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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4450_Библиотеки_им_академика_М_И_Перельмана
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Localization
Septal deformities may be distinguished on the basis of
their location. We may thus speak of a basal crest, a
posterior spine, or an anterior deviation. In this respect,
one may add the Cottle area where the deformity is
localized (see ▶ Five-Area Division of Cottle). An alternative is
to use specific anatomical terms to indicate the location of
the deformity, such as nostril, vestibule, valve area, middle
(inferior) meatus, infundibulum, and choana.
Etiology
Septal pathology may also be classified in terms of its
cause: genetic, developmental, traumatic, or infectious.
Traumatic deformities may be classified into frontal,
lateral, basal, frontolateral, or basolateral, according to the
(likely) impact of the injury. Vernon Gray has drawn
attention to the fact that fractures ventral to an imaginary
line drawn from the anterior wall of the sphenoid bone to
the anterior nasal spine (Gray’s line) are mostly vertically
oriented, and those dorsal to this line are mostly
horizontally oriented (▶ Fig. 2.105).
Fig. 2.105Gray’s line. Septal fractures anterior to this line tend to be vertically
oriented, whereas those posterior to this line are usually horizontally oriented.
Function
Finally, septal deformities may be subdivided on the basis
of the leading symptom. Although instructive, this is not
common practice.
Specific Septal Pathology
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Dislocated Caudal Septal End (▶ Fig. 2.106)
Fig. 2.106Dislocated caudal septal end.
The caudal end of the cartilaginous septum is dislocated to
one side, so that it protrudes into the vestibule and the
nostril. This is a common type of pathology. It may lead to
breathing obstruction, vestibulitis with crusting, and to
cosmetic complaints. A caudal septal dislocation is often
combined with a vertical septal fracture at the level of the
valve area on the opposite side. It is generally caused by
trauma with a (baso)lateral impact. If the causative injury
occurred in childhood, the septum may show excessive
growth in the caudal direction, causing an ugly protrusion
into the nostril.
Single Vertical Fracture (▶ Fig. 2.107)
Fig. 2.107Single vertical fracture.
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The cartilaginous septum is fractured in a craniocaudal
direction due to an injury with a lateral or laterobasal
impact on the cartilaginous part of the external pyramid.
The vertical fracture line is usually located at the level of
the piriform aperture (i.e., the valve area) on the side of the
impact. A vertical fracture is usually associated with
dislocation of the caudal end of the septum to the other
side. The external pyramid shows deviation of the
cartilaginous pyramid to the opposite side. Severe
inspiratory breathing obstruction, or even total blockage of
the airway, is a common symptom. Local irritation,
infection, crusting, or bleeding as a result of abnormal air
currents is regularly seen.
Multiple Vertical Fractures (▶ Fig. 2.108)
Fig. 2.108Multiple vertical fractures.
The septum shows two or three nearly vertical fractures
posterior to each other. This type of septal deformity is
usually caused by frontal trauma with its impact on the
lower half of the external pyramid. The cartilaginous
dorsum is impressed (sagging) and twisted (“crooked
nose”). In patients with a double vertical septal fracture,
the first fracture line is usually located at the valve area,
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the second at the septoperpendicular junction. In cases
with three fractures, the second is found 1 to 2 cm
posterior to the first, while the third is located at the
chondroperpendicular junction.
Horizontal Fracture (▶ Fig. 2.109)
Fig. 2.109Horizontal fracture.
The cartilaginous septum is fractured in dorsoventral
direction as a result of lateral nasal trauma to the bony part
of the external pyramid. The fracture line is located at the
septal base at the level of the chondropremaxillary and the
chondrovomeral junctions. A horizontal fracture is usually
associated with a basal crest and a spur on the same side,
and a high deviation of the cartilaginous and bony septum
in area 3 and 4 to the other side. The external pyramid
generally shows deviation of the bony and cartilaginous
pyramid to the opposite side. Breathing obstruction is
common if the deformity is severe. Neuralgic symptoms
may occur in cases where the septum impacts into the
inferior or middle turbinate (Charlin syndrome, see ▶
Anterior (Posterior) Ethmoidal Neuralgia).
Mixed Fracture (▶ Fig. 2.110)
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Fig. 2.110Mixed fracture.
The septum is fractured both vertically and horizontally.
Various different types of mixed fracture may occur,
depending upon the severity of the trauma.
High Cartilaginous Deviation (▶ Fig. 2.111)
Fig. 2.111High cartilaginous deviation.
The superior part of the cartilaginous septum is deviated.
This type of pathology often goes together with a basal
crest. The cartilaginous pyramid is often deformed.
Deviations of this type in areas 2 and 4 mostly cause
functional complaints. Those in area 3 usually cause few
symptoms.
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