1. DR PRIYANKA

2.  Development
 Anatomy
 Septal diseases : deviated septum
septal perforation
septal fractures
involvement in systemic
diseases

3.  DEVELOPMENT
 Developin brain and pericardium forms two
prominent bulgings on the ventral aspect of
embryo separated by stomatodaeum
 Mesoderm covering the forebrain forms a
downward projection : frontonasal process
 Mandibular arch forms the lateral wall of the
stomatodaeum which gives off a bud nd grows
to form maxillary and mandibular process

4.  Ectoderm in frontonasal
process forms b/l localized
thickenings to form nasal
placodes.
 These sink below the surface
to form nasal pits.
 Edges of the pit are raised to
form the medial and lateral
nasal process

5.  Maxillary process grows
medially fuses with the
lateral nasal process and then
with the medial nasal
process
 Medial and the lateral nasal
process fuse

6.  Nasal septum develops with the fusion of maxillary
process and frontonasal process.
 Initially its entirely cartilagenous, together with
triangular cartilages forms a cartilagenous structure
that supports the nose from the crista galli to the lower
third of nose
 A midline ridge develops from the posterior edge of
frontonasal process in the roof of oral cavity and
extends posteriorly to the opening of the rathkes pouch
 This becomes the nasal septum which is continuous
with the partition anteriorly between the primitive
nasal cavities

7.  On either side of the anterior septum, an invagination
of ectoderm forms the vomeronasal organ :
rudimentary in humans
 Longitudinal strips of cartilage 7-15mm in length may
be identified in embryos lyin adjacent to the
vomeronasal organ on either side of the septal cartilage
 Cephalic part of septum ossifies from the
perpendicular plate of ethmoid bone.
 Vomer develops in the tissues covering the
posteroinferior part of septal cartilage

8.  Two ossification centres appear for vomer at 8th
week on eithr side of cartilage uniting to form a
deep groove in which the cartilage sits
 Nasal bones arise during 10th and 11th weeks

9.  ANATOMY
 NASAL SEPTUM HAS 3 PARTS :
 COLUMELLAR : Columellar septum. It is
formed of columella
Containing the medial crura of alar cartilages
united together by fibrous tissue and covered on
either side by skin.

10.  Membranous septum. It consists of double layer of
skin with no bony or cartilaginous support. It lies
between the columella and the caudal border of
septal Cartilage. Both columellar and membranous
parts are freely movable from side to side.

11.  Septum proper. It consists of osteocartilaginous
framework, covered with nasal mucous membrane.
 Cartilagenous portion composed of quadrilateral
cartliage, contributions from lower and upper
lateral cartilages.

13.  Quadrilatral cartilage(Septal cartilage) not only forms a
partition between the right and left nasal cavities but also
provides support to the tip and dorsum of cartilaginous
part of nose.
 Septal cartilage lies in a groove in the anterior edge of
vomer and rests anteriorly on anterior nasal spine
 Its destruction leads to drooping of nasal tip and
depression of nose
 is 3-4 mm thick in its centre and increases to 4-8 mm
anteroinferiorly, this is called the footplate
 Similar expansion of cartilage can be seen posteriorly
known as lateral posterior process at the junction of
lateral nasal cartilage
 Anteroinferior edge lies free in the columellar septum

14.  It sits inferiorly in the nasal crest of the
palatine process of maxilla
 Its anterosuperior margin is connected to the
posterior border of the internasal suture
 Distal end of superior margin is connected by
fibrous tissue on each side to the medial crurae
of the major alar cartilage
 Posterosuperior border is continuous with the
perpendicular plate of ethmoid
 Posterior septal angle formed where septum
articulates with the nasal spine anteroinferiorly

15.  A : Anterior septal
angle
 B mid septal angle
 C : posterior septal
angle

16.  Bony septum : mainly by perpendicular plate
of ethmoid and vomer
 Minor contributions : crest of nasal bone
nasal spine of frontal bone
rostrum of sphenoid
crest of palatine bone
crest of maxilla
anterior nasal spine of maxilla

18.  Bony septum: perpendicular plate of ethmoid forms
the superior and anterior bony septum, which is
continuous above with the cribriform plate and crista
galli.
 Vomer defined as keel shaped bone, extends anteriorly
from spenoid and superiorly from nasal crest of
maxilla and palatine bone.
 forms the posterior and inferior nasal septum and
articulates by its two alae with the rostrum of sphenoid
creating vomerinovaginal canals which transmit
pharyngeal branches of maxillary artery.

19.  Inferior border of vomer articulates with nasal
crest formed by maxillae and palatine bones.
 Anterior border articulates with perpendicular
plate of ethmoid and septal cartilage inferiorly.
 Posterior border forms the free edge

20.  ARTERIAL SUPPLY
 Internal and external carotid system
 Sphenopalatine artery : posteroinferior septum
 Greater palatine artery anteroinferior part of
septum
 Superior labial artery branch of facial artery
 anterior and posterior ethmoid arteries

22.  Sphenopalatine artery : enters through the
sphenopalatine foramen and immediately
divides into posterior septal and posterior
lateral rami
 Posterior septal branch runs medially across
the sphenoid to the posterior part of septum
 Takes course anteroinferiorly in
mucoperichondrium
 Terminal branches anastomose in littles area

23.  Anterior ethmoid artery traverses the anterior
ethmoid canal, descends into cavity through slit
by the side of crista galli, runs along inner
surface of nasal bone and supplies the nasal
septum
 Usually in a mesentry just below skull base
between ethmoid fovea and lamina papyracea
 Posterior ethmoid artery enters posterior
ethmoid foramen situated 5mm anterior to
optic canal,
 Gives nasal branches which enters nasal cavity
through the cribriform plate apertures and
anstomoses with sphenopalatine artery br.

24.  Nerve supply
 Maxillary division of trigeminal nerve
 Nasopalatine nerves supplies bulk of nasal
septum
 Enters via SPF passing medially across the roof
of upper septum and runs down and forwards to
incisive canal
 Anterosup part is supplied by the anterior
ethmoidal branch of nasociliary nerve
 Anteroinferior portion : anterior superior
alveolar nerve
 Posteroinf : nerve from pterygoid canal and
posteroinferior branch of anterior palatine nerve

26.  Aetiopathogenisis:
-Trauma inflicted from front, side or below.the
septum may buckle on itself, fracture vertically,
horizontally or get crushed.
-fracture of septal cartilage or its dislocation can
occur without nasal bones fracture in cases of
trauma to lower nose.

28.  Classification
 Nature of injury
 Extent of deformity
 Pattern of fracture

29.  Extent of deformity
 Grade 0 : bones perfectly straight
 Grade 1 : boones deviated less than half the
width of bridge of nose
 Grade 2: deviated half to full width
 Grade 3: deviated greater than one full width
 Grade 4: bones almost touching cheek

30.  Pattern of fracture
 Class 1: chevallet
 Low or moderate degrees of force
 Extent of deformity is less
 Simplest form is a depressed nasal bone
 Fractured segment is in position due to its inferior
attachment to upper lateral cartilages
 Nasal septum is not involved, except for in severe
injuries

31.  Fracture line runs parallel to nasomaxillary
suture, then connects across to contralateral
side runs paralleljust below the dorsum
 Cartilagenous septum is fractures 0.5 cm below
the dorsum may extend posteriorly into bony
septum through the perpndicular plate of
ethmoid
 Children : greenstick fracture

32.  Class 2 : jarjavay
 Significant cosmetic
deformity
 Fracture nasal bones with
frontal process of maxilla and
septum
 Grade 2
 Fracture begins just beneath
the nasal tip in quadrilateral
cartilage, extends posteriorly
through perp plate of ethmoid
to the anterior border of
vomer
 And runs forward through
lower part of perpendicular
plate of ethmoid into inferior
part of quadrilateral cartialge

33.  Frontal impact can cause gross flattening and
widening of dorsum
 Lateral blow can cause a high deviation of
nasal skeleton
 Perpendicular plate of ethmoid inevitably
involved
 Correction of both septum and nasal bones for
proper cosmetic results

34.  Class 3 : high velocity trauma
 Naso orbital ethmoid fractures
 Ass with # of maxilla
 Quadrilateral cartilage falls back
 Saddled nose, nostrils facing more anteriorly
like the snout of a pig

35.  Sypmtoms : nose bleed
 Nasal obstruction
 Diplopia, epiphora
 Watery rhinorrhea
 Hyposmia

36.  Signs : External deformity difficult to examine
in acute condition,
 Better seen after the edema has reduced
 Look for movements of eye
 Palpate the nose to look for : deformity,
deviation, crepitus, mobility, any tenderness
 Look for septal hematoma, abscess
 Investigation : xray nasal bone
 In severe facial injury : ct pns to be done

38.  Treatment
 Most patients don’t need any active treatment
 Reduction of fracture : under GA or LA
 Principle for reduction : mobilize the fragments
first by increasing and then decreasing the
degree of deformity
 An initial slight increase away from the side of
impact, followed by steady movement back
and then across the midline towards the side of
blow

41.  Instruments : freer
hiller
ashe
walsham forceps
Splints may be necessary

42.  Open reduction : b/l fractures with dislocation
of nasal dorsum and significant septal
deformity
 Fractures of cartilagenous pyramid
 Infraction of nasal dorsum

43.  Complications
 Residual deformity
 Nasal obstruction : septal deviation, collapse of
upper lateral cartilages, depressed nasal bones
 Septal complications : septal hematoma, septal
abscess
 Septal perforation

44.  DEVIATED NASAL SEPTUM
 Extremly common
 May be present at birth
 Etiology : trauma with or without nasal bone fractures
 Birth mouldin theory given by Gray
 Abnormal intrauterine postures with compression
forces acting on the nose and upper jaws
 Post natal trauma
 Childs nose is cartilagenous, any trauma can cause
irreversible deviation of cartilage

45.  Types :
 Spurs : sharp angulations occuring at the junction of
vomer below with the septal cartilage or ethmoid bone
above.
 Usually a result of vertical forces
 Fracture through the septal cartilage may also produce
spurs

46.  Deviations
 Cartilagenous, C or s
shaped deviations either
in vertical or horizontal
plane
 Cartilagenous deviations
: upper bony septum and
bony pyramid is central,
deviation of the
cartilagenous part

47.  C shaped: displacement
of upper bony septum to
one side and whole of
cartilagenous septum and
vault to opposite side
 S shaped : deviation of
middle third is opposite
to that of lower and
upper one third

48.  Disclocations : lower border
ofseptal cartilage displaced
from its median position and
projects into one of the
nostrils

49.  Symptoms : nasal obstruction
 Can be on the same side of the deviation or opposite
side because of the hypertrophic changes in turbinate
 Snoring
 Mucosal changes : dryness, crusting
 Neurologic pain : pressure exerted by septal deviations
on adjacent sensory nerves
 Anterior ethmoidal nerve syndrome
 Deviations in region of nasal valve cause greatest
obstruction : cottle test

51.  History of septal surgery
 19th century : dns was identified and treated
 Acute spurs and angulations were removed by shaving
down convexities
 Langenbeck 1843
 Dieffenbach 1845
 Chassaignac 1851
 Or complete removal of deviation with punch forceps
 Rubrent 1868
 Resulted : perforations

52.  Development of Submucus resection ( SMR )
 1881 Ingalls : earliest
 Refined by freers and killian
 Freers 1902 : radical approach
 Septal cartilage did not contribute to support of nasal
pyramid
 Septal cartilage culd be completely removed
 Saddling of dorsum in supratip region

53.  Killian 1904 described technique of retention of both
dorsal and caudal struts of cartilage
 Prevents any external change in shape
 Septum is divided by a vertical line drawn from the
nasal process of frontal bone to nasal process of
maxilla, any deviations posterior to this corrected by
smr and anterior ones by septoplasty
 Even then surgeries were followed by supra tip
depression and columellar retraction
 To minimize : killians technique was followed.
 Deviations in dorsal and caudal areas could not be
corrected

54.  COTTLES LINE

55.  Significant change brought about by Metzenbaum
1929
 Avoided producing a large defect in cartilagenous
septum by mobilizing and repositioning spetum in
central position
 Applicable to caudal dislocation of septum
 Compared the principle to a swinging door
 Incision given at the level of the deviation
 Free inferior border
 Posterior free border created by separating the septal
cartilage from the vomer

57.  No anterior free border,
septum tethered to
displaced upper cartilage
resulting in recurrence
ofdeviation

58.  Peer 1937 completely
excised deviated
caudal segment of
cartilage
 Reinserted as free
graft

59.  Galloway 1946
 Removed the entire septal
cartilage and replaced it with
single autograft cut from the
excised cartilage
 Graft was held in place with
mattress sutures nd later
suture removed

60.  Problems with this method : unequal scar
contraction : recurrence
 Absorption of autograft : saddling of supratip
 Alternative solution : mobilization and
repositioning of septal cartilage : Cottle and
then advocated by Rubin

61.  INDICATIONS
 DNS causing symptoms of nasal obstruction and
recurrent headache.
 DNS causing obstruction of paranasal sinuses and
middle ear.
 Recurrent epistaxis from septal spur
 As a part of septorhinoplasty
 As a preliminary step in
 Hypophsectomy (Trans septal trans sphenoidal
approach)
 Vidian neurectomy (Trans septal apprach)

62.  SMR
 Infiltration: subperichondrial infiltration with 2%
xylocaine with adrenaline
 Incision: killian’s incision- curvilinear incision 2-3mm
behind the anterior end of septal cartilage
 Elevation of flaps: the mucoperichondrial and
mucoperiosteal flap is elevated
 Incision of the cartilage- cartilage is incised just posterior
to the first incision
 Elevation of opposite mucoperichondrial and
mucoperiosteal flap

63.  Removal of cartilage and
bone - cartilage can be
removed with Ballinger
swivel knife or luc’s
forceps. Bony spur is
removed using gouge
and hammer
 Preserve a strip of 1cm
wide cartilage along the
dorsal and caudal borders
(struts)

64. Complications
 Bleeding
 Septal haematoma
 Damage to surrounding structures
 Septal abscess
 Septal Perforation
 Depression of bridge
 Retraction of columella
 Synichae
 Flapping septum

65.  Septoplasty
 Incisions / approaches to
septum
 Killians : vertical incision in
septal mucoperichondrium
1.5 cm cranially from the
caudal septal border
 Mucoperichondrium is
relatively easily elevated
from this part of the septum
and incision gives good
access to all parts of septum
except for the caudal most
cartilagenous portion

66.  Total transfixion incision
 Verticular vestibular skin incision caudally
from the caudal septal margin through the
membranous septum
 Good exposure of nasal valve area and dorsum
 Attachments of medial crura to the caudal
septum is sacrificed

68.  Rethi incision
 Horizontal midcolumellar incision
 Used in rhinoplasty
 Elevation of skin from the nasal tip and
dorssum, medial crura of alar cartilages
divided, membranous septum divided and then
caudal border is exposed.
 May also be used in septoplasty

69.  Hemitransfixation
incision
 Also known as freers
 Vertical vestibular skin
incision at the level of
caudal septal cartilage,
mucocutaneous junction
 Good access to entire
septum

70.  Steps :
 Infiltration
 Incision: Freer’s incision– a unilateral hemitransfixation
incision at the caudal border of the septum
 Advantages of this incision : incision is in relatively
avascular zone
 Decreased risk of mucosal tears
 Easy access to whole septum including he caudal septal
bborder
 To combine with rhinoplasty it can be easily extended
to the opposite side and produce a transfixion incision

71.  Exposure : usually best to expose the cartilagenous and
bony septum by elevating the mucosal flap on concave
side
 Difficulty in flap elevation occurs mainly at the junction
of septal cartilage above, with the anterior nasal spine
and vomer below
 Perichondrium encloses the septal cartilage in a
complete envelope which does not fuse with the
periosteum
 Periosteum forms another envelope over adjacent bony
septum

72.  Anterior tunnel created between the cartilage and
perichondrium from the freers incision
 The periosteum over the anterior nasal spine incised
and elevated backwards on both sides over
premaxillary crest then vomer keeping below the
chondrovomerine suture. This forms the inferior tunnel
 Unite the anterior and the inferior tunnels using a knife
: maxilla premaxilla approach
 Inferior part of the septum separated from its osseous
base, anterior nasal spine, premaxillary and maxillary
crest
 Incsion made between posterior part of septal cartilage
and bony septum : posterior chondrotomy

73.  Straightening
 Require removal of a stirp of cartilage, 3-4mm wide
from the lower border, and placed in saline during the
procedure for later use
 Straighten the vomerine crest to accommodate the
septal cartilage
 Anterior spine is deviated, can be fractured and
repositioned.
 Angulated spurs at junction between ethmoid and
vomer, vertical incision is made just behind the cottles
line

74.  Mucosal flap is elevated and deviated portion of bone
and cartilage removed.
 While making the vertical incision careful not to make
it too anteriorly
 Reconstruction of septum
 Once the cartilage has been freed attempt made to
reposition it back in midline.
 Require removal of a stirp of cartilage, 3-4mm wide
from the lower border, and placed in saline during the
procedure for later use
 Pts own cartilage or ear or rib cartilage as substitutes

75.  Stabilizing the septum
 Nasal packing
 Sutures
 Internal nasal splints

76. SMR
1. Radical surgery
2. Not done in children
3. Killian’s incision
4. Flaps elevated on both
sides
5. Most of cartilage
removed
6. Caudal dislocation not
corrected
7. Perforation chance
higher
8. Post operative
saddling may be
present
9. Revision surgery
Septoplasty
1. Conservative surgery
2. Can be done in
children
3. Freer’s incision
4. Flap elevated on
concave side only
5. Most of cartilage
preserved
6. Caudal dislocation
corrected
7. Perforation rare
8. Post operative
deformity absent
9. Revision surgery easier

77.  SEPTAL PERFORATION
 Majority involves septal cartilage
 Most common cause : trauma with or without
secondary infection
 Iatrogenic : septoplasty, mainly during smr ( killians
incision )
 Tight nasal packing
 b/l cauterizations for nose bleed
 Inadequately treated septal hematoma/ abscess
 Foreign bodies
 intubation

78.  Surface irritants
 Cocaine sufuric acid, chromic
 Decongestant nasal sprays phosphorus
 Arsenicals, mercury copper smelting fumes
 Hydrofluric acid, calcium nitrate
Infections:
Syphilis ( bony perforation ) rhinoscleroma
Wegners granulomatosis mucor
Leprosy rhinosporidiosis
Diphtheria histoplasmosis

79.  Symptoms
 Mainly asymptomatic
 Size and site of perforation
 Anterior and large perforations symptomatic
 Drying, crusting
 Recurrent epistaxis
 Nasal obstruction
 Whisting sounds
 Saddling of nose

80.  Management
 Nonsurgical and surgical
 No specific treatment for asymptomatic perforations
 Reducing the dryness, crusting
 Nasal douching, petroleum based ointments
 Cure the causative causes

81.  Obturators
 Cover the inflamed mucosal
margin
 Usually silastic
 Prevent drying and encourage
epithelialization over the
cartilage, bony septum.
 Major disadvantage :cleaned
or replaced regularly, can
increase blockage
 granuloma formation

82.  SURGICAL
 Vertical height of perforation more critical than the ap
dia
 Approximation of mucoperichondrial edges from the
floor of nose to the dorsum of septum causes greatest
tension
 Extremely difficult to close perforations larger than
2cm in dia

83.  Free grafts : simple or composite grafts
 allograft
Pedicled flaps : local nasal mucosal
buccal mucosal
composite septal cartilage
composite skin / cartilage
 Rotation or advancement of mucoperichondrial or
mucoperiosteal flaps
 b/l mucosal flaps with main blood supply from
sphenopalatine vessels form the basis of most
techniques

84.  Grafts used temporalis fascia, mastoid periosteum,
septal/ auricular cartilage
 Small defects can be closed with bipedicled flaps
 Larger perforations require larger flaps which are
pedicled posteriorly based on sphenopalatine vessels
 Amount of mucosa available for closure is inversely
proportional to the dia of perforation
 Endonasl : broad based elevations via hemitransfixion
incisions and bipedicled flaps preserving anterior and
posterior blood supplies
 With horizontal relieving incisions and interposition
grafts gives good results for perforations < 0.5cm

85.  External rhinoplasty approach via trans columella
approach or a columella – philtrum incision
 Sectioning of columella below the medial crural
footplates and connecting to transfixion and
intercartilagenous incisions provides excellent
exposure of septum and lower dorsum.
 Alar crease incisions limited access not to be
combined with transcolummellar approach

86.  MIDFACE DEGLOVING APPROACH
 Extensive dissection of face for >2cm perforations
 Used with rotation transposition mucosal flaps

87.  Septal hematoma
 It is collection of blood under the perichondrium or
periosteum of nasal septum
 When septum is subjected to a sharp buckling stress,
submucosal blood vesels are torn if mucosa remains
intact this will result in hematoma
 If severe injury , septal fracture, blood will flow to opp
side and cause b/l hematoma
 Blood accumulates in subperichondrial layer :
interferes with vitality of cartilage
 Cartilage can remain viable for 3 days, absorption
follows

89.  Symptom : nasal obstruction
 Examination will reveal smooth rounded b/l septal
swelling which often extends upto the lateral nasal
wall
 Treatment : early surgical drainage
 Long hemitransfixation incision made, blood
aspirated.
 If there is a defect in the cartilage, supported with a
homograft
 Complications : external deformity
 Septal abscess

90.  Septal abscess
 Etiology
 Secondary infection of septal haematoma
 Furuncle of the nasal vestibule
Clinical features
 Severe bilateral nasal obstruction with pain and
tenderness over bridge of nose
 Fever with chills
 Frontal headache
 Skin over the nose may be red and swollen
 Smooth bilateral swelling of the nasal septum
 Congested septal mucosa

91.  Treatment
 Abscess should be drained as early as possible
 Pus and necrosed cartilage removed by suction
 Incision may required to be re-opened daily for 2-3
days to drain any pus or remove any necrosed piece of
cartilage
 Systemic antibiotics to be started as soon as possible
and continued for two weeks

92.  Complications
 Depression of the cartilagenous dorsum
 Septal perforation
 Meningitis and cavernous sinus thrombosis
(rare)

93.  Involvement of septum in systemic disorders
 Infectious diseases : tb, syphilis, leprosy,
diphtheria
 Autoimmune : wegners granulomatosis, lupus
erythematosus, sarcoidosis
 Vascular disorders : arteriosclerosis, osler weber
rendu

94.  WEGNERS GRANULOMATOSIS
 Autoimmune disorder, necrotizing granulomatous
lesion of respiratory tract, vasculitis of small and
medium arteries and glomerulonephritis
 M:F 1:1, 20 – 40yrs
 Constitutional symptoms of fever, night sweats, wt
loss, malaise, weakness
 Nose : nose and pns r most frequently affected in head
and neck
 Foul smelling rhinorrhea, recurrent epistaxis
 Nasal obstruction, hyposmia or anosmia
 Nasal crusting, eythematous tissue, granulation tissue

95.  Perforation in septum
 Chronic sinusitis
 Diagnosis : ANCA +
 Biopsy : pns tissue offers most favourable results
 Treatment : corticosteroids, immunosuppresive
therapy, cytotoxic drugs : cyclophosphamide,
chlorambucil or azathioprine may b used

96.  SYPHILIS
 Sexually transmitted disease, cause by spirochete,
treponema pallidum
 Primary syphilis presence of a chancre at the site of
treponemal inoculation
 Secondary syphilis represents hematogenous
dissemination followed by a latent or asymptomatic
phase
 This might progress into tertiary syphilis
 Congenital syphilis : early and late stages

97.  Early congenital syphilis
 Purulent nasal discharge
 Fissuring and excoriation of nasal vestibule
 Late congenital syphilis
 Gummatous lesion destroy the nasal structure
 Corneal opacity
 Deafness
 Hutchinson’s teeth

98.  Primary sysphilis of nose is rare, but occurs at the
mucocutaneous junction
 Secondary ssyphilis manifests as rhinitis with scant
thick discharge and irritation of anterior nares
 Tertiary : gummata of nose
 Septum is commonly involved and eventually
destroyed
 Diagnosis
 VDRL, FTA – ABS, TPHA
 TREATMENT : Benzathine penicillin 2.4 million units
i.m weekly x 3week

99.  TUBERCULOSIS
 Primary nasal infection is rare
 Secondary to pulmonary T.B.
 Nodular infiltration of anterior part
 Ulceration and perforation of the cartilaginous part of
the septum
 Diagnosis by Biopsy
 Anti tubercular drug is the t/t

100.  LUPUS VULGARIS
 Low grade tubercular infection
 Commonly involve the nasal vestibule and skin
of the face
 Characteristic feature is “apple-jelly nodules”
brown, gelatinous nodules
 Perforation of the cartilaginous septum
 Biopsy is diagnostic
 Anti-Tubercular t/t.

101.  LEPROSY
 Caused by M.leprae
 Mostly by Lepromatous leprosy
 Starts from the nasal vestibule and involve the
septum and inf turbinate
 Nodular lesion Ulcers Perforation
Atrophic rhinitis  Retraction of collumela
 Diagnosis by Biopsy
 Anti-leprotic therapy

102.  SARCOIDOSIS
 Unknown etiology, mutiorgan disorder
 Young and middle aged
 Presents with b/l hilar lymphadenopathy, pulmonary
infiltration, ocular and skin lesions
 Formation of epitheloid granuloma, noncaseating
 Nose – obstruction, postnasal drip, headache, recurrent
sinus infections, purulent nasal discharge
 Dry friable lesions involving septum and inferior
turbinates with thick discharge and crusting
 Granulomatous inflammation result in subcutaneous
yellowish nodules
 Polypoid tissue and spetal perforations can occur

103.  Diagnosis
 Clinical and radigraphic findings
 Histological finding of non caseating granuloma
 Exclusion of other diseases
 Biopsy : transbronchial lung biopsy, bronchoalveolar
lavage : cd 4/ cd 8 ratio increased
 Treatment : systemic corticosteroids

104.  Mucormycosis
 Found in uncontrolled diabetics and pt with
immunosuppressive therapy
 Rapidly fatal condition
 Affinity of the fungus to artery ,causes thrombosis
 Black necrotic mass eroding the septum and hard palate
 T/t – Surgical debridement, amphotericin B ,control of
underlying cause.

105.  Believe to be a type of Lymphoma, t cell / nk
cell lymphoma
 Stewart granuloma
 Destructive disease in the nose and mid facial
region
 Common in males, 5-6th decade
 Differentiated from Wegener's granulomatosis
by absence of pulmonary and renal
involvement.

106.  Purulent nasal discharge, persistent rhinorrhea
with nasal obstruction,
 Nasal crusting, necrosis
 Progressive destruction of nasal framework
 Gross mutilation of face
 Metastasis
 Diagnosis : biopsy
 Necrotic area with atypical cellular infiltrate
 Immunohistochemistry using monoclonal
antibodies against t cell differentiation antigen
can b used for diagnosis
 Tratment : radiotherapy