 2 weeks, patients are allowed to blow their nose normally.
   
8. During postoperative care frequent saline irrigations of the nasal cavities are continuously used until the healing process is complete.
   
9. Encourage relaxation techniques and deep-breathing exercises for anxiety associated with nasal passage blocked
   
10. Patient typically regains about 80% of their energy in one week after the surgery patient. Patient is able to resume reasonable activities after three to four days and can go back to work after five to seven days. However, full recovery from the procedure is achieved after one month.
    

PREVENTION

1. You may be able to prevent the injuries to your nose that can cause deviated septum with these precautions:
2. 
   
3. Wear a helmet when playing contact sports, such as football and hockey
   
4. Wear a seat belt when riding in a motorized vehicle 
   

Complications

If you have a severely deviated septum it may cause:

• Chronic sinus infections
• Postnatal drip or nasal congestion
  
• Nosebleeds
  
• Facial pain and headaches
  

DEVIATED NASAL SEPTUM - Causes and Risk Factors, pathophysiology, clinical manifestations, diagnostic evaluations, medical management, surgical management and prevention