Nasal Septum – Anatomy

What is Nasal Septum?

Nasal septum एक midline structure है जो nasal cavity को दो halves (right और left) में divide करती है। Ideally, यह perfectly straight और midline में होनी चाहिए, लेकिन practically 70-80% people में कुछ deviation होती है।

Components of Septum:

1. Cartilaginous Part (Anterior)

• Quadrangular Cartilage:
  • Front part of septum
  • Mobile, flexible
  • Contributes to nasal tip support
  • Common site of deviation

2. Bony Part (Posterior)

• Perpendicular Plate of Ethmoid: Upper-posterior
• Vomer: Lower-posterior
• Less commonly deviated

3. Mucosal Covering:

• Both sides lined with respiratory mucosa
• Rich blood supply (Kiesselbach’s plexus anteriorly)

Normal Functions:

• Divides nasal cavity symmetrically
• Provides structural support to nose
• Directs airflow patterns
• Contributes to nasal resistance (optimal airflow)

Types of Septal Deviations

Based on Location:

1. Anterior Deviation

• Most common और symptomatic
• Quadrangular cartilage involved
• Blocks nasal valve area (narrowest part)
• Maximum obstruction

2. Posterior Deviation

• Bony septum (vomer, perpendicular plate)
• Can block sinus ostia → sinusitis

3. Caudal Deviation

• Very anterior, tip of septum
• Visible externally
• Affects nasal tip symmetry

Based on Shape:

1. C-shaped

• Septum curves to one side
• One side completely blocked, other side patent

2. S-shaped

• Curves in opposite directions at different levels
• Both sides can be partially obstructed

3. Spur/Crest

• Sharp projection from septum
• Can traumatize lateral nasal wall
• Causes bleeding, crusting

Causes of DNS

1. Congenital/Developmental

Birth Trauma:

• During delivery, nasal trauma can occur
• Especially difficult delivery, forceps use
• Cartilage damage → later deviation

Unequal Growth:

• During childhood/adolescence
• Cartilaginous और bony septum grow at different rates
• Buckling can occur
• Most deviations manifest by puberty

2. Traumatic

Most common cause in adults

Types of Trauma:

• Sports Injuries: Cricket, football, kabaddi
• Road Traffic Accidents
• Falls
• Physical Assault

Mechanism:

• Direct blow to nose
• Cartilage/bone fractures
• Heals in deviated position if not reduced
• “पुरानी चोट” history often present

3. Iatrogenic

• Previous nasal surgery complications
• Septal perforation repair

Symptoms of DNS

Primary Symptoms:

1. Nasal Obstruction (Main Complaint)

• Unilateral (One-Sided): More common
  • Blocked side = convex side of deviation
  • Persistent
  • Doesn’t improve with decongestants
• Bilateral:
  • If S-shaped deviation
  • If compensatory turbinate hypertrophy on opposite side
  • “Nasal Cycle” – alternating blockage exaggerated
• Worse at Night: Lying down position
• Exercise Limitation: Can’t breathe through nose during exertion

2. Mouth Breathing

• Especially during sleep
• Leads to:
  • Dry mouth
  • Throat dryness, soreness
  • Bad breath
  • Dental problems (if chronic from childhood)

3. Snoring

• Due to turbulent airflow
• Mouth breathing during sleep
• Can contribute to sleep apnea

Secondary Symptoms/Complications:

4. Recurrent Sinusitis

• Deviation blocks sinus ostia
• Poor sinus drainage
• Recurrent infections

5. Recurrent Nosebleeds (Epistaxis)

• Turbulent airflow → mucosal drying
• Crusting on septal spur
• Trauma to prominent areas

6. Facial Pain/Headache

• If spur touches lateral nasal wall (contact point headache)
• Vacuum headache (if sinus drainage blocked)

7. Reduced Sense of Smell

• Airflow doesn’t reach olfactory area
• Chronic sinusitis contribution

8. Sleep Disturbance

• Poor sleep quality due to breathing difficulty
• Daytime fatigue
• Morning headaches

Diagnosis at Prime ENT Center

1. Clinical History

• Chief complaint – which side blocked? Both sides?
• Duration – since childhood या recent onset?
• History of nasal trauma?
• Previous nasal surgery?
• Associated symptoms – sinusitis, epistaxis, snoring?
• Response to decongestants (DNS doesn’t improve)

2. Anterior Rhinoscopy

• With nasal speculum
• Good lighting (headlamp/otoscope)
• Assess:
  • Degree of deviation
  • Location (anterior/posterior)
  • Type (C/S-shaped, spur)
  • Compensatory turbinate hypertrophy

3. Diagnostic Nasal Endoscopy

Gold standard examination – Dr. Harshita Singh performs

• Topical decongestant + anesthesia
• Rigid या flexible endoscope
• Complete visualization:
  • Entire septum (anterior to posterior)
  • Nasal valve area
  • Inferior, middle, superior turbinates
  • Sinus ostia
  • Nasopharynx
• Video recording – patient can see their anatomy

4. Imaging

CT Scan Paranasal Sinuses:

• Indications:
  • If chronic sinusitis present
  • Surgical planning (septoplasty + FESS)
  • Suspected bony pathology
• Information:
  • Exact location और extent of deviation
  • Bony spurs
  • Sinus disease
  • Other anatomical variations

X-ray:

• Limited use
• Can show gross deviation
• CT much better

Treatment Options

Medical Management – Symptomatic Relief Only

Important: Medical treatment cannot correct structural deviation – only provide temporary symptom relief

When Used:

• Mild symptoms
• Patient not ready for surgery
• Medical contraindications to surgery

Medications:

• Nasal Decongestant Sprays:
  • Short-term relief (max 3-5 days)
  • Shrink turbinates
  • Risk of rebound congestion
• Nasal Steroid Sprays:
  • If associated inflammation
  • Allergic rhinitis component
  • Long-term use safe
• Antihistamines: If allergies present

Surgical Management – Septoplasty (Definitive Treatment)

Only way to permanently correct DNS

Indications:

• Significant nasal obstruction affecting quality of life
• Recurrent sinusitis due to DNS
• Recurrent epistaxis from septal spur
• Sleep-disordered breathing
• Access for sinus surgery (if FESS needed)
• Severe headaches from contact points

Contraindications:

• Active nasal infection (defer)
• Severe uncontrolled medical conditions
• Age <16 years (septum still growing - exceptions if severe symptoms)
• Unrealistic expectations

Septoplasty Procedure at Prime ENT Center

Pre-operative:

• Complete history, examination
• Nasal endoscopy with counseling
• CT scan (if needed)
• Routine blood tests
• Anesthetic fitness
• Photos (documentation)
• Informed consent

Technique:

Traditional vs Endoscopic Septoplasty:

Endoscopic Septoplasty (Preferred at Prime ENT Center):

• Better visualization
• Magnified view
• Can address posterior deviations better
• Less trauma
• Faster recovery

Step-by-Step:

1. Anesthesia: General anesthesia (rarely local)
2. Approach: Through nostril (no external cut)
   • Hemitransfixion incision (inside nose)
3. Septal Flap Elevation:
   • Mucoperichondrial flaps raised on both sides
   • Exposes septal cartilage and bone
4. Correction:
   • Deviated cartilage: Resection या reshaping
   • Bony spurs: Removal
   • Deviated bony septum: Fracture और straightening
   • Principle: Remove what’s necessary, preserve as much as possible (structural support)
5. Flap Repositioning: Mucosal flaps replaced in midline position
6. Support:
   • Quilting sutures (holds flaps together)
   • Silicone splints placed (between flaps) – prevent adhesions
7. Nasal Packing:
   • Modern: Absorbable packs या no packing
   • Traditional: Gauze packing (removed after 24-48 hours)

Duration: 45-90 minutes typically

Additional Procedures (Often Combined):

• Turbinate Reduction: If compensatory hypertrophy
  • Submucosal diathermy
  • Radiofrequency ablation
  • Partial turbinectomy
• FESS: If sinusitis present
• Rhinoplasty: If external deformity (crooked nose)

Post-operative Care:

Hospital Stay:

• Day care (discharged same day) या
• Overnight stay (1 night)

First 24-48 Hours:

• Nasal congestion feeling (packing/splints in place)
• Mild pain (usually well-controlled)
• Mouth breathing necessary
• Ice packs on face (reduce swelling)
• Head elevated (2-3 pillows)
• Avoid: Nose blowing, straining, bending

Splint Removal (Day 5-7):

• Done at clinic
• Minor discomfort (brief)
• Immediate breathing improvement

Week 1-2:

• Nasal Care Essential:
  • Saline irrigation 3-4 times daily
  • Removes crusts, blood clots
  • Keeps nasal passages moist
• Nasal ointment (inside nostrils)
• Continue avoiding: Nose blowing, hot showers, strenuous activity
• Back to light work/school possible

Weeks 2-6:

• Gradual return to all activities
• Exercise can resume (after 3 weeks usually)
• Continued nasal care
• Swelling gradually resolves

Final Result:

• Full healing: 3-6 months
• Breathing improvement: Gradual, maximum by 3 months

Expected Outcomes:

• Significantly improved nasal breathing (80-90% cases)
• Reduced/eliminated mouth breathing
• Decreased snoring
• Better sleep quality
• Reduced sinus infections
• Improved exercise tolerance
• Overall quality of life improvement

Possible Complications (Rare):

• Bleeding:
  • Minor oozing common first few days
  • Significant bleeding rare (needs attention)
• Septal Perforation:
  • Hole in septum
  • 1-3% incidence
  • Can cause whistling, crusting
• Septal Hematoma:
  • Blood collection between flaps
  • Needs drainage
• Infection: Rare with antibiotics
• Adhesions (Synechiae):
  • Septum sticks to lateral wall
  • Prevented by splints, regular care
• Numbness: Upper teeth/lip (temporary, resolves)
• Persistent Deviation:
  • Incomplete correction
  • Revision rate 5-10%
• CSF Leak: Very rare, serious

Why Choose Prime ENT Center for Septoplasty?

• Experienced Surgeons:
  • Dr. Harshita Singh – Fellowship trained Rhinology specialist
  • Dr. Prateek Porwal – 15+ years ENT surgery experience
• Endoscopic Expertise: Better visualization, precision
• Modern Techniques: Minimal trauma, faster recovery
• Complete Pre-op Evaluation: Thorough endoscopy, counseling
• State-of-Art Equipment: HD endoscopes, modern OT
• Comprehensive Post-op Care:
  • Regular follow-ups
  • Debridement as needed
  • 24/7 availability for emergencies
• Realistic Expectations: Clear communication about outcomes
• Combined Procedures: Can address multiple issues (septoplasty + turbinates + FESS) in one sitting