Nasal Septum & Epistaxis Flashcards
What are the three parts of the septal skeleton?
septum proper, columellar septum, membranous septum
What bones contribute to the septum proper?
- Ethmoid perpendicular plate
- Vomer
- Maxilla - crest & ant spine
- Palatine - crest
- Quadrangular cartilage
- Nasal - crest
- Frontal - Nasal spine
- Sphenoid - Rostrum
What is the columellar septum formed of?
columella containing the medial crura of alar cartilages united by fibrous tissue and covered by skin
What does the membranous septum consist of?
a double layer of skin with no bony or cartilaginous support
Where does the membranous septum lie?
between the columella and the caudal border of septal cartilage
What are the common causes of septal deviation?
- Developmental factors
- Adenoid hypertrophy
- Cleft lip and palate
- Dental abnormalities
- Hereditary factors
True or False: Septal deviation can result from hereditary factors.
True
What is the management for epistaxis?
Immediate nasal packing if epistaxis present.
What should be done if a hematoma has formed?
Immediate incision and drainage if hematoma formed.
What is the immediate action for a grossly displaced fracture?
Immediate reduction using Asch forceps for septal fractures and Walsham forceps for nasal bone fractures.
What should be done if reduction is difficult due to oedema?
Wait for 7-10 days and then do reduction.
What happens if reduction is delayed for more than 2-3 weeks?
Callus formation and bone remodelling occur, making reduction difficult.
What procedure is needed if reduction is delayed for more than 3 months?
Open septo-rhinoplasty needs to be done.
What is the most common cause of septal deviation?
Trauma during birth (nose gets pressed while passing through birth canal).
What are other causes of septal deviation?
- Developmental error
- Adenoid hypertrophy
- Cleft lip and palate
- Dental abnormalities
- Hereditary
What occurs in chronic cases of septal deviation?
Opposite side inferior turbinate hypertrophy as a physiological compensation.
What are the types of septal deviation?
- S-shaped deflection
- C-shaped deflection
- Nasal spur impinging on turbinate
- Thickening of nasal septum
- Anterior dislocation
What are some clinical features of septal deviation?
- Nasal obstruction
- Headache
- Sinusitis
- Epistaxis
- Anosmia
- External deformity
- Middle ear infection
What is Ethmoid neuralgia also known as?
Anterior ethmoidal nerve syndrome.
What causes the headache in Ethmoid neuralgia?
Branches of anterior ethmoidal nerve get compressed by middle turbinate.
What does the Cottle test assess?
It assesses the nasal valve’s ability to open and increase airflow from the nasal cavity side when the cheek is pulled away from the midline.
What is the difference between Submucous resection (SMR) and Septoplasty?
In SMR, the deviated part of the septum is removed and flaps are sutured back, while in Septoplasty, the deviated part is reshaped and kept back.
What is a septal hematoma?
A collection of blood between the cartilage and its perichondrium.
What are some causes of septal hematoma?
- Trauma
- Surgery
- Bleeding disorders
What are the clinical features of septal hematoma?
- Bilateral obstruction
- Frontal headache
- Sense of pressure over the nasal bridge
How is septal hematoma examined?
It presents as a smooth rounded swelling of the septum in both cavities and is soft and fluctuant on palpation.
What is the treatment for septal hematoma?
Incision and drainage immediately, followed by packing and antibiotics.
What are the complications of septal hematoma?
- Fibrous change leading to a permanently thickened septum
- Secondary infection causing abscess with cartilage necrosis
What is a septal abscess?
An abscess that results from a secondary infection of a hematoma, following a furuncle of the nose or upper lip, or after acute infections like typhoid or measles.
What are the clinical features of a septal abscess?
- Bilateral obstruction
- Pain and tenderness over the nasal bridge
- Fever with chills
- Frontal headache
- Red and swollen skin over the nose
How is a septal abscess examined?
It shows bilateral swelling of the nasal septum, fluctuant, and congested mucosa.
What is the treatment for a septal abscess?
Incision in the most dependent part, excision of a piece of septal mucosa, reopening incisions daily for 2-3 days to drain pus, and systemic antibiotics.
What are the complications of a septal abscess?
- Perforations
- Meningitis
- Cavernous sinus thrombosis due to the involvement of the danger zone
What is a septal perforation?
A through and through defect of the nasal septum
Septal perforation can result from various causes, including trauma, infections, and systemic disorders.
What are the common causes of septal perforation?
- Trauma (iatrogenic-SMR)
- Nasal steroid and decongestant sprays
- Infections like syphilis and leprosy
- Systemic disorders like Wegener’s, sarcoidosis, and SLE
Iatrogenic refers to an injury or condition caused by medical treatment.
What is the most common location for septal perforation?
Anterior quadrilateral cartilage
This area is particularly susceptible due to its structure and blood supply.
What are the clinical features of septal perforation?
- Whistling (if small)
- Dryness and crusting (if anterior and large)
- Recurrent epistaxis (due to inflammation at margins)
Epistaxis refers to bleeding from the nose.
What is the management approach for septal perforation?
- Enlarge the perforation if whistling is the main trouble
- Close the perforation using silastic buttons, free grafts, or pedicled flaps (rotation/advancement)
Management strategies depend on the severity and symptoms caused by the perforation.
What is the blood supply of the nasal septum?
- Internal carotid system (anterior & posterior ethmoidal branches of ophthalmic)
- External carotid system (superior labial branch of facial, greater palatine, sphenopalatine branch of maxillary)
Understanding the blood supply is crucial for surgical interventions and management of septal perforations.
True or False: The anterior ethmoidal artery is part of the blood supply for the nasal septum.
True
The anterior ethmoidal artery is one of the branches of the internal carotid system supplying the nasal septum.
Fill in the blank: The _______ branch of the maxillary artery supplies the nasal septum.
sphenopalatine
The sphenopalatine branch is a significant contributor to the blood supply of the nasal area.
What is Little’s area?
A region in the nasal cavity that is a common site for epistaxis
Little’s area is important in the context of nasal bleeding and perforation.
What is Woodruff’s plexus?
A network of veins located in the nasal cavity that can be involved in epistaxis
Understanding Woodruff’s plexus is essential for managing nasal bleeding.
What is Little’s Area?
It is situated in the anterior inferior part of the nasal septum, just above the vestibule
It is an important site for epistaxis due to the vascular plexus formed here.
Which arteries form Kiesselbach’s plexus?
- Anterior ethmoidal
- Septal branch of superior labial
- Septal branch of sphenopalatine
- Greater palatine
This plexus is the usual site for epistaxis in children and young adults.
What is the most common site for epistaxis in children?
Little’s area
It is often caused by finger nail trauma.
What is the significance of the sphenopalatine artery?
It forms the majority of blood supply to the nasal septum, hence called the ‘artery of epistaxis’
It plays a key role in cases of nasal bleeding.
Where does the retro columellar vein run?
It runs vertically downwards just behind the columella and crosses the floor of the nose
This vein is a common site of venous bleeding in young people.
What is Woodruff’s plexus?
A plexus of veins situated inferior to the posterior end of the inferior turbinate
It is a site of posterior epistaxis in adults, commonly associated with hypertension.
What is the dangerous area of the face?
Anteroinferior part of the nose and region above the upper lip anteriorly
Infections from this area have a higher chance to spread into the cranium due to connections with deep facial veins.
What is the most common cause of epistaxis in adults?
Hypertension
In children, the most common cause is nose picking.
What causes unilateral bleeding from foreign bodies in the nose?
Foreign bodies generally cause unilateral bleeding
This is especially true in cases of nasal obstruction.
What condition should be suspected in adolescent males with profuse nasal bleeding?
Juvenile Nasopharyngeal Angiofibroma (JNA)
This condition is characterized by significant bleeding.
What are some other causes of epistaxis?
- Septal spur
- Patients on anticoagulants
- Patients on topical steroid sprays for hereditary hemorrhagic telangiectasia
- Bleeding disorders like hemophilia
Genetic conditions can also contribute to epistaxis.
What is the initial treatment for epistaxis?
Trotter
Other methods include chemical cauterization and anterior nasal packing.
What is the Osler-Weber-Rendu syndrome?
An autosomal dominant condition associated with vascular malformations
It features symptoms such as bleeding from multiple sites, including the lungs and spleen.
