Nasal septal malformations: causes, symptoms, diagnosis, treatment

Developmental defects of the nasal septum are manifested by its curvature.

Almost all healthy people have some deviations of the nasal septum, which, however, do not cause them any discomfort. Only those curvatures of the nasal septum that interfere with normal nasal breathing and entail some diseases of the nose, paranasal sinuses and ears are pathological. Deformations of the nasal septum can be extremely diverse; among them, thickenings, various types of curvatures, spinous and comb-shaped deformations, curvatures in the form of the letter C or S and various combinations of these deformations are distinguished.

Curvatures can be localized in all sections of the nasal septum, although they are much less common in the posterior sections of the nasal septum. Sometimes, curvatures in the form of a fracture are observed, when the upper part is bent at an angle relative to the lower part. Thickenings in the form of spikes and ridges are usually on the convex part of the nasal septum, mainly at the junction of the cartilage with the upper edge of the vomer. In children under 7 years of age, curvature of the nasal septum is rare, although the French rhinologist M. Chatelier claimed that he observed curvature of the nasal septum even in an embryo. The development of curvature of the nasal septum begins at approximately 5-7 years of age and continues until the age of 20, when the development of the bone skeleton of the maxillofacial region ends.

The occurrence of a deviated nasal septum is explained by the uneven growth of the cartilage of the nasal septum and its bony "frame" formed by the vault and floor of the nasal cavity: while the bony skeleton develops rather slowly, the cartilage outstrips it in development and, due to the closed space, is curved during growth. Another reason for the curvature of the nasal septum may be a birth injury to the nose or its bruise in the postnatal period, which causes a fracture of its cartilages.

The most common type of nasal septum deformity is the so-called essential curvature of the nasal septum, about the occurrence of which there are various theories.

The rhinological theory explains the curvature of the nasal septum in children with impaired nasal breathing, as a result of which a Gothic vault of the hard palate develops, pressing from below on the nasal septum and curving it. The authors of this theory see proof of this in the fact that with timely restoration of nasal breathing (adenotomy), curvature of the nasal septum does not occur.

The theory of congenital deviations of the nasal septum explains this dysgenesis by a hereditary predisposition to deformations of the nasal septum. This theory finds evidence in the corresponding clinical observations.

A biological theory according to which the curvature of the nasal septum occurs only in humans due to the adoption of a vertical position during evolution and the increase in the mass of the brain, the pressure of which on the base of the skull, and in particular on the bottom of the anterior cranial fossa, leads to the deformation of the nasal septum. The authors of this theory see confirmation of this in the fact that 90% of monkeys have normal, non-curved nasal septums.

The theory of rachitic genesis of nasal septum deviations explains this defect by primary disturbances in the process of osteogenesis and morphological dysplasias corresponding to this disease.

The dental theory sees the cause of the curvature of the nasal septum in developmental disorders of the maxillofacial region (underdevelopment of the upper jaw, high hard palate, the presence of supernumerary teeth, which ultimately leads to deformation of the endonasal structures).

Symptoms and clinical course. The main primary manifestation of pathological curvature of the nasal septum is impaired nasal breathing on one or both sides, which can also cause impaired olfactory function. Impaired normal aeration of the nasal cavity leads to secondary changes in blood circulation in the nasal turbinates, congestion, swelling, trophic disorders, up to the development of various types of non-inflammatory and then inflammatory diseases of the nasal cavity and paranasal sinuses (hypertrophy of the turbinates, nasal polyps, sinusitis). Rhinoscopy reveals various forms of curvature of the nasal septum. Usually, on the concave side of the deviated nasal septum, there is compensatory hypertrophy of the lower or middle turbinate, corresponding to this concavity. The contact ridges and spines of the nasal septum, resting against the nasal conchae, are the cause of irritation of the sensitive and autonomic nerve fibers, richly represented in the nasal mucosa, which is the cause of vasomotor disorders in the nasal cavity, and then trophic disorders of its anatomical formations. The clinical course of the curvature of the nasal septum can develop in two directions - adaptation to this defect with moderately compensated curvatures, when a mixed type of breathing is possible - oral and nasal, and maladaptation to this defect, when nasal breathing is absent and when the curvature of the nasal septum provokes reflex local and general reactions. With maladaptation, there is a high probability of developing many complications.

Complications. Deviations of the nasal septum can cause and maintain inflammatory processes locally, nearby and at a distance. By preventing aeration and drainage of the nose and paranasal sinuses, deformations of the nasal septum contribute to the chronicity of acute rhinitis, create conditions for the development of sinusitis and its chronic course, dysfunctions of the auditory tube and inflammatory diseases of the middle ear. Due to the constant mouth breathing, pharyngitis and acute tonsillitis become frequent, turning into chronic forms. Impaired nasal breathing excludes important functions of the internal nose, such as disinfecting, moisturizing and warming the inhaled air, which contributes to the development of acute and chronic laryngitis, tracheitis and inflammatory diseases of the lower respiratory tract.

Treatment of nasal septum deviations is only surgical and in cases where it decompensates the respiratory function of the nose, especially when one or another of the above-mentioned complications of this decompensation have already arisen. However, in case of complications characterized by purulent inflammatory processes (chronic purulent sinusitis, chronic tonsillitis, salpingootitis and purulent inflammation of the middle ear, etc.), before proceeding to surgical correction of nasal septum deformations, it is necessary to sanitize all the above-mentioned foci of infection. Contraindications to surgical interventions on the nasal septum are also dental diseases (dental caries, gingival pyorrhea, periodontitis, etc.), which are also subject to preoperative sanitization.

The method and extent of surgical intervention depend on the type of deformation of the nasal septum. In the presence of spines, spurs, small ridges, they are limited to their subperichondrium removal (cristotomy). In case of significant curvatures (C- or S-shaped or angular), spreading to a large part of the nasal septum, they resort to resection of the nasal septum according to Killian, in which almost all of its cartilage is removed. This type of operation is characterized by radicalism and often leads to subsequent atrophy of the mucous membrane of the nasal septum, up to its spontaneous perforation, the cause of which is the absence of cartilage, which apparently performs not only a supporting, but also a certain trophic function.

In this regard, V.I. Voyachek (1953) wrote: “Foreign authors, on the contrary, proposed to remove all skeletal parts of the septum, which was disadvantageous in many respects (the septum was often made floating, through perforations were formed, the possibility of additional intervention in cases of partial success was excluded, etc.). In addition, when only simple mobilization of the septum is necessary, resection of its skeletal parts is not justified in any way.” One cannot but agree with the latter statement, since, although it concerns a particular case, it reflects the universal concept of the outstanding scientist about the gentle principle in ENT surgery.

To eliminate this complication, V. I. Voyachek proposed "submucous redressing, or submucous mobilization of the septum skeleton", which consists of one-sided separation of the mucous membrane with the perichondrium from the cartilage and its dissection on the separated side into several discs, without cutting the mucous membrane and perichondrium of the opposite side. This manipulation makes the nasal septum mobile and amenable to correction (redressing), which is performed by "pressure of the nasal dilator" on the curved parts of the nasal septum that have become mobile. Fixation of the nasal septum straightened in this way is carried out using a tight loop tamponade for 48 hours, then it is replaced by a lighter one, changed daily for 3-4 days. Noting the positive aspects of the method of mobilization of the cartilage of the nasal septum proposed by V.I. Voyachek, it should be noted that it is effective only for "subtle" curvatures, when only the middle (cartilaginous) part of the nasal septum is deformed, which is easily mobilized and redressed. When the cartilage is sharply thickened, there are massive cartilaginous and bone ridges, this method, in principle, is not applicable and other surgical approaches are required, based on the principles of endonasal rhinoplasty, of course, with optimal sparing of those structures that can be used for reconstruction of the nasal septum.

The arsenal of rhinological instruments should also include a sharp-pointed scalpel, straight chisels, nasal scissors, nasal and ear forceps, as well as pre-prepared loop and insert tampons soaked in Vaseline oil with an antibiotic or sulfanilamide suspension for loop tamponade according to V.I. Voyachek.

Surgical technique. In case of spurs, thorns and ridges located in the anterior parts of the nasal septum, which are disturbing to the patient, they can be removed with a straight chisel after separating the mucoperichondrium flap from their surface. The flap is peeled off after an incision is made over these deformations. After the defect is removed, the sheets of the mucoperichondrium flap are put back in place and fixed with gauze tampons for 48 hours. If the above deformations also affect the bone part, the same operation is performed with the bone ridges, smoothing them with a straight or grooved chisel using light blows of a surgical hammer.

In case of more significant curvatures of the nasal septum and the presence of large bone-cartilaginous ridges, especially contact ones, which cause significant functional disorders, they resort to the operation proposed by Killian and called "submucous resection of the nasal septum" or "septum operation". In fact, this is not a submucous resection, but a subperichondral and subperiosteal (if we are talking about bone deformations) resection, since a correctly performed operation involves separating the mucous membrane together with the perichondrium and periosteum. Killian's operation involved total removal of the nasal septum, which in most cases is functionally and pathogenetically unjustified. Currently, rhinosurgeons try to preserve those fragments of cartilage during septum operations that do not interfere with nasal breathing, but even, on the contrary, facilitate it, ensuring the rigidity of the nasal septum.

Local anesthesia or intratracheal anesthesia. With local anesthesia, premedication is administered before surgery to eliminate preoperative psychoemotional stress, reduce reflex excitability, pain sensitivity, secretion of salivary glands, and with intratracheal general anesthesia with artificial ventilation - and bronchial glands, potentiate local and general anesthetics. To ensure adequate sleep before surgery, a tranquilizer (seduxen or phenazepam) and a sleeping pill from the barbiturate group (phenobarbital) are prescribed per os at night. In the morning, 30-40 minutes before surgery, seduxen, promedol and atropine are administered in doses appropriate to the patient's body weight and age. For patients prone to allergic reactions, antihistamines (pipolfen, diphenhydramine, suprastin) are included in the premedication. Immediately before the operation, 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 anesthetic administration with its infiltration into the area of the bottom of the nasal cavity. In some cases, with large bone ridges extending to the bottom of the nasal cavity, 1-2 ml of ultracaine is injected subperiosteally in the area of the frenulum of the upper lip from the side of the ridge to prevent sharp pain sensations that occur in the incisors when these bone ridges are removed. With the correct subperichondrium injection of novocaine with adrenaline, the mucous membrane of the nasal septum becomes white, while novocaine under the pressure of the syringe produces hydraulic detachment of the perichondrium, which subsequently facilitates the operation.

An arcuate incision with an inward concavity, 2 cm long, is made in the vestibule of the nose from the side of 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 or perforate it. Then the mucous membrane with the perichondrium is separated from the side of the incision to the depth of the deformed part of the nasal septum, pressing all the time against the cartilage so as not to perforate the mucoperichondrium flap. After this, the quadrangular cartilage in the vestibule of the nose is cut without injuring the perichondrium of the opposite side, leaving a strip of 2-3 mm to maintain support for the tip of the nose; a blunt raspatory is inserted between it and the perichondrium of the opposite side, and it is detached to the required depth. If there are scars between the perichondrium and cartilage, they are carefully dissected with a convenient cutting instrument, trying not to perforate the mucoperichondrium flap. Similar detachment is performed over the bone ridges. It should be emphasized that the favorable course of the postoperative period depends on the success of the detachment of the mucous membrane. Perforations of the mucous membrane petals often occur even in experienced surgeons, but it is important that these perforations are not through, i.e., not located opposite each other, otherwise chronic perforation of the nasal septum with possible known consequences (atrophy of the mucous membrane, wheezing, etc.) will inevitably develop in the postoperative period. Next, using appropriate cutting instruments - a straight chisel, a Belanger knife, a dovetail knife, or a pointed scalpel - only the curved part of the nasal septum is removed, preserving the removed parts on the operating table for instruments for possible plastic surgery of the through perforation of the nasal septum. When removing the cartilage of the nasal septum from above, along its back, a strip of cartilage 2-3 mm wide is preserved to prevent the nasal back from sinking. Bone ridges that interfere with the placement of mucous membrane flaps are knocked down with a chisel. Fragments of cartilage and bone are removed with Luke or Brunings forceps. The bone surfaces remaining after the removal of ridges and spines are smoothed with a chisel. Before laying and suturing the wound, check for the presence of cartilaginous and bone chips between the mucous membrane petals, wash the cavity between them with an isotonic solution of sodium chloride with an antibiotic, then put the mucous membrane petals back in place and apply 1-2 silk or kstgut sutures to the edges of the incision. The operation is completed with a dense loop tamponade according to V. I. Voyachek with tampons soaked in vaseline oil with an antibiotic suspension. Apply a horizontal sling-like bandage, which should be replaced with a fresh one before going to bed. The tampons are removed after 2-3 days.

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