Section 3


Describe the abnormality shown in the picture.

Saddle nose deformity

Name 3 possible causes for the above

  • Trauma
  • Post septoplasty
  • Relapsing polychondritis
  • Cocaine abuse
  • Lupus
  • Syphilis

How would you manage this?

Septorhinoplasty

Name 4 components forming the nasal septum

  • Perpendicular plate of the ethmoid
  • Vomer
  • Quadrilateral cartilage
  • Maxillary crest

Supporting Information

Septoplasty 

Indications: improve nasal airway and cosmesis. 

  1. Infiltrate local anaesthetic into the submucoperichondrial plane.
  2. Incision into anterior nasal septum
    1. Killians
    2. Hemitransfixion
  3. Nasal mucosa is lifted off the septum both sides until the perpendicular plate of the ethmoid and the vomar are reached.
  4. Adjustments are made to the cartilage, perpendicular plate of ethmoid and maxillary crest so the septum lies straight.
  5. Care taken to not remove anterior structures–> saddle nose deformity
  6. Turbinate reduction may be done also. 

Risks – bleeding, infection, saddle nose, septal perforation/haematoma, no resolution of symptoms. 

Rhinoplasty – may be combined with septoplasty – cosmesis or nasal airway. Important to clarify expectations. Techniques:

  • Nasal dehumping
  • Osteotomies
  • Lower lateral cartilage rotation

Risks – bleeding, perforation, worsening of appearance, periorbital haematoma

Granulomatosis with polyangiitis causes destructive lesions in the upper and lower respiratory tracts. It causes glomerulonephritis with granuloma formation and destructive necrotising vasculitis. 

It is believed to be an immune reaction to infection. It can commonly present with nasal symptoms:

  • Crusting
  • Sanguineous discharge
  • Ulceration
  • External and middle ear damage
  • Biopsy = only way to diagnose
  • c-ANCA positive – cytoplasmic antineutrophil cytoplasmic antibodies

Treatment may be immunosuppressants and low dose antibiotics. 

Septal perforation– normally cartilaginous and anterior (if syphilitic- bony/posterior). Causes:

  • Trauma – picking nose, septoplasty, bilateral cautery
  • Infection – TB, syphilis, leprosy, septal abscess
  • inflammatory – wegeners, sarcoidosis
  • Neoplastic – SCC
  • Chemical – cocaine

Presentation – bleeding, whistling, saddle nose deformity, crusting if extensive→ blockage. Large perforations can cause rhinolalia – perceived nasal speech. 

Investigations– FBC, ESR, c-ANCA, pANCA, ACE, VDRL. CXR, UandE, urine dip

Treatment

  • Conservative – if asymptomatic- douching and cream. Avoid nasal cautery over bone.
  • Surgical – flap repair, septal button, if whistling make it larger. 

Anatomy of nasal septum

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