Malformations of the nasal septum: causes, symptoms, diagnosis, treatment

The developmental defects of the septum of the nose are manifested by its curvature.

Virtually all healthy people have some deviation of the septum of the nose, which, however, does not cause them any anxiety. Pathological are only those curvatures of the septum of the nose that interfere with normal nasal breathing and entail certain diseases of the nose, paranasal sinuses and ears. Deformations of the septum of the nose are extremely diverse; among them distinguish thickenings, all kinds of curvatures, spike-like and crest-like deformations, curvatures in the form of the letter C or S, and various combinations of these deformations.

Curvatures may be localized in all parts of the septum, although they are much less common in the posterior parts of the septum. Sometimes there are curvatures in the form of a fracture, when the upper part is bent at an angle with respect to the lower part. Thickening in the form of thorns and ridges usually occur on the convex part of the septum of the nose, mainly at the junction of the cartilage with the upper edge of the opener. In children under 7, the curvature of the septum of the nose is rare, although the French rhinologist M. Chatelier argued that he was observing the curvature of the septum of the nose even in the embryo. The development of curvature of the septum of the nose begins approximately at the age of 5-7 years and lasts until the age of 20 when the development of the skeleton of the maxillofacial region ends.

The appearance of curvature of the septum of the nose is explained by the uneven growth of the cartilage of the septum of the nose and its bone "frame" formed by the arch and the bottom of the nasal cavity: while the bone skeleton develops rather slowly, the cartilage outruns it in development and, due to closed space, curves in the process of growth. Another cause of curvature of the septum may be a birth injury to the nose or a bruise in the postnatal period, in which a fracture of its cartilage occurs.

The most common form of deformation of the septum is the so-called essential curvature of the septum of the nose, about the occurrence of which there are different theories.

Rinological theory explains the curvature of the septum of the nose in children with impaired nasal breathing, resulting in the development of a gothic arch of hard palate pressing down on the septum of the nose and distorting it. Proof of this the authors of this theory see in the fact that with the timely restoration of nasal breathing (adenotomy), curvature of the septum of the nose does not occur.

The theory of congenital curvature of the septum of the nose explains this dysgenesis with a hereditary predisposition to deformities of the septum of the nose. This theory finds evidence in relevant clinical observations.

Biological theory, according to which the curvature of the septum of the nose occurs only in humans in connection with the adoption in the process of evolution of the vertical position and the increase in the mass of the brain, whose pressure on the base of the skull, and in particular on the bottom of the anterior cranial fossa, leads to deformation of the septum of the nose. Confirmation of this theory is seen by its authors in the fact that 90% of monkeys have normal, non-curved, septa of the nose.

The theory of the rachitic genesis of the curvature of the septum of the nose explains this vice by primary violations of the process of osteogenesis and morphological dysplasias corresponding to this disease.

Stomatological theory sees the cause of curvature of the septum of the nose in the development of the maxillofacial region (underdevelopment of the upper jaw, high hard palate, the presence of superfine teeth, which ultimately leads to deformation of the endonasal structures).

Symptoms and clinical course. The main primary manifestation of the pathological curvature of the septum of the nose is the violation of nasal breathing from one or both sides, which can also cause a violation of the olfactory function. Violation of the normal aeration of the nasal cavity leads to secondary changes in the circulation in the nasal concha, stagnation, edema, trophic disorders, up to the occurrence of various types of non-inflammatory and then inflammatory diseases of the nasal cavity and paranasal sinuses (hypertrophy of nasal conchae, polyps of the nose, sinusitis) . At a rhinoscope various forms of a curvature of a septum of a nose are marked. Usually on the concave side of the curved nasal septum compensatory hypertrophy of the lower or middle nasal cone corresponding to this concavity is observed. Contact ridges and thorns of the septum of the nose, resting against the nasal concha, cause irritation of sensitive and autonomic nervous fibers, richly represented in the nasal mucosa, which is the cause of vasomotor disorders in the nasal cavity, and then trophic disturbances of its anatomical formations. The clinical course of curvature of the septum of the nose can develop in two directions - adapting to this defect with moderately compensated curvatures, when a mixed type of respiration, oral and nasal, is possible, and disadaptation to this defect, when nasal breathing is absent and when the curvature of the septum provokes reflex local and general reaction. With disadaptation, the probability of many complications is high.

Complications. Curvatures of the septum of the nose can cause and support the inflammatory processes of local localization, in the neighborhood and at a distance. Preventing the aeration and drainage functions of the nose and paranasal sinuses, deformities of the septum contribute to the chronicization of acute colds, create conditions for the occurrence of sinusitis and their chronic course, auditory tube dysfunctions and inflammatory diseases of the middle ear. Due to the persistence of oral breathing, pharyngitis and acute tonsillitis become chronic, resulting in chronic forms. Disturbance of nasal breathing excludes important functions of the internal nose, such as disinfecting, moisturizing and warming the inhaled air, which contributes to the emergence of acute and chronic laryngitis, tracheitis and inflammatory diseases of the lower respiratory tract.

Treatment of curvature of the septum of the nose is only surgical and in those cases when it decompensates the respiratory function of the nose, especially when some of the above complications of this decompensation have already arisen. However, with complications characterized by purulent inflammatory processes (chronic purulent sinusitis, chronic tonsillitis, salpingitis and purulent inflammation of the middle ear, etc.), before proceeding to surgical correction of the deformities of the septum of the nose, it is necessary to sanitize all the indicated foci of infection. Contraindication to surgical interventions on the septum of the nose are also dental diseases (dental caries, gingival pyorrhea, periodontitis, etc.), also subject to preoperative sanitation.

The method and extent of surgery depends on the type of deformation of the septum of the nose. In the presence of thorns, spurs, small ridges are limited only to their subarctic removal (kristotomiya). With significant curvatures (C- or S-shaped or angular), extending to most of the septum of the nose, resort to resection of the septum of the nose by Killian, in which virtually all of its cartilage is removed. This type of operation differs radicalism and often leads to the subsequent atrophy of the mucous membrane of the septum of the nose, up to its spontaneous perforation, the reason for this is the absence of cartilage, which apparently performs not only a basic but also a specific trophic function.

In this regard, VI Voyachek (1953) wrote: "Foreign authors suggested, on the contrary, to remove all the skeletal parts of the septum, which in many respects was unprofitable (the septum was often floated, perforations formed, the possibility of additional intervention in cases of incomplete success was excluded etc.). In addition, if necessary, just a simple mobilization of the septum, the resection of skeletal parts of it is in general not justified. " The last statement can not be disagreed, since it, while touching on a particular case, reflects the universal concept of an outstanding scientist on the sparing principle in ENT surgery.

To exclude this complication, VI Voyachek proposed "submucosal redression, or submucosal mobilization of the septal skeleton", consisting in unilateral separation of the mucous membrane from the perichondrium from the cartilage and dissecting it from the dissected side into several discs, without cutting the mucous membrane and the perichondrium of the opposite side . This manipulation makes the nasal septum mobile and supple to correction (redression), which is performed by the "nasal dilator" pressure on the curved parts of the septum that have moved. Fixation of the rectified nasal septum is carried out with a tight loop tamponade for 48 hours, then it is replaced by a lighter, replaced daily for 3-4 days. Noting the positive aspects of the method of mobilization of the cartilage of the septum of the nose proposed by VI Voyachek, it should be noted that it is effective only with "fine" curvatures, when only the middle (cartilaginous) part of the septum of the nose is deformed, easily amenable to mobilization and redression. When the cartilage is sharply thickened, there are massive cartilaginous and bony crests, this method, in principle, is inapplicable and other operational approaches based on the principles of endonasal rhinoplasty, of course, with optimal sparing of those structures that can be used to reconstruct the septum of the nose.

In the arsenal of rhinological instruments, it is also necessary to have a pointed scalpel, straight chisels, nasal scissors, nasal and auricles, as well as pre-formed loop and intercalary tampons impregnated with vaseline oil with a suspension of antibiotic or sulfonamide, for a loop tamponade according to VI Voyachek.

Operative technique. With spurs, thorns and ridges located in the anterior part of the septum, which cause concern to the patient, they can be pulled down by a straight chisel after the mucosandillary flap is removed from their surface. The flap exfoliates after the cut is made over these deformations. After removal of the defect, the leaf of the muco-perichondrium flap is put in place and fixed with gauze pads for 48 hours. If the deformities capture the osseous part, then the same operation is performed with the bone ridges, smoothing them with a straight or chiselled chisel by light strokes of the surgical hammer.

With more significant curvatures of the septum of the nose and the presence of large bone-cartilaginous crests, especially the contact ones, which cause pronounced functional disturbances, resort to the operation proposed by Killian and called "submucosal resection of the septum", or "septum operation." In fact, this is not submucosal resection, but subarched and subperiosteal (if it is a question of bone deformations) resection, since a properly performed operation provides for the separation of the mucosa together with the perichondrium and periosteum. With the operation of Killian, a total removal of the septum of the nose was envisaged, which in most cases is functionally and pathogenetically unjustified. Currently, rhinosurgeons in septum surgery try to preserve those fragments of cartilage that do not interfere with nasal breathing, and even, on the contrary, promote it, providing rigidity of the septum of the nose.

Anesthesia is local or intratracheal anesthesia. With local anesthesia premedication is performed prior to surgery, aimed at eliminating preoperative psychoemotional stress, reducing reflex excitability, pain sensitivity, salivary secretion, and with intratracheal general anesthesia with IVL and bronchial glands, potentiating local and general anesthetics. To ensure a proper sleep before surgery for the night appoint per os tranquilizer (seduksen or fenazepam) and hypnotics from the barbiturate (phenobarbital) group. In the morning for 30-40 minutes before the operation, introduce seduxen, promedol and atropine in the appropriate body weight and age of the patient doses. Patients who are prone to allergic reactions include antihistamines (pipolphen, dimedrol, suprastin) in premedication. Immediately before the operation, the application (dicaine, cocaine) and infiltration anesthesia (1% solution of novocaine with adrenaline) are performed.

In the presence of bone ridges in the lower parts of the septum and in the area of its transition to the bottom of the nasal cavity, it is advisable to supplement this localization of the injection of anesthetic and infiltration of it into the region of the bottom of the nasal cavity. In some cases, in large bony crests extending to the bottom of the nasal cavity, 1-2 ml of ultracaine is injected subperiosteally in the region of the bridle of the upper lip from the side of the ridge to prevent sharp pains that arise in the incisors when these bone ridges are blown. With the right podnahhrjacchnichnom introduction of novocaine with adrenaline mucosa of the septum of the nose becomes white, while novocaine under the pressure of the syringe produces a hydraulic detachment of perichondrium, which subsequently facilitates the operation.

An arcuate incision with a concavity inside the length of 2 cm is made on the threshold of the nose from the concave part of the curvature at the junction of the mucous membrane with the skin part to the cartilage, trying not to damage it and not perforate. Then, the mucous membrane is cut off from the perichondrium from the side of the incision to the depth of the deformed part of the septum of the nose, pressing all the time to the cartilage, so as not to perforate the muco-perigandric flap. After that, cut the quadrangular cartilage on the threshold of the nose, not wounding the perichondrium of the opposite side, leaving a strip of 2-3 mm to retain the support of the tip of the nose; introduce a blunt raspator between it and the perichondrium of the opposite side, and produce its detachment to the required depth. In the presence of scars between the perichondrium and the cartilage, they are carefully dissected with a convenient cutting tool, trying not to perforate the muco-perichondrial flap. A similar detachment is made over the bony crests. It should be emphasized that the successful course of the postoperative period depends on the success of detachment of the mucosa. Often even experienced surgeons have perforations of the petals of the mucous membrane, but it is important that these perforations are not through, t. Did not settle against each other, otherwise in the postoperative period, chronic perforation of the septum of the nose with possible known consequences (atrophy of the mucous membrane, wheezing nasal breathing, etc.) will inevitably develop. Further, using the appropriate cutting tools - a straight chisel, a Belanger knife or a dovetail or a pointed scalpel - only the curved part of the nasal septum is removed, keeping its remote parts on the surgical table for the instrumentation for possible perforation of the perforation of the septum of the nose. When removing the cartilage of the septum of the nose from above, along its back, retain a strip of cartilage 2-3 mm wide to prevent the nasal folding of the back of the nose. Chisel bone ridges, which interfere with the laying of flaps of the mucous membrane, are chiselled. Fragments of cartilage and bones are removed by Luke or Brunings forceps. Bony surfaces, left after removal of ridges and thorns, smooth out the chisel. Before laying and suturing the wound, check the presence of cartilage and bone chips between the petals of the mucous membrane, the cavity between them is washed with an isotonic sodium chloride solution with an antibiotic, then the petals of the mucosa are laid in place and 1-2 silk or Kstutut sutures are applied to the edges of the incision. The operation is completed with a tight loop tamponade according to VI Voyachek with tampons impregnated with vaseline oil with an antibiotic suspension. Apply a horizontal bandage bandage, which it is advisable to replace with a fresh one before bedtime. Tampons are removed after 2-3 days.

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