Anatomy of Paranasal Sinuses

## **Chapter 1**

## Perspective Chapter: Frontal Sinus – Updates on Classification and Surgical Approaches

*Hardip Singh Gendeh and Balwant Singh Gendeh*

## **Abstract**

Endoscopic approaches to the frontal sinus have grown significantly in the last decades and due to its complex anatomy, including the possibility of pneumatization in different cells and anatomical variations, possess numerous challenges to the endoscopic surgeon. Moreover, the proximity to noble structures such as the cribriform plate, orbit and anterior ethmoidal artery can increase the risk of injury. Unlike the maxillary, ethmoidal and sphenoidal sinuses, the frontal sinus is not in line of visualization with a zero-degree endoscope and often requires an angled endoscope. Several anatomical classification methods have already been proposed for frontal sinus, however, these previous systems present limitations of anatomical details. In 2016, the International Frontal Sinus Anatomy Classification (IFAC) was described by Wormald et al. The authors propose improved classification of the frontoethmoidal cell in diagrammatic nomenclature to facilitate greater accessibility in surgical planning.

**Keywords:** updates, frontal sinus, anatomical variations, classification, surgical approaches

## **1. Introduction**

The frontal sinus is still a challenge for rhinologists due to its anatomy. The location of the frontal sinus which is in between the eyes and superior to the nasal cavity limits accessibility. It is believed to be an extension of the ethmoidal sinus via superior pneumatization of ethmoidal air cells. Unlike the maxillary, ethmoidal and sphenoidal sinuses, the frontal sinus is not in the line of visualization with a zero-degree endoscope and often requires an angled scope (70 or 120 degrees). The frontal sinus outflow tract or ostium may not be easily identified by an untrained eye. A surgeon with little experience with the frontal sinus may easily become disoriented and confused with its anterior and posterior boundaries, resulting in frontal sinus surgery being challenging. Besides, the anatomical variation that impedes the frontal sinus drainage is challenging and will require identification with a computed tomographic (CT) scan [1]. The space limitation of the frontal sinus ostium or anterior and posterior diameter of the frontal sinus impedes access to endoscopic sinus surgery instruments to the periphery, posing a challenge for clearance in tumor surgery. Unlike the maxillary and sphenoid sinuses that have a visible ostium during endoscopic sinus surgery, the

visualization of frontal sinus ostium is often hindered by air cells, making its approach more tedious and the need for a good understanding of its three-dimensional anatomy.

It is for these reasons that frontal sinus surgery often gets its own chapter in the literature and books. A functional endoscopic sinus surgery (FESS) involves ventilation and drainage of the maxillary, anterior ethmoids, posterior ethmoidal and sphenoid sinus. A full house FESS consists of a FESS and frontal sinusotomy [2]. It is vital to understand the frontal sinus anatomy both radiological and clinical prior to a surgical approach. The objectives of this chapter are firstly to discuss the latest accepted classification of the frontal sinus based on air cell anatomy and radiology, and secondly to describe the approaches of the frontal sinus based on its classification.

## **2. Anatomy**

The frontal sinus is not present at birth but starts to form and invade the frontal bone at approximately 4 years. It extends superiorly and laterally and completes its pneumatization by the second decade of life [3]. Essentially it is located in between the anterior and posterior tables of the frontal bone being the anterior and posterior boundaries respectively. Its inferior boundary is the frontal sinus beak.

The frontal sinus ostium is the opening of the frontal sinus superiorly to the nasal cavity. It is the narrowest area bounded by the frontal sinus superiorly and frontal recess inferiorly. It is bounded anteriorly by the frontal sinus beak; posteriorly by the skull base, laterally by the lamina papyracea and *medially* by the vertical segment of the middle turbinate [4].

The frontal recess is located inferior to the frontal sinus ostium and it is the space at which the frontal sinus drains. It consists of air cells and space superior to the ethmoidal bulla [4]. The presence of air cells in the frontal recess may further narrow the viable drainage pathway of the frontal sinus known as a nasofrontal duct. This is a misnomer as it is not a true duct but an anatomical description of a tubular mucosal structure forming its drainage pathway. Its boundaries are the uncinate process anteriorly and ground lamella of the ethmoidal bulla posteriorly. In some cases, the posterior superior wall of the agger nasi may form the anterior boundary of the nasolacrimal duct. The nasofrontal duct may open anterior superior to the infundibulum (59%), directly into the infundibulum (40%) or rarely drain superior to the bulla (1%) [5, 6]. Stenosis of the nasofrontal duct due to scar tissue formation or residual disease leads to failure of frontal sinus surgery with recurrent frontal sinusitis.

Stammberger et al. have described the frontal sinus and recess as an hourglass figure. Here the frontal sinus is located superiorly and the frontal recess is located inferiorly. The frontal ostium forms the narrowest bottleneck of the hourglass center (**Figure 1**) [7]. Occasionally, a narrowed nasofrontal duct within the frontal recess may become narrower forming a tubular stricture tapering inferiorly at the nasofrontal duct [5].

## **3. Historical approaches to the frontal sinus**

*"surgical treatment of chronic frontal sinusitis is difficult, often unsatisfactory and sometimes disastrous. The many surgical techniques available are expressions of our uncertainty and perhaps of our failure."*


*Perspective Chapter: Frontal Sinus – Updates on Classification and Surgical Approaches DOI: http://dx.doi.org/10.5772/intechopen.114313*

#### **Figure 1.**

*Sagittal view of the frontal sinus. Authors annotation of the frontal infundibulum and nasofrontal duct. The frontal recess is the nasofrontal duct (green) and surrounding air cells (blue). Appreciate the hourglass figure formed by the frontal sinus and nasofrontal duct. FS: Frontal sinus; ANC: Agger nasi cell; SP: Sphenoid sinus; IT: Inferior turbinate.*

The approach to the frontal sinus dates back to 1750. Hassan et al. state that the best approach is one that should fulfill five criteria namely complete relief of symptoms, disease eradication, preservation of sinus function, minimal morbidity and minimal cosmetic dysfunction [9]. Over the years approaches to the frontal sinus have progressed from external approaches to combined external and endoscopic.

Frontal sinus surgery has experienced many eras in order of timeline (**Figure 2**) [10].


#### **3.1 Early**

In the 1890s, Schaeffer described the intranasal approach of opening the nasofrontal duct for ventilation and drainage of the frontal sinus in chronic suppurative frontal sinusitis. Ingals, Halle, Good and Wells went on to describe techniques to enlarge the nasofrontal ducts that were associated with high morbidity and mortality. Ogston in

#### **Figure 2.**

*Coronal views of the frontal sinus. A: Draf I involving a frontal sinustomy with clearance of the frontal recess and leaving the floor intact; B: Draf IIa resection of the floor to the middle turbinate; C: Draft IIb resection of the frontal sinus floor of the frontal sinus from the lamina papyracea to the nasal septum; and D: Resection of the floor of the frontal sinus from one lamina papyracea to the other.*

1884 described anterior table trephination, dilatation of nasofrontal duct, placement of drainage tube and curation of the frontal sinus mucosa to aid drainage [11]. This was described by Luc several years later, forming the Ogston Luc technique [12]. This technique failed due to restenosis of the frontal-ethmoidal drainage pathway [9]. Lyan in 1895 described the Khunts technique involving the removal of the anterior table, stripping of the superior nasofrontal duct mucosa, placement of nasofrontal duct stent and sinus obliteration via placement of skin on the remaining posterior table [13]. However, this was associated with significant deformity of frontal cosmesis. Riedel-Schenke in 1898 introduced a complete obliteration of the frontal sinus by removal of anterior table and floor, stripping of frontal sinus mucosa and sinus obliteration via placement of skin on the remaining posterior table [14]. Once again poor cosmesis resulted in its failure. Killian in 1903 tried to improve cosmesis by preserving the superior orbital rim, harvesting a nasal mucosa and rotating it into the frontonasal duct and placing a nasofrontal duct stent [15]. This was associated with necrosis of the supraorbital rim and still significant cosmesis defect.

#### **3.2 Conservatism**

Due to the cosmetic deformity caused by external approaches, many have tried intranasal approaches with little success due to the mortality associated as a result of poor visualization. Lothrop in 1915–1917 introduced a technique involving resection of bilateral anterior ethmoids, resection of the anterior floor of the frontal sinus, resection of the superior nasal septum and internisus septum to widen a narrow nasofrontal duct which is a cause of frontal sinus disease. It was technically challenging and associated with restenosis of the nasofrontal duct [10, 16, 17]. This was a combined intranasal and extranasal ethmoidectomy.

#### **3.3 External**

Both Lynch and Howarth described an external ethmoidectomy in 1921 in the United States and the United Kingdom respectively [18, 19]. It involved a medial periorbital incision, excision of ethmoidal air cell, removal of lamina papyracea, removal of the frontal process of maxilla, removal of the floor of the frontal sinus, curettage of frontal sinus mucosa, placement of drain for 5 days followed by postoperative dilatation. This technique showed initial success but it was later learned that herniation of orbital contents from the lateral boundary to the medial aspect of the nasofrontal duct led to restenosis.

Nasofrontal duct widening had failed and many then considered closure of the frontal sinus by obliterating it. This then led to the popularization of the osteoplastic flap as it provided good visualization and access to the frontonasal duct. Although the osteoplastic flap was first reported by Schonborn in 1894 and Brieger in 1895, it was only first performed in the US by Goodale and Montgomery in 1958. Complications involved, CSF leak, frontal paresthesia, headaches and lack of exposure to the ethmoids [10].

#### **3.4 Endonasal**

Endonasal ethmoidectomy gained popularity based on the understanding that marsupialization of the ethmoidal air cells restored ventilation and drainage of the frontal sinus. Mosher in 1912 introduced radical ethmoidectomy, middle turbinectomy and curettage of anterior ethmoidal air cells [20]. In 1972, Eichel described a technique of posterior to anterior ethmoidectomy, probing of the nasofrontal duct and removal of the anterior ethmoidal air cells, he believed in mucosal preservation to ensure its function in mucociliary clearance and disease eradication via ventilation and drainage [21, 22]. They indicated that intranasal techniques should be used for recurrent frontal sinusitis sinusitis and frontal sinusitis with impending complications, failure of which will require a second transnasal or external approach [10].

#### **3.5 Endoscopic**

Masserklinger popularized the use of nasal endoscopy in the 1970s in Europe. His teachings were then brought to America by Kennedy and the rest of Europe by Stammberger through the English medium. In 1990, Schaefer and Close used an endoscope for frontal sinus disease. Shortly after, Draf in 1991 combined the use of microscope and endoscopy in performing frontoethmoidectomy. The types of procedures are shown in **Figure 3** and remain popular until today [22].

*Draf I:* Simple drainage via anterior ethmoidectomy and opening of the nasofrontal duct in pansinusitis without frontal sinus opacification.

*Draf II:* Extended drainage unilateral resection of the floor of the frontal sinus from the lamina papyracea to the nasal septum in pansinusitis with frontal sinus opacification.

**Figure 3.**

*Timeline of significant historical progress in frontal sinus surgery.*

*Draf III:* Median Drainage. Bilateral frontal sinus floor resection from the lamina papyracea of one orbit to the other and removal of the internisus septum. To be considered in revision surgeries, intracranial or orbital complications and failed open procedures.

The Draf technique saw less frontal sinus mucocele post procedure. However, during the time of publishing his work, Draf had proposed the combination of external and intranasal micro-endoscopic approaches in recurrent frontal disease, presence of ethmoidal disease in previously operated patients. Draft preferred an external approach should the frontal sinus be large, orbital complications, intracranial complications, lateral mucocele, large fractures and presence of osteomas. Draf also preferred obliterating the frontal sinus in revision cases [22]. However, re-evaluation of an obliterated frontal sinus is still challenging today despite being aided by imaging. The success of endoscopic frontal sinus surgery was possible owing to the increased availability of CT scans of the paranasal sinuses allowing surgeons to identify the frontal sinus recess and anatomical variations.

The Draf II was modified to include the following.

*Draf IIa:* Unilateral resection of the floor from the ipsilateral lamina papyracea to the axilla of the middle turbinate.

*Draf IIb:* Unilateral resection of the floor from the ipsilateral lamina papyracea to the nasal septum.

Gross in 1995 rekindled the Lothrop's procedure in resecting the medial floor of the frontal sinus, superior nasal septum and intersinus septum via an external and intranasal technique. Gross pointed out that the Lothrop's technique had been lost in translation over the years and could be performed in the twentieth century via an endoscope and completely intranasal. Gross had also acknowledged Draf 's median drainage technique via a microscope and endoscope with or without an external approach as similar. Essentially both of them described a similar technique at different times, one in the early twentieth century and the other later.

*Perspective Chapter: Frontal Sinus – Updates on Classification and Surgical Approaches DOI: http://dx.doi.org/10.5772/intechopen.114313*

This gave rise to the Draft III being termed as the endoscopic modified Lothrop procedure [23, 24].

Harvey in 2023 demonstrated the Crolyn's window approach whereby an axillectomy lateral to the middle turbinate is performed with a high-speed drill leading straight into the frontal sinus. This is a simplified approach to the Draft IIa frontal sinus with a zero-degree rigid scope, particularly useful when there is a small anterior posterior diameter limiting access to instruments [25].

Many have pushed the boundaries to rely solely on endoscopic intervention. In today's world, open procedures are only reserved for distorted intranasal landmarks, failed multiple endoscopic surgeries, frontal sinusitis with intracranial or intraorbital complications and disease extending to the lateral boundaries [9]. With the latter, a combined approach of external and endoscopic surgery may suffice.

#### **3.6 Frontal sinus classification**

*"The sinus frontalis is in the vast majority of cases a derivative (a) of the recessus frontalis directly, (b) of one or more of the cellulae ethmoidales anterior which have their genesis in frontal pits, or (c) of both, when present in duplicate or triplicate."*


The frontal sinus is an extension of the anterior ethmoids into the frontal region. It consists of varying anatomy of air cells in different individuals. In the early days, frontal cells were identified during dissection intraoperatively or in cadavers. Improved imaging in the 90s and a shift from radiographs to CTs have allowed for better identification of frontal cells in large volumes of individuals.

Bent in 1994 identified the four variations or possibilities among frontal cells which are above the agger nasi; which is the anterior most ethmoidal air cell (Types I to IV). These cells arise from posterior to the agger nasi cell and may obstruct the frontal sinus drainage [27, 28]. The cells are as follows.

*Type I:* Single frontal cell superior to the agger nasi (**Figure 4**).

*Type II:* Several layers of cells superior to the agger nasi (**Figure 4**).

*Type III:* Large single cell extending superiorly into the frontal sinus (**Figure 5**).

*Type IV:* Isolated single cell in the frontal sinus (**Figure 5**).

This was known as Bent and Khun's classification of the frontal sinus and was referred to by many books and literature for two decades. The authors learned the frontal sinus anatomy based on Bent and Khun's classification.

Over the years, many have been able to further detail the origins of these frontal cells and the role of frontal recess obstruction. This has allowed for a better understanding of the frontal sinus drainage and the role played by the surgeon to individualize their surgery based on the anatomical variations and requirements of the disease. Wormald et al. published the International Frontal Sinus Anatomy Classification (IFAC) in 2016 that classified frontal cells into anterior, posterior and medial cells. It identifies specific cell types and explains how these cells affect the drainage of the frontal sinus [4]. Anterior cells tend to distort the frontal sinus drainage to medial, posterior or posterior medial, posterior cells distort it anteriorly while medial cells distort it laterally. The IFAC should be made by viewing a CT on its three planes of axial, coronal and sagittal simultaneously to accurately appreciate its origins and extensions. This takes practice for good coordination. Below is the IFAC [4].

**Figure 4.** *Coronal view of the frontal sinus. Khun's type I and II frontal air cell. ANC: Agger nasi cell.*

#### **Figure 5.**

*Coronal view of the frontal sinus. Khun's type III and IV frontal air cell. S: Septum; FS: Frontal sinus; IT: Inferior turbinate; ANC: Agar nasi cell.*

*Perspective Chapter: Frontal Sinus – Updates on Classification and Surgical Approaches DOI: http://dx.doi.org/10.5772/intechopen.114313*

## **3.7 Anterior cells**


## **3.8 Posterior cells**

1.*Supra bulla:* Supra bulla cell (SBC) is a cell that sits just superior to the ethmoidal bulla. This cell does not extend into the frontal sinus and its anterior wall will be in continuation with that of the ethmoidal bulla (**Figure 9**).

#### **Figure 6.**

*Sagittal view of the frontal sinus. SAC (blue) situated above the ANC. FS: Frontal sinus; FB: Frontal beak; ANC: Agger nasi cell; MT: Middle turbinate; IT: Inferior turbinate; SP: Sphenoid sinus.*

#### **Figure 7.**

*Sagittal view of the frontal sinus. Small SAFC (blue) situated above the ANC pneumatization into the frontal sinus. FS: Frontal sinus; FB: Frontal beak; ANC: Agger nasi cell; IT: Inferior turbinate; SP: Sphenoid sinus.*


## *3.8.1 Medial cells*

1.*Frontal septal:* The frontal septal cell (FSC) is a pneumatization within or at the interfrontal sinus septum. It may be an anterior ethmoid medial cell or frontal sinus inferior cell (**Figure 12**).

## **3.9 Updated surgical classification**

The IFAC has allowed for an updated surgical approach based on the anatomy and obstruction caused by frontal air cells. Together with the IFAC, Wormald et al. also proposed a termed classification of the extend of endoscopic frontal sinus surgery (EFSS). The benefit of this improved classification is that it considers the anatomical variation resulting in frontal sinus obstruction and surgical difficulty encountered in the operative procedures. This allows for a step-wise approach to Otorhinolaryngology trainees or surgeons in tackling operative procedures to the

*Perspective Chapter: Frontal Sinus – Updates on Classification and Surgical Approaches DOI: http://dx.doi.org/10.5772/intechopen.114313*

#### **Figure 8.**

*Sagittal view of the frontal sinus. Large SAFC (blue) pneumatization into the frontal sinus. FS: Frontal sinus; FB: Frontal beak; ANC: Agger nasi cell; IT: Inferior turbinate; SP: Sphenoid sinus.*

#### **Figure 9.**

*Sagittal view of the frontal sinus. SBC (blue) situated above the BE and not extending into the frontal sinus. FS: Frontal sinus; FB: Frontal beak; BE: Bulla ethmoidalis; MT: Middle turbinate; IT: Inferior turbinate; SP: Sphenoid sinus.*

#### **Figure 10.**

*Sagittal view of the frontal sinus. SBFC (blue) situated above the BE and pneumatization into the frontal sinus. FS: Frontal sinus; FB: Frontal beak; BE: Bulla ethmoidalis; MT: Middle turbinate; IT: Inferior turbinate; SP: Sphenoid sinus.*

#### **Figure 11.**

*Coronal view of the frontal sinus. SBFC (blue) in the right FS situated above the BE and pneumatized into the frontal sinus. In the left frontal sinus. The SOEC is situated above the AEA and orbital rim. Appreciate the nipple sign (arrow) FS: Frontal sinus; AEA: Anterior ethmoidal artery; BE: Bulla ethmoidalis; M: Maxillary sinus; NLD: Nasolacrimal duct; S: Septum.*

*Perspective Chapter: Frontal Sinus – Updates on Classification and Surgical Approaches DOI: http://dx.doi.org/10.5772/intechopen.114313*

#### **Figure 12.**

*Coronal view of the frontal sinus. FSC (blue) located medially and originating from the interfrontal sinus septum. FS: Frontal sinus; S: Septum.*


#### **Table 1.**

*EFSS classification and comparisons to the Draf classification.*

frontal sinus and recess. For the ease of understanding, it can be divided into three groups with increasing difficulty and invasiveness (**Table 1**).

Comparing it to the Draf classification, The authors are of the opinion that Grades 1 to 3 may correspond to a Draf I, Grades 4 and 5 being a Draf II and Grade 6 represents a Draf III or modified Lothrop. The ambiguity in the extent of air cell removal still persists until today for a Draf I procedure. How much of or little is adequate for a Draf I? This is where the classification of EFSS has better defined the frontal recess clearance to aid classification and accurate reporting of surgical outcomes. Grade 6 surgery is preferred in revision surgery where there was previously failed endoscopic sinus surgery to the frontal sinus, disease recurrence or tumor surgery. The frontal sinus drill out simply allows for better postoperative surveillance and delivery of topical medications to the frontal sinus.

## **4. Conclusion**

The frontal sinus is no more of a mystery. Imaging and endoscopic sinus surgery has allowed for an improved and better understanding of the origins and threedimensional anatomies of air cells within the frontal recess and frontal sinus and its obstruction to drainage. This has led to an improved classification allowing for a more individualized surgery to be performed for the ventilation and drainage of the frontal sinus.

## **Author details**

Hardip Singh Gendeh1,2 and Balwant Singh Gendeh3,4\*

1 Department of Otorhinolaryngology, Head and Neck Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia

2 Allergy Unit, Hospital Canselor Tuanku Muhriz, Kuala Lumpur, Malaysia

3 Pantai Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

4 Department of Otorhinolaryngology, Head and Neck Surgery, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia

\*Address all correspondence to: bsgendeh@gmail.com

© 2024 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Perspective Chapter: Frontal Sinus – Updates on Classification and Surgical Approaches DOI: http://dx.doi.org/10.5772/intechopen.114313*

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[3] Dhingra PL, Dhingra S. Diseases of Ear, Nose and Throat & Head and Neck Surgery. 7th ed. India: RELX India Pvt. Ltd; 2018. ISBN: 978-81-312-4884-3

[4] Wormald PJ, Hoseman W, Callejas C, Weber RK, Kennedy DW, Citardi MJ, et al. The international frontal sinus anatomy classification (IFAC) and classification of the extent of endoscopic frontal sinus surgery (EFSS). International Forum of Allergy & Rhinology. 2016;**6**(7):677-696

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[6] Gendeh BS. Endoscopic dacryocystorhinostomy. In: Streba CT, Gheonea DI, Vere CC, editors. Endoscopy: Novel Techniques and Recent Advancements. London, UK: IntechOpen; 2019. ISBN: 978-1-78985-125-0

[7] Stammberger H. Functional Endoscopic Sinus Surgery. Philadelphia: BC Becker; 1991. pp. 82-87

[8] Ellis M. The treatment of frontal sinusitis. The Journal of Laryngology and Otology. 1954;**68**:478-490

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[12] Luc H. Lecons Sur Le Suppurations de L'Oreille Moyenne et des Cavities Accessoires des Fosses Nasales et leurs Complications Endocraniennes. Paris: Baillere; 1900

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[15] Killian G. Die Killianische Radicaloperation Chronischer Stirnhohleneiterungen. Weiteres Kasuistisches Material and Zusammenfassung. Arch Laryngol Rhinol. 1903;**13**:59-65

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[18] Lynch RC. The technique of a radical frontal sinus operation which has given

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[20] Mosher HP. The applied anatomy in the intranasal surgery of the ethmoidal labyrinth. Trans Am Laryngol Assoc. 1912;**34**:25-39

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## **Chapter 2**

## Perspective Chapter: Nasal Septum – A Review of the Pathology, Clinical Presentation and Management

*Kharoubi Smail*

## **Abstract**

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.

**Keywords:** nasal septum, deviated nasal septum, nasal obstruction, epistaxis, benign nasal tumor, malignant nasal tumor, nasal surgery septum, endoscopic endonasal surgery

## **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.

## **2. Embryology**

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].

## **3. Anatomy**

## **3.1 Descriptive anatomy**

The nasal septum is midline structure of the nose constituted by three parts:


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.*

*Perspective Chapter: Nasal Septum – A Review of the Pathology, Clinical Presentation… DOI: http://dx.doi.org/10.5772/intechopen.112424*

The blood supply to the septum includes branches of the sphenopalatine artery, the ethmoidal artery, and the facial artery (**Figure 2**) [3].

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 2.** *Blood supply of nasal septum.*

**Figure 3.** *Endoscopic view left side nasal septum (anterior, posterior pre choanal).*

## **4. Histology**

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].

## **5. Examination and exploration of nasal septum**

## **5.1 Physical examination**

Inspection of the external nose in relation of the face. Palpation of nasal soft tissues, bones structures, columella, alar cartilages.

## **5.2 Objective investigation**


*Perspective Chapter: Nasal Septum – A Review of the Pathology, Clinical Presentation… DOI: http://dx.doi.org/10.5772/intechopen.112424*

presence of a nasal respiratory obstruction and to evaluate the structures that mostly cause it (turbinates, septum).

• Olfactometry, measurement and control of odors [7].

## **5.3 Imaging**


**Figure 5.**

*CT scan nasal septum. A. Coronal view: Normal B: Axial view: Deviated septum. C. Axial view: Septal perforation. D. Axial view: Septum tumor (pleomorphic adenoma).*

**Figure 6.** *MRI axial and coronal view (nasal septum, maxillary sinusitis).*

**Figure 7.** *Cone-beam nasal septum normal view (A.B), deviated nasal septum (stellar).*

## **6. Pathology of nasal septum**

## **6.1 Congenital pathology of nasal septum**

## *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].

## *6.1.3 Congenital nasal bifid septum*

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].

*Perspective Chapter: Nasal Septum – A Review of the Pathology, Clinical Presentation… DOI: http://dx.doi.org/10.5772/intechopen.112424*

## *6.2.1 Etiology*


## *6.2.2 Diagnosis*


*COTTEL'S CLASSIFICATION:* Type 1: simple deviated septum. Type 2: obstructed deviated septum. Type 3: impacted deviated septum. *DEPENDING ON THE SITE:*


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.*

**Figure 10.** *CT scan septal deviation (left) and turbinal hypertrophy (right).*

#### **Figure 11.** *CT scan (axial) septal deviation (right).*

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**).

## *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].

*Perspective Chapter: Nasal Septum – A Review of the Pathology, Clinical Presentation… DOI: http://dx.doi.org/10.5772/intechopen.112424*

#### *6.3.1 Etiology*

Nasal septal perforation etiologies include trauma, autoimmune, infectious (syphilis, fungal disease, tuberculosis), or neoplastic (**Tables 2** and **3**).

Iatrogenic septal perforation can occur after patient self-manipulation, after cautery for epistaxis, or after elective septoplasty [18–20].

We also found intranasal drug abuse, steroid nasal spray, vasoconstrictor nasal spray.

#### *6.3.2 Diagnosis*


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**).

Trauma: external, fracture, hematomas, piercing injuries, nasal packing, turbulent airflow, nasogastric tube placement.

Iatrogenic: nasal and endonasal surgery, cryosurgery, nasotracheal intubation.

```
Medicines/Chemicals: vasoconstrictive nasal sprays, steroids nasal sprays, cocaine, smoking, acids
substances, heavy metal, Graft-versus-host disease.
```
Inflammatory: vasculitides, collagen diseases, sarcoidosis, Wegener's granulomatidis, renal diseases,

ulcerative colitis (extraintestinal complication).

Neoplastic: squamous cell carcinoma, adenocarcinoma.

Infectious: tuberculosis, syphilis, rhinoscleroma, mucor, AIDS.

Unknown or idiopathic

#### **Table 2.**

*Nasal septal perforations etiologies.*


#### **Table 3.**

*Nasal septal perforation in pediatrics.*

Self inflicted: nose picking, foreign bodies.

Medicaments: bevacizumab, docetaxel, aflibercept, methotrexate

**Figure 12.** *Endoscopic aspect of septal perforation.*

**Figure 13.** *CT axial septal perforation.*

**Figure 14.** *Lateral sagittal selected view: Middle perforation (iconography-Mocella S. Ref. [21]).*

*Perspective Chapter: Nasal Septum – A Review of the Pathology, Clinical Presentation… DOI: http://dx.doi.org/10.5772/intechopen.112424*

**Figure 15.** *Septal nasal button.*

#### *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**).

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*


#### *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.


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**).

## *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.

**Figure 16.** *Coexistent fracture with involvement of the nasal septum (red arrow).*

*Perspective Chapter: Nasal Septum – A Review of the Pathology, Clinical Presentation… DOI: http://dx.doi.org/10.5772/intechopen.112424*

## *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.

## *6.4.2.1 Etiology*


## *6.4.2.2 Diagnosis*


**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, saddlenose 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].

*Perspective Chapter: Nasal Septum – A Review of the Pathology, Clinical Presentation… DOI: http://dx.doi.org/10.5772/intechopen.112424*

## *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*


Imaging (CT scan) authorize diagnostic and many informations: location, size, state of sinuses, measurements, and loco-regional complications (**Figure 19**).

## *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.

**Figure 19.** *Coronal and axial CT-scan. Nasal septum abscess.*

## **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].

## *6.5.1.1 Etiology*


## *6.5.1.2 Microbiology*

virus: rhinovirus, adenovirus, coronavirus, myxovirus. bacteria: streptococcus, pneumococcus, haemophilus, moraxella.

## *6.5.1.3 Diagnosis*


## *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.

**Figure 20.** *Acute rhinitis - endoscopic view (redness septal and turbinal mucous).*

*Perspective Chapter: Nasal Septum – A Review of the Pathology, Clinical Presentation… DOI: http://dx.doi.org/10.5772/intechopen.112424*

## *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).

## *6.5.2 Specific infectious*

## *6.5.2.1 Clinical presentation*


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.


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*


Imaging can show mucosal swelling, atrophic aspect of nasal cavity, nasal bone deformation and lysis.

Serology: VDRL, TPHA, FTA

• Therapy: antibiotherapy benzathine penicilline G, doxycycline, macrolides or ceftriaxone.

*6.5.2.4 Nasal septal leprosy*


Imaging can show mucosal swelling, nasal cartilaginous and bone deformation and destruction.

Positive diagnosis: bacteriologic exam (zieel-nelsen coloration). Serology: IgM (family screening).

• Therapy: rifampicin, clofazimine, dapsone.

## **6.6 Tumors of nasal septum**

#### *6.6.1 General presentation and clinical work up*

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].

• Signs and symptom: nasal airway obstruction, rhinorrhea, epistaxis, smell dysfunction, epiphora.

*Perspective Chapter: Nasal Septum – A Review of the Pathology, Clinical Presentation… DOI: http://dx.doi.org/10.5772/intechopen.112424*


#### **Table 4.**

*Classification most frequent benign and malignant nasal tumors.*

• 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).

#### *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].

**Figure 22.** *Nasal septal endoscopic hemangioma. (iconography-Than SN. Ref. [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).

## *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 smoothsurfaced, 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

**Figure 23.** *Endoscopic view - nasal inverted papilloma.*

*Perspective Chapter: Nasal Septum – A Review of the Pathology, Clinical Presentation… DOI: http://dx.doi.org/10.5772/intechopen.112424*

**Figure 24.** *Nasal endoscopic schwannoma (iconography-Alrasheed W. Ref. [43]).*

lesions on T2-weighted images and would exhibit enhancement on giving contrast. Surgical excision is the treatment of choice (endoscopic approach) [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].

## *6.6.3.1.2 Nasal septal extra nodal NT/K lymphoma*

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].

## *6.6.3.1.3 Nasal septal melanoma*

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].

## **6.7 Nasal septum and epistaxis**

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**).

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

**Figure 26.** *CT scan: Unclear margin necrosis, midline destruction. Histology (nasal NT/K lymphoma).*

*Perspective Chapter: Nasal Septum – A Review of the Pathology, Clinical Presentation… DOI: http://dx.doi.org/10.5772/intechopen.112424*

**Figure 27.** *Endoscopic view (black colored mass). Histology (nasal mucosal melanoma).*

**Figure 28.** *Keisselbach plexus (nasal endoscopy).*

primary care physician. If bleeding persists and visible most cases of epistaxis can be successfully treated using electrical, chemical cautery.

## **7. Medical therapy in nasal septum pathology**


• Nasal decrusting: oily solution, oily ointment and extraction with Lubet-Barbon nasal dressing forceps.

## **8. Surgery of nasal septum**


## **8.1 Description endoscopic septoplasty**

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].

• Septal perforation: local, rotational, advancement, free flap.

## *Description Septal Perforation Repair: Inferior Turbinate. Flap repair.*

*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]).* *Perspective Chapter: Nasal Septum – A Review of the Pathology, Clinical Presentation… DOI: http://dx.doi.org/10.5772/intechopen.112424*

## **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**).

## **9.3 Dermoid cyst of nasal septum**

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**).

## **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**).

**Figure 30.** *Nasal septum swell body. (iconography-Meng X. Ref. [51]).*

**Figure 31.** *CT scan lobuled cystic mass within the nasal septum extending into frontal sinus. (iconography-Lee DH. Ref. [52]).*

**Figure 32.** *RMI nasal septal mcocles. (iconography-Choo DW. Ref. [53]).*

**Figure 33.** *Rosai-Dorfman nasal septal mucosa. (iconography-Wang ref. [54]).*

## **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].

## **10. Conclusion**

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.

*Perspective Chapter: Nasal Septum – A Review of the Pathology, Clinical Presentation… DOI: http://dx.doi.org/10.5772/intechopen.112424*

## **Author details**

Kharoubi Smail Faculty of Medicine, University Hospital Center of Annaba, University Badji Mokhtar, Annaba, Algeria

\*Address all correspondence to: smail.kharoubi17@gmail.com

© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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## Section 2
