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The nasal septum is an important structure in the architecture of nasosinusal cavities. He represents a medial osteocartilaginous structure that separates the nasal cavities into two parts. It has an important function in maintaining the nasal structure and the physiology of breathing. Furthermore, nasal septum can to be interested in many disturbances and several pathologies: congenital, traumatic, infectious, inflammatory, toxic, tumoral (benign and malignant). Many surgical technical procedures have been described to overcome the various dysfunctions of the nasal septum.
Faculty of Medicine, University Hospital Center of Annaba, University Badji Mokhtar, Annaba, Algeria
*Address all correspondence to: smail.kharoubi17@gmail.com
1. Introduction
The nasal septum is one of the most fully conserved structures in vertebrates. It separates nasal cavity into two airways dividing the two nostrils. The nasal septum has mixed structures; cartilage in the anterior part and bones in posterior part. The nasal septum transforms the nasal airway into a parallel circuit and supports the nasal dorsum. Nasal septal pathologies may cause nasal airway obstruction, epistaxis, perforation, smell disorders, rhinorrhea and cosmetic deformity.
The nasal septum is included in many pathologies: infectious, inflammatory and systemic diseases, tumors, deviations and cysts (congenital and acquired). The diagnosis of these entities may require culture, imaging, specialized laboratory testing and biopsy.
In practice, nasal septum pathology is dominated by architectural disturbances (deviations), perforation (toxic etiology-cocaine), tumors (benign and malignant), and mucosal infiltration in systemic diseases. The approach is based primarily on anamnesis, physical exam (endoscopy), imaging and biopsy (suspected lesions).
Furthermore, nasal septum may be concerned by uncommon and rare pathologies and required a delicate approach and a large documentation to understand a lot of anatomic, functional or pathologic disturbances.
The surgical approach of nasal septum anomalies benefited substantially and in many cases by endoscopic endonasal surgery.
The nasal placodes, oval thickenings of surface ectoderm, develop inferior and lateral to the frontonasal prominence at the end of the fourth week of the embryonic period. They contain mesenchyme near the outer edges that begin to proliferate to form the medial and lateral nasal prominences. As a result, the nasal placodes reside in deep nasal pits, which are the primitive anterior nares and nasal cavities.
The lateral nasal prominences form the alae of the nose. The medial nasal prominences forms the nasal septum, ethmoid bone, and cribriform plate [1].
The nasal septum is midline structure of the nose constituted by three parts:
Small anterior membranous portion.
Cartilaginous portion: The septal cartilage, which has a quadrilateral shape, extents from the anterior face including the columella (the visible soft part of the septum separating the nostrils) to posterior at the margins of the ethmoid bone and vomer.
Bony portion: The perpendicular plate of the ethmoid bone (supero posterior) and the vomer (infero posterior) meet and articulate diagonally [2].
The nasal septum is the dividing wall between the two nasal cavities and participates in the sense of smell because its upper part contains olfactory cells (Figure 1).
Figure 1.
Anatomy of nasal septum. 1. Perpendicular plate of ethmoid, 2. nasal bone, 3. choanae, 4. vomer, 5. quadrangular cartilage, 6. nasal crest of maxillary bones, 7. medial crura.
The blood supply to the septum includes branches of the sphenopalatine artery, the ethmoidal artery, and the facial artery (Figure 2) [3].
Figure 2.
Blood supply of nasal septum.
Kiesselbach’s Plexus (Little’s Area): Kiesselbach’s plexus is a vascular anastomosis between the anterior ethmoid artery, superior labial artery, greater palatine artery, and the terminal branch of the posterior septal branch of the sphenopalatine artery. This vascular plexus is located in the anterior nasal septum and is the most common site of epistaxis [4].
3.2 Endoscopic anatomy
The practitioner can utilize flexible or a rigid endoscope without or after local anesthesia. The nasal septum divides the nasal cavity into two sides. The nasal septum comprises cartilage anteriorly and bone posteriorly. Septal mucous is reddish with or without mucous secretions and can present a variety of architectural anomalies: deviate (superior, inferior, posterior), septal spur, thickening or deposit mucous (Figures 3 and 4) [5].
Figure 3.
Endoscopic view left side nasal septum (anterior, posterior pre choanal).
The mucous membrane is predominantly respiratory with a small area of olfactory epithelium superiorly adjacent to the cribriform plate. Respiratory epithelium is composed of ciliated and non-ciliated pseudo stratified columnar cells, basal pluripotential stem cells and goblet cells. Seromucinous glands are present in submucosa and are more important in mucus production in the nasal cavity [6].
Inspection of the external nose in relation of the face. Palpation of nasal soft tissues, bones structures, columella, alar cartilages.
5.2 Objective investigation
Nasal endoscopy authorizes evaluation of endonasal cavity, the right and left side of septum in anterior, medium and posterior parts. We can appreciate architectural, mucous and neoformations. In this procedure, we make different sampling; bacteriology, cytology (eosinophilic cell), or biopsy if necessary.
Rhinomanometry measures air pressure and the rate of airflow during breathing and used to calculate nasal airway resistance. Authors consider rhinomanometry is an indispensable aid in the selection of patients for functional septoplasty and for assessing the results of operation.
Acoustic rhinometry uses a reflected sound signal to measure the cross-sectional area and volume of the nasal passage. This examination enables us to detect the presence of a nasal respiratory obstruction and to evaluate the structures that mostly cause it (turbinates, septum).
Olfactometry, measurement and control of odors [7].
6.1.1 Congenital absence of the nasal septum (hyporhynia)
Congenital absence of the nasal septum is an abnormality of facial embryogenesis in which there is absence or deficiency of the soft tissues that make up the external nasal structures. It is an extremely rare condition and frequently occurs in association with other congenital anomalies of the craniofacial area and the central nervous system (microcephaly, preauricular tags) [12, 13].
6.1.2 Congenital vomer agenesis
Vomer agenesis is a rare anomaly reported presented with symptoms, such as nasal obstruction, posterior nasal dripping, and coughing. Diagnosis is made easily after endoscopic or imaging investigation (Figure 8) [14].
In this anomaly embryologically there might have been a change in expression of bone morphogenetic protein in the frontonasal area leading to caudal extension of the nasal bone. This in turn interferes with the fusion of nasal septum resulting in the bifid septum and dual dome morphology [15].
6.2 Deviated nasal septum
Up to 90% of people have nasal septal deviations, but the majority is asymptomatic. Deviation of nasal septum is a frequent etiology of nasal airway obstruction, in which the nasal septum is displaced [16].
Examination: external examination evaluate the nasal dorsum, columella, caudal septum. Nasal endoscopy are helpful in diagnosing the location, type and severity of septal deformity (Table 1). Also identifying polyps, posterior septal deviations, bony spurs and turbinal anomalies (concha bullosa) (Figure 9) [17].
COTTEL’S CLASSIFICATION: Type 1: simple deviated septum. Type 2: obstructed deviated septum. Type 3: impacted deviated septum. DEPENDING ON THE SITE:
anterior or cartilaginous deviation.
posterior or bony deviation.
mixed or complex deviation.
TYPE OF DEVIATION: C-shape, S-shape, Caudal subluxation, Septal spur.
Table 1.
Classification of septum deviated.
Figure 9.
Endoscopic view of posterior (caudal- septal spur) nasal septum deviation.
Rhinometry, acoustic rhinometry, smell identification measurements complete para clinical evaluation. CT scan shows deviation (cartilaginous or osseous), size, and associated disturbances (Figures 10 and 11).
Figure 10.
CT scan septal deviation (left) and turbinal hypertrophy (right).
Figure 11.
CT scan (axial) septal deviation (right).
6.2.3 Therapy
Septoplasty is a tissue-sparing procedure. The area of deviation is corrected or resected in order to leave behind as much cartilage and bone as possible.
Cartilage resection is minimized and can be repositioned, reshaped or recontroured, using a variety of methods.
6.2.4 Evolution
Frequent complications include haematoma, abscess, cerebrospinal fluid leak (avulsion or damage to cribriform plate). Other complications include synechiae, residual deviation, septal perforation and cosmetic nasal deformities.
6.3 Septal perforation
Nasal septal perforation is a full-thickness defect of the nasal septum. Nasal septal perforations occur with disintegration of the septal anatomy and also can impair in nasal physiology not only for anatomical reasons but also for mucosa dysfunction.
Frequency of this pathology in unknown, in Swedish population the prevalence of septal perforation is 0.9% [8].
6.3.1 Etiology
Nasal septal perforation etiologies include trauma, autoimmune, infectious (syphilis, fungal disease, tuberculosis), or neoplastic (Tables 2 and 3).
Nasal Septal Perforation in Children Mean age: 10 years. Signs: epistaxis, nasal crusting. Etiologies: Trauma (digital nasal trauma, button batteries) iatrogenic sources, neoplasm. Site of perforation: anterior septum. Average size: 1 cm. Treatment:
Iatrogenic septal perforation can occur after patient self-manipulation, after cautery for epistaxis, or after elective septoplasty [18, 19, 20].
We also found intranasal drug abuse, steroid nasal spray, vasoconstrictor nasal spray.
6.3.2 Diagnosis
Signs and symptoms: Symptoms can include nasal obstruction, whistling, epistaxis, crusting, pain, rhinorrhea, chronic rhinosinusitis, or foul smell.
Endoscopic exam can noting details of perforation: size, measurements, quality of borders, distance between columella and choanal area, mucous around perforation. Biopsy of perforation borders is performed when the cause is less clear (Figure 12).
Figure 12.
Endoscopic aspect of septal perforation.
Septal perforation can to classified according to size and we recognize: small perforation (<1 cm in diameter), medium perforation (1–2 cm) and large (>2 cm).
Workup laboratory can be helping us especially in specific and general diseases. we practice blood screening, ANCA, ACE, PCR and QUANTIFERON if tuberculosis is suspected, serology of syphilis.
Imaging may be indicated and can include CT scan of the sinuses and 2D MRI (Figures 13 and 14).
Figure 13.
CT axial septal perforation.
Figure 14.
Lateral sagittal selected view: Middle perforation (iconography-Mocella S. Ref. [21]).
6.3.3 Therapy
Medical management: local measures, intranasal hydration, lubricant, antibiotic lotions, and hemostatic agents in the event of epistaxis.
Septal button: designed for non-surgical closure of septal perforation, made of soft silicone (Figure 15).
Figure 15.
Septal nasal button.
Surgical management: many types of surgical repair have been described easily or not and with successful variable results. The literature review reports many procedures: bilateral mucoperichondrial flap repair with an interpositional graft, staged inferior turbinate flap, acellular dermis graft, auricular cartilage interposition, facial artery musculomucosal (FAMM) flap, autologous fascia lata graft, temporoparietal fascia graft, nasal labial flaps, sublabial flaps, mastoid periosteum.
Small perforations can be successfully repaired, by surgery but closure may be to be difficult in larger perforations and has the risk of failure.
6.3.3.1 Indications
small perforation: septal button, surgical bilateral flap (rhinoplasty procedure or endoscopic repair).
large perforation (superior to 20 mm): surgical bilateral flap, posterior septal resection (attenuate mitigate symptoms).
6.3.4 Evolution
Large septal perforations >20 mm have a higher failure rate after the repair than smaller ones. Success rates of effective closure and resolution of symptoms remain variable, with reported success rates of 30–100% [22].
6.4 Traumatic pathology of nasal septum
6.4.1 Nasal septum fracture
The nasal bone and nasal septum are the most commonly fractured bones in the facial skeleton. Nasal septal fractures have been associated with nasal bone fractures in 42–96% of cases [23].
Nasal bone and septal fractures are much more common in men and boys compared to women and girls.
6.4.1.1 Etiology
The most common causes of nasal bone and septal fractures globally are traumatic: interpersonal violence, motor vehicle accident, sporting accidents, falls.
6.4.1.2 Diagnosis
It is essential to determine the mechanism of trauma and the direction of impact. Praticien will to determinate premorbid appearance of patients and asked if they notice obvious deviation or deformity compared to before injury. The patient should also be questioned regarding any prior nasal trauma or surgeries.
External examination evaluate deviation of nose, quality of skin (ecchymose, wound, ulceration). Endonasal evaluation with nasal speculum or rigid endoscope show septal deviation, septal hematoma, intranasal lacerations or mucosal disruptions.
A CT scan without intravenous contrast of the facial bones is the gold standard for evaluating bony trauma of the maxillofacial area if there is a concern for more extensive facial injuries. CT scan show bone and septum fracture with or without displacement (Figure 16).
Figure 16.
Coexistent fracture with involvement of the nasal septum (red arrow).
6.4.1.3 Therapy
Observation without surgical intervention is recommended in patients who do not have an obvious cosmetic deformity or nasal obstruction. Closed reduction of nasal bone and septal fractures is generally recommended for fractures that cause nasal deviation or airway obstruction. The reported timing of closed reduction varies in the literature, with some sources advocating early intervention within five to 7 days. Closed reduction may also be performed on the nasal septum using a Asch forceps or Martin clamp and a postoperative splint is applied to the nasal dorsum.
6.4.1.4 Evolution
Nasal deformity remains present in 9–50% of patients after closed reduction [24]. The difficult or late cases can be performed by open septorhinoplasty after 3 to 6 months post-injury.
6.4.2 Septal hematoma
A septal hematoma is blood collection under the perichondrium of the septum, which separates the vascular supply from the underlying cartilage. It may be unilateral or bilateral.
The incidence of septal hematoma remains unknown and a large number of cases are undiagnosed.
Surgery of septum (septal correction), sinuses or turbinate surgery.
Anticoagulant and antiplatelet therapy.
Blood diseases and diathesis (heamophilia, leukemia) [25].
6.4.2.2 Diagnosis
Signs and symptoms: include nasal airway obstruction with pain, swelling, philtrum and upper lip hematoma or ecchymosis, rhinorrhea.
rhinoscopy showed asymmetry of the septum with bluish or reddish mucosal swelling. Fells and fluctuant consistence is found after palpation with swab and confirm collection (Figures 17 and 18) [26, 27].
Figure 17.
Bilateral septal hematoma.
Figure 18.
CT coronal bilateral septum hematoma.
CT scan may be considered in difficult cases or if the diagnosis is equivocal on physical exam.
6.4.2.3 Therapy
Therapy consist of a drainage through a mucoperichondrial incision and evacuation of collection. The incision is given in the anteroposterior direction parallel to the nasal floor. Splints or transeptal dissolving suture or bilateral nasal packing are placed to obliterate the potential space and prevent collection.
Antibiotic drugs (staphylococcus) is admitted to infection prevent into 7 days.
6.4.2.4 Evolution
It can result cartilage necrosis within 3 days and developing perforation, saddle-nose deformity, columellar retraction, surinfection. Immediate treatment is necessary to prevent those problems.
6.4.3 Nasal septal abscess
6.4.3.1 Etiology
Trauma is the leading cause of nasal septum abscess (surinfection of nasal septal hematoma).the most common trauma is associated with accidents, falls, fights, nasal packing, nasogastric intubation, septal surgery, septal cauterization (electric, radiofrequency).
Nasal septal abscess has been caused also by sinusitis (ethmoiditis, sphenoiditidis), dental origin [28, 29].
An uncommon etiology has been reported in literature; nasal septum abscess complicate nasal swab test in COVID-19. Indeed, Fabbris reported one case of nasal septum abscess after a nasal swab test in 4876 cases for SARS-CoV2 screening [30].
6.4.3.2 Bacteriology
Aerobic bacteria are the most common cause of nasal septum abscess: staphylococcus aureus, pneumococcus, haemophilus influenzae, fungal infection, anaerobic bacteria (peptostreptococcus, fusobacterium, propionibacterium).
6.4.3.3 Diagnosis
signs and symptoms: The most frequent symptoms nasal obstruction, earache, purulent rhinorrhea, headache, fever.
clinical assessment with rhinoscope or nasal endoscope shows a bilateral fluctuant septal swelling with erythema of septal mucous and around the nasal vestibule. Palpation with swab is painful and the puncture will bring back pus.
Imaging (CT scan) authorize diagnostic and many informations: location, size, state of sinuses, measurements, and loco-regional complications (Figure 19).
Figure 19.
Coronal and axial CT-scan. Nasal septum abscess.
6.4.3.4 Therapy
If nasal septal abscess is diagnosed, rapid decompression of subperiochondrial collection should be performed through surgical incision, drainage and nasal packing during 48 hours. Systemic antibiotics is performed during 7 days (augumentin, penicillin, cloxacillin, and cefuroxime).
6.4.3.5 Evolution
Safety management of nasal septal abscess prevent serious intracranial and orbital complications and cosmetic deformity.
6.5 Infectious pathology of nasal septum
6.5.1 Non specific infectious
Acute rhinitis and rhinosinusitis is an inflammatory disease affecting the nose and paranasal sinuses [31].
Clinical examination: congestion of oropharynx and sensible adenopathy. In endonasal exam nasal mucosa is thick, with redness and swelling. We can see congestion and hyper vascularisation in septal mucous. Mucopurulent secretions occupied nasal fossa (Figure 20). Nasal swab is not necessary at this step and will be recommended if symptoms duration, complications, or co-morbidity. Imaging and laboratory workup is not done in majority of time.
Figure 20.
Acute rhinitis - endoscopic view (redness septal and turbinal mucous).
6.5.1.4 Therapy
Nasal irrigation (saline solution), Intranasal decongestants, paracetamol, aspirin during 3 or 4 days. Vitamin (C), zinc, herbal medicines.
Antibiotherapy if bacterial rhinitis or co-morbidity.
6.5.1.5 Evolution
In majority of cases the evolution is simple after a few days. Complications affecting paranasal sinus (rhinosinusitis), orbit, or chest (pneumopathy).
Nasal endoscopy: congestion, nasal discharge, ulceration, nodular lesions, anomalies of mucous (infiltration, swelling, multiple ulceration, necrosis, pus), cartilage lysis, bone lysis and, bone sequestrum [32, 33].
Workup laboratory and imaging help to diagnosis, staging of disease, treatment follow-up, complications and health community screening.
6.5.2.2 Nasal septal tuberculosis
Tuberculosis is the second most common infection, affecting the humans in the world. Nasal tuberculosis is usually due to extension from primary pulmonary or from facial tuberculosis.
Bacteriology: mycobecterium tuberculosis.
Signs and symptoms: epistaxis, nasal airway obstruction, nasal crusting, rhinorrhea.
Nasal examination: rhinoscopy or endonasal endoscopy after aspiration can shows a many variable aspects. Swelling, nodular nasal mucous, ulceration, septum perforation (Figure 21).
Figure 21.
Erosion of superior-most aspect of nasal sepum (septal tuerculosis). (iconography-Sagar P. Ref. [34]).
The diagnosis is established by isolating acid-fast bacilli from tissue excised or nasal secretions by nasal swab. Another biological tests are developing last years from rapid diagnosis like PCR test, T-SPOT-TB, QUANTIFERON-TB GOLD.
Therapy: Anti-tuberculous drugs (4 drogues during 6 moths). INH, rifamycin, ethambutol, pyrazinamide during 2 months and INH, rifampicin during 4 months.
6.5.2.3 Nasal septal syphilis
Bacteriology: spirochete - Treponema pallidum.
Signs and symptoms: nasal cosmetic deformity, nasal crusting, epistaxis
Nasal examination: swelling nasal mucous with hyper secretion (rich in leprae bacillus) and purulent discharge, yellowish white confluent nodular nasal mucous. We also describe a decolorized zone of 5 at 10 mm with red halo (vascular); Le Mee sign, backward muco cutaneous septal junction. During evolution nasal leprosy infection makes cartilaginous and bone destruction [37].
Imaging can show mucosal swelling, nasal cartilaginous and bone deformation and destruction.
Tumors of the nasal cavity is an uncommon disease and very diverse about histological variety (Table 4). Theses tumors are seen at any age without specificity in semiological aspect [38].
Clinical and para clinic workup: the management of nasal septal tumors is based on tree procedures. Nasal endoscopic evaluation (size, measurements, color, pedicle, extension), imaging (CTscan - MRI), biopsy. In some anatomo clinical varieties the result of biopsy is so difficult and we must analyze all the tumor specimen after surgery with modern biological procedure (immunohistochemistry, molecular biology).
Classification most frequent benign and malignant nasal tumors.
6.6.2 Benign tumors
Benign tumors are dominated by papillomas (epithelial variety) and hemangiomas (mesenchymal variety) (Table 4). Management of these tumors reposed in endoscopic evaluation, imaging and biopsy. Surgical procedure (endoscopic endonasal) is the gold standard treatment. Follow-up of these tumors is very important (relapse, malignant transformation) and based in endoscopy and imaging [39].
6.6.2.1 Benign tumors: anatomo clinic description of frequent varieties
6.6.2.1.1 Nasal septal hemangioma
It represents for about 31% of the entities of intranasal hemangiomas in adults. The origin is unknown. Trauma and hormonal factors may play a role in the pathogenesis of the hemangioma. There are three characteristic histologic subtypes: capillary, cavernous, and mixed hemangiomas. The signs and symptoms of intranasal hemangioma are mainly epistaxis, nasal obstruction, rhinorrhea, and pain. Endoscopic examination is necessary to diagnose intranasal hemangioma (Figure 22) [41].
Generally, it presents as a red or purple mass that bleeds easily in touch at endoscopy. MRI, the lesion appears with hyperintensity in T2 and spontaneous hypointensity in T1.
The treatment of choice is the endoscopic excision with histologically clear resection margins. The recurrence rate of these hemangiomas varies from 0–42% [38, 40].
6.6.2.1.2 Nasal septal papilloma
Inverted papilloma, also known as Schneiderian papilloma, is a benign neoplasm that is associated with three key biological characteristics: tendency to recur, capacity for local destruction, as well as a tendency towards malignant transformation in 3–10% of cases. Smoking, allergy or certain occupational exposures may play a role in the pathogenesis. Besides, human papilloma virus (HPV) has been suspected of playing a major role in the pathophysiology of inverted papilloma. The signs and symptoms of intranasal papilloma are mainly nasal airway obstruction, rhinorrhea, epistaxis, epiphora, and facial pain. In 4–23% of cases, the lesion is asymptomatic and discovered serendipitously [42]. Endoscopic exploration of the nasal cavities finds a reddish-gray lobulated tumor, more firm than an inflammatory polyp (Figure 23). In MRI hyposignal in T1 on T2 weighted sequences, the tumor is generally iso- or hypo-intense. Treatment of inverted papilloma is surgical (external approach or endonasal endoscopic approach).
Figure 23.
Endoscopic view - nasal inverted papilloma.
6.6.2.1.3 Nasal septal schwannoma
Schwannomas arising from the nasal septum are much rarer.. Nasal septal schwannoma most often presents with unilateral nasal obstruction, epistaxis, headache or rhinorrhoea in that order of frequency. Epistaxis, if present, could be due to secondary ulceration or erosion of the surface mucosa. Examination, any sinonasal schwannomas including that attached to the septum would appear as a smooth-surfaced, mucosa-covered mass in the nasal cavity (Figure 24). CT findings of sinonasal schwannoma include homogenous soft-tissue opacity with or without bony erosion. MRI, sinonasal schwannomas would appear as intermediate signal intensity lesions on T2-weighted images and would exhibit enhancement on giving contrast. Surgical excision is the treatment of choice (endoscopic approach) [43].
Figure 24.
Nasal endoscopic schwannoma (iconography-Alrasheed W. Ref. [43]).
6.6.3 Malignant tumors
Malignant tumors are dominated by squamous carcinoma (epithelial variety), adenocarcinoma, nasal lymphoma (NT/K) and mucosal malignant melanoma (mesenchymal variety) (Table 4). Management of these tumors reposed in endoscopic evaluation, imaging and biopsy. Surgical procedure is the gold standard treatment associated with radiotherapy. The role of chemotherapy is unclear and applies generally to palliative therapy [38].
6.6.3.1 Malignants tumors: anatomo clinic description of frequent varieties
6.6.3.1.1 Nasal septal epidermoid carcinoma
Sinonasal squamous carcinoma cell have been decreasing in recent years. Tumors occur predominantly in men in their 50’s and 60’s.Chief complaints are primarily nasal obstruction, facial pain, rhinorrhea, and epistaxis (bleeding). Diagnosis required endoscopic evaluation (site of implantation, extension), imaging (CTscan, RMI, TEP scan) and tumor biopsy (Figure 25). Global evaluation and TNM classification help making therapeutic protocol. Treatment varies somewhat depending on the stage, patient performance status, comorbidities. Surgical resection (external or endoscopic) with post operative radiotherapy appears to be the optimal approach. The prognosis remains poor averaging 50% at 5 years [44, 45].
Extranodal natural killer (NK) cell/T-cell lymphoma, nasal type, is an aggressive peripheral T-cell lymphoma with an historic median survival of less than 2 years. The classic presentation involves a palatal perforation, or epistaxis, rhinorrhea, nasal airway obstruction. Work-up of nasal lymphoma includes dedicated imaging of the nasal sinuses by magnetic resonance imaging or computed tomography. Direct visualization with nasal endoscopy and biopsy is critical for the diagnosis. Lesions demonstrate extensive angioinvasion and necrosis as well as positive staining for CD2, CD56, cytoplasmic CD3 (but not surface CD3), and cytotoxic markers. There are three major approaches to therapy: sequential therapy with chemotherapy followed by consolidative radiation; concurrent radiation and chemotherapy; or radiation therapy (RT) alone (Figure 26) [46].
Mucosal malignant melanoma (MM) is a rare malignancy. It comprises about 1% of all melanomas with an aggressive natural history and poor long-term prognosis. Epistaxis, nasal airway obstruction, rhinorrhea and pain are frequently reported. Nasal endoscopy showed a red-purple or black colored mass. MRI is useful for melanoma diagnosis and typically shows a high signal intensity on T1- and a low signal intensity signal on T2-weighted images. Surgery is regarded as the first-line treatment for malignant mucosal melanomas. Radiotherapy is suggested in cases of residual tumor cells in the surgical margins or local recurrence. Chemotherapy is applied for palliative treatment or in metastatic cases. Immunotherapy’s, such as anti-PD1/PDL-1 agents, have been suggested with inconstant results (Figure 27) [47].
Epistaxis is most commonly classified into anterior or posterior bleeds. More than 90% of episodes of epistaxis occur along the anterior nasal septum which is supplied by Keisselbach’s plexus in a site known as the Little’s area (Figure 28).
Figure 28.
Keisselbach plexus (nasal endoscopy).
Etiology: The cause of epistaxis can be divided into local, systemic, environmental, medications or, in the majority of cases, idiopathic [48]. Local causes of epistaxis include trauma, neoplasia, septal abnormality, inflammatory diseases and iatrogenic causes. Local trauma is common among children who present with post-digital trauma or irritation. In 65–70% of cases of epistaxis, simple first aid measures provided by the primary care physician. If bleeding persists and visible most cases of epistaxis can be successfully treated using electrical, chemical cautery.
Saline irrigation: sodium chloride irrigation solution 0.9%. Nasal saline irrigation hypothesized to function by thinning mucous, improving mucociliary clearance, decreasing edema, and reducing antigen load in the nasal cavity.
Nasal decrusting: oily solution, oily ointment and extraction with Lubet-Barbon nasal dressing forceps.
Rigid endoscope 4 mm, 0°. Local infiltration (lidocaine 2% with 1/100000 adrenaline), Killian incision was made using N° 15 blade on the side of deviation. The submucosal flaps were elevated and the deviated segment was removed with an adequate strut left intact to prevent columellar collapse. Cartilage was replaced and nasal packing was used [49].
Open septoplasty approach is used and bilateral septal flaps are elevated. The inferior turbinate flap is harvested. The inferior turbinate flap is passed through the septal perforation laid under the eggs of the ipsilateral septal perforation and secured to the controlateral nasal septal flap (PDS 5–0 sutures) [50].
9. Rare and uncommon nasal septal pathology: about few cases
9.1 Nasal septum pneumatisation
Pneumatisation of the nasal septum is rarely observed (0% to 4§). In some cases, this pneumatisation may narrow the spheno-ethmoidal recess thereby limiting access to the sphenoid ostium (Figure 29) [2].
Figure 29.
Nasal septum pneumatisation (white arrow). (iconography-Celina F. Ref. [2]).
9.2 Nasal septal swell body
The nasal septal swell body is a distinct structure located in the anterior part of the nasal septum adjacent of the anterior part of the middle turbinate contains bone and cartilage components (Figure 30).
Nasal dermal cyst present habitually as a mass from the glabella to columella. In this case the lesion developed in the nasal septum (Figure 31).
Figure 31.
CT scan lobuled cystic mass within the nasal septum extending into frontal sinus. (iconography-Lee DH. Ref. [52]).
9.4 Nasal septal mucoceles
Nasal septal mucoceles are rare and seen after surgery, trauma or idiopathic etiology. Nasalairway obstruction is principal symptom and diagnosed by imaging (CT scan, RMI) (Figure 32).
9.5 Nasal septal mucosa localisation of rosai dorfman disease
Rosai-Dorfman is an agnogenic rare benign histiocytic proliferative disease and can be classified as lymph node, extra-nodal or mixed. The nasal cavity and sinuses are usual sites of extra nodal invasion commonly presented with nasal obstruction and epistaxis (nasal septal is rarely invaded). Diagnosis is make after biopsy and biologics evaluation. Hormones, antibiotics, immunomodulatory therapy, local low-dose radiotherapy, chemotherapy, target therapy can be used (Figure 33) [54].
The nasal septum disturbances are heavily dominated by architectural anomalies (deviations) and perforations. In other cases, we can be confronted with inflammatory or tumoral pathologies. The approach needs to be speedy and targeted: endoscopic exam, imaging, laboratory testing, and biopsy. We must differentiated local or autonomous nasal septum disease and systemic projection. Therapeutic management using medical nursing (nasal irrigation and local topics) and surgical correction especially by endonasal endoscopic technic’s. We must observe the quality of life of patients and the acceptable cosmetic aspect.
Conflict of interest
No conflict of interest.
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Written By
Kharoubi Smail
Submitted: 21 May 2023Reviewed: 04 July 2023Published: 03 April 2024
Open access peer-reviewed chapter
