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 1 SEPTAL DEFORMITIES Type1 Type2 2 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? 2 SEPTAL DEFORMITIES IMPAIRED NASAL BREATHING Type 1 150 3 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. 3 NASOPULMONARY REFLEX 4 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. 4 NASOPULMONARY REFLEX 5 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 5 NASOPULMONARY REFLEX 6 6 SEPTAL DEFORMITIES Type 2 Branches of the nasociliary n. (V1) Branches of the nasopalatine nerve (V2) Trigeminal nucleus (medula oblongata) “-150” 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! 7 SEPTAL DEFORMITIES Type3 C - shaped 8 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). 8 SEPTAL DEFORMITIES Type3 Reverse C - shaped 9 9 SEPTAL DEFORMITIES Type 3 10 10 SEPTAL DEFORMITIES Type 3 S MT 11 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 air- stream 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! 11 THE TYPES OF SEPTAL DEFORMITIES: WORLDWIDE DISTRIBUTION explored by native anterior rhinoscopy solely Type 33 20.36% Type 1 & 2 16.30% Type 5 13.98% Straight septum 10.81% N= 2589 (14 countries involved in the study) 12 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! 12 SEPTAL DEFORMITIES Type 3 S MT 13 Please read the notes of the slide No. 11 13 SEPTAL DEFORMITIES: CLINICAL IMPLICATIONS Chronic rhinosinusitis Type 3 Bilaterally impaired nasal breathing Headache 14 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! 14 SEPTAL DEFORMITIES Type4 15 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. 15 SEPTAL DEFORMITIES Type 4 Chronic rhinosinusitis, bilaterally impaired nasal breathing, headache 16 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) 16 SEPTAL DEFORMITIES Type 5 >98% OF FATHERS or/and MOTHERS 17 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.