CLINICAL IMPLICATIONS OF NASAL SEPTAL DEFORMITIES

Ranko Mladina, MD, PhD, Professor Department of ORL Head & Neck Surgery Clinical Hospital Center Zagreb, Croatia Head, Referral Center for Rhinosinusology and Endoscopic Sinus Surgery Ministry of Health, Republic of Croatia 1

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SEPTAL DEFORMITIES

Type 1

Type 2

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These two types od so called VERTICAL DEFORMITIES are located in the close vicinity of the anterior nasal valve (limen nasi in Latin) thus diminishing more or less the normal value of the anterior nasal valve angle (the angle between septum and limen nasi, see next slide) from 150 to less. In these very slide both deformities are to the left, just by chance. It does not meter which side is occupied by these types of deformities. They are always either type 1 or type 2. What really meters is that both of these two deformities have great implications on both subjective feeling of nasal breathing quality and rhinomanometric, acoustic rhinometric and body pletizmography findings. They also have a strong influence on the so called nasothoracal reflex, responsible for the real depth of nasopulmonary breathing. How it works? In the region of the anterior nasal valve there are a lot of neural buds belonging to the ophthalmic nerve (nasociliary nerve branches), and maxillary nerve (nasopalatine nerve branches), which are normally agitated by the air stream passing through the nose at the circumstances of anterior nasal valve angle of 150. If the aerodynamic circumstances are changed, and they are changed in cases of both type 1 and type 2 septal deformities, the buds belonging to nasopalatine and nasociliary nerves will not be agitated and no action potential will be forwarded towards the nuclea of the trigeminal nerve in medulla oblongata. In normal conditions, an ordinary action potential comes to nuclea, and owing to the anastomoses with the vagal nerve and its cervical plexus, the electric potential spreads towards the phrenic nerve nucleus, thus producing a strong contraction of the diaphragm. This ensures a long, deep inspirium which can be easily recorded during the body pletizmography measurements. Interesting story, isn’t it?

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SEPTAL DEFORMITIES

IMPAIRED NASAL BREATHING

Type 1

150

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There is an elastic membrane (red arrow) between the caudal edge of the triangular cartilage (dark blue arrow) which allows the movements of triangular cartilage towards the nasal septum during the nasal inspirium and vice versa during the expirium.

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NASOPULMONARY REFLEX

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The diaphragm is a large, strong muscle. When relaxed, it is convex with the arch upwards (blue arch in this picture). When contracted, it becomes horizontal, streched, thus enlarging the capacity of the thoracic cavity, producing the negative pressure and promoting the deep inspirium.

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NASOPULMONARY REFLEX

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The diaphragm has been contracted by the action of the phrenic nerve (yellow dotted line), supported by the action potential coming also from the anterior valve region from the nerve buds of nasopalatine (ophthalmic nerve branches) and nasocilliary (maxillary nerve branches) nerves

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NASOPULMONARY REFLEX

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SEPTAL DEFORMITIES

Type 2

“-150”

Branches of the nasociliary n. (V1) Branches of the nasopalatine nerve (V2)

Trigeminal nucleus (medula oblongata) Anastomoses to the vagal nerve and CERVICAL PLEXUS (PHRENIC NERVE)

AGITATION OF THE DIAPHRAGM CONTRACTION NASO-THORACIC REFLEX

IMPAIRED NASAL BREATHING IMPAIRED PULMONARY BREATHING 7

Septal deformity type 2 sometimes is so emphasized that literally pushes limen nasi laterally. It sometimes can be seen even from outside as a deformity of the nasal apex. We use to say that the desired, physiological value of the anterior nasal , valve angle is not any longer fifteen but minus fifteen degrees!

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SEPTAL DEFORMITIES

Type 3

C - shaped

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This deformity is also unilateral as are previous two, but contrary to both of them, this one is located more posterior, i.e. At the borderline between cartilaginous and osseous part of the nasal septum (quadrangular lamina and perpendicular lamina). It belongs also to so called VERTICAL DEFORMITIES.The most prominent point of its convexity stays usually very close to the head of the middle turbinate or obstructs the view to the ostiomeatal complex (see slide No. 10).

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SEPTAL DEFORMITIES

Type 3

Reverse C - shaped

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9

SEPTAL DEFORMITIES

Type 3

10

10

SEPTAL DEFORMITIES

Type 3 S MT

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On CT scans it is normal to see that the middle turbinate at the deformity side is thinned, whereas on the opposite side, because the nasal cavity is enormously wide, middle turbinate in rule is pneumatized (so called compensatory hypertrophy). You can see one example in the middle picture of this slide. Both arrows indicate the mucosal edema that can be usually find in this type of septal deformities as a result of constant irritation by “wrong” air-stream. What does it mean? It means that at the narrower side, owing to the well known Bernoulli’s rule from aerodynamic science, the speed of the airstream must be accelerated as to be able to reach the target (nasopharynx) in the same moment as the airstream from the other nasal cavity does. Because of that, the air-stream in the narrow side reaches hurricane speeds and, as a side effect, erases the highly differentiated respiratory epithelium resulting in the onset of a simple multilayer, squamous cell epithelium (see slide No. 13). Ostiomeatal complex is seriously impaired! On the other, wider side, the air-stream speeds are not that high, of course, but they are, instead of being laminar, smooth, very confused, in rule turbulent, and the result on the respiratory epithelium is the same as at the opposite side. That means that in this type of septal deformity one can expect to have bilateral impairment of the mucociliary transport in the ostiomeatal region. In other words, the essential prerequisites for the onset of chronic rhinosinusitis are here!

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THE TYPES OF SEPTAL DEFORMITIES: WORLDWIDE DISTRIBUTION explored by native anterior rhinoscopy solely

Type 3

20.36%

Type 1

16.30%

&

2

Type 5

13.98%

Straight septum

10.81%

N= 2589 (14 countries involved in the study) study)

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Based on the native anterior rhinoscopy, which means without the decongestion, it seems that the type 3 is quite largely spread all over the world. Maybe it can be considered as a “stigma” of the man kind septum. We believe that this type has to do with the inheritance or, most probably, with the action of so called “cranial pincers”, in other words by the squeezing of the splanchocranium by both anterior and posterior skull base, so typical angulations (Huxley’s angle of 1350) in adult humans. This angle does not exist in quadrupeds (that is why they do not have a sphenoid sinus!), nor it can be found in human newborns and small children until the age of approximately seven. This supports the theory that the human ontogenesis is just a short recapitulation of the whole phylogenesis! Anyhow, type 3 is very frequently seen in chronic rhinosinusitis patients!

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SEPTAL DEFORMITIES

Type 3 S

MT

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Please read the notes of the slide No. 11

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SEPTAL DEFORMITIES: CLINICAL IMPLICATIONS

Chronic rhinosinusitis

Type 3

Bilaterally impaired nasal breathing Headache

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Because in most of the type 3 cases there is a close contact between two neighboring surfaces, i.e. The surface of the head of the middle turbinate and the surface of nasal septum (deformed at this side), a lot of action potentials are released from this area to the central nervous system (CNS) alarming it for the pain. Of course, it is not possible to know where exactly the pain comes from, patient does not come to the doctor saying: “Doctor, my middle turbinate is so painful!”, but comes complaining of the stubborn headache. If the headache has it origin in this region, the doctor will be able to immediately stop the pain by inserting in the ostiomeatal region a small cotton ball previously immersed in the xillocaine solution. In very many cases it works perfect! And makes a very clear indication for the septal surgery in particular patient!

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SEPTAL DEFORMITIES

Type 4

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Here we have two vertical deformities in one nose, i.e. Type 1 or 2 on one side, and type 3 on the opposite side. Depending on which one is most anterior, the schematic shape of nasal septum, as looking from above, gives an impression of the letter “S” or letter “Z”. This deformity on this slide has the “S” shape since the anterior deformity (type 2) looks to the left side.

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SEPTAL DEFORMITIES

Type 4 Chronic rhinosinusitis, bilaterally impaired nasal breathing, headache

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Typical axial CT appearance of the type 4. Please note the mucosal thickening of the ethmoid on the side of the type 3 septal deformity (yellow arrow)

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SEPTAL DEFORMITIES

Type 5

>98% OF FATHERS or/and MOTHERS

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It usually goes for an ascending, almost horizontal septal spur, but always unilateral! In very many patients the opposite side of the septum could be almost ideally straight! In this very case you can easily see even by anterior rhinoscopy (after the decongestion, of course) the left superior turbinate (red arrow)! You can also see that left middle turbinate has a so called paradoxical shape, i.e. it is convex towards the lateral nasal wall. A discrete signs of the type 3 can be seen on this side of the nasal septum. Contrary to that, the horizontal deformity is nicely seen. You can imagine how large contact between the tip of this spur in the deep nasal areas (Cottle region 4 and 5) could be, particularly when the nasal cycle produces the predominance of the parasympathetic influence. In this very moment, since the changes between two neurovegetative (sympathetic and parasympathetic) components alternate very quickly, starts the typical, unilateral (all the times the same side!) headache. Again, if the patient comes to the doctor with the pain, and if the doctor perform the decongestion and local anesthesia, the headache will immediately be cut off! In addition, this deformity is absolutely inherited and has nothing to do with whichever kind of trauma to the nose! It is inherited from one generation to the next. The side and the intensity of the deformity is not inheritable, but the essential shape yes!

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Unilateraly disturbed ventilation of the middle ear

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In some cases as in this one, in which you can see an extremely deformed septum according to type 5 to the right side, the contact between lateral nasal wall and surrounding structures, like Eustachian tube orifice etc., may be so close and pushy that even very intensive decongestion does not help in detaching one structure from the other! The are almost accreted!

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SEPTAL DEFORMITIES

Type 5

Unilateral headache Unilaterally impaired nasal breathing

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Right-sided type 5. On the left you can see the appearance during the anterior rhinoscopy after the decongestion. Before the decongestion this deformity was not noticed at all! It was hidden by the nasal mucosa. On your right you can see the fiberendoscopic view ot the same deformity, a close-up view. Blue arrows indicate on both pictures the tip of the type 5 deformity spur, while the white arrow on the right picture shows unusually elongated head of the superior turbinate. It is absolutely clear why this patient had his nasal breathing problems, mostly unilateral (to the right side) and why he had intermittent attacks of the unilateral headaches (located to the right side)

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SEPTAL DEFORMITIES

Type 6

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This is the so called QUIN OF ALL DEFORMITIES! It goes for an anteriorly located unilateral septal groove (yellow arrow on the right picture) and the basal crest on the opposite septal side, at the corresponding septal area (Cottle 1-2). This groove appears only and exclusively in type 6! A close-up view of it is in the next slide

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SEPTAL DEFORMITIES

Type 6 LEFT MIDDLE TURBINATE

LEFT INFERIOR TURBINATE

LEFT WING OF THE NTERMAXILLARY BONE

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Blue arrows indicate the septal groove

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SEPTAL DEFORMITIES

Type 6 Quante 1978: >80% left-sided

?

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It was Quante to publish on this deformity which he found to be left-sided in more than 80% of population. The groove is composed of the wing of the intermaxillary bone and the lower portion of the nasal septum. Intermaxillary bone is supposed to have a “V” shape, thus serving as a good fuse for the palatal septal edge against the sliding out from the midline position. In case when intermaxillary bone does not grow normally, i.e. One part grows normally, which means it moves downwards and anterior, while the opposite side stays like it is, the result is an asymmetric “V” which allows the lateral escape of the palatal edge which than forms a typical basal crest (C on the drawing). In the case presented in the drawing, the right half of the intermaxillary bone has grown normally. The result is asymmetry of the bone, escaping of the palatal edge laterally and a deep groove between the left wing and the septum. Hard palate is oblique, thwart to the right. This could be easily seen during the oropharyngoscopy. Please, don’t forget to palpate the hard palate. Why? Because in many cases of type 6 you will be able to palpate discrete signs of so called submucosal palatal cleft! In some cases of type 6 septal deformity you will be able even to find bifid uvula, indicating in a way that you are facing the patient with the submucosal cleft. Make also the audiological tests, particularly tympanometry! You will be surprised in very many cases! Next slide will show you why.

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SEPTAL DEFORMITIES: CLINICAL IMPLICATIONS >98% OF FATHERS or/and MOTHERS

Type 6

CLP children vs. non-CLP children

80.6

% and 3.7%, respectively

Cleft palate

Type 6 in 58% of (at least one) of the examined parents None in parents of healthy children

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Type 6 can not be found in children until the puberty. Only than appear, very bashfully, first cases! In children suffering from cleft lip/palate, this type is very frequent! This suggest the possible genetic influence in the onset of this type of septal deformity. It is well known that type 6 is absolutely inherited, at least one of the parents have this otherwise not that frequent deformity. This all gives a hope for the future: once discovered, the gene (if any!) responsible for the onset of type 6 septal deformity (and maybe for the cleft lip/palate, who knows?) will be changed by means of gene therapy techniques of the future medicine science and praxis and thus cleft lip/palate will disappear from the list of human diseases once for ever! It will be needed that the couple who intend to have a baby undergo simple anterior rhinoscopy and in case that any of them carries type 6, the gene should be removed instantly. After that, the chances to have a CLP baby born will be zero!

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CONCLUSIONS

1. SEPTAL DEFORMITIES APPEAR IN WELL DEFINED SEVEN TYPES 2. AT LEAST TWO OF THEM ARE ABSOLUTELY INHERITED (types 5 & 6) 3. NONE OF THEM IS CLINICALLY INOCENT 4. TYPE 6 SEEMS TO BE DIRECTLY CONNECTED TO THE CLEFT LIP/PALATE

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