DEFLECTION OF THE SEPTUM 
NARIUM 
BY 
E. FLETCHER INGALS, A.M., M.D, 
Professor of Diseases of the Throat and Chest, Woman's Medical College of 
Chicago ; Lecturer oil Diseases of the Chest and Laryngology, 
Rush Medical College, etc. 
[Reprinted from the Archives of Laryngology, Vol. iii, No. 4, Oct., 1882] DEFLECTION OF THE SEPTUM NARIUM * 
E. FLETCHER INGALS, M.D., 
CHICAGO, ILL. 
DEFLECTION of the nasal septum consists of a 
bending to one side either of the cartilaginous or 
bony septum, or of both. It is characterized by more or 
less obstruction of the naris and deformity of the nose. A 
slight degree of deflection is very common, indeed it is so 
often found that it is not considered a pathological condi- 
tion ; but a degree of distortion sufficient to materially 
interfere with respiration, and to cause more or less de- 
formity of the nose is frequently met with. It is to these 
latter cases that I wish to direct attention. 
For the sake of convenience in description I will divide 
the cases into four classes: I. Those in which there is 
slight bending of the whole septum. 2, Those in which 
there is bending of the septum and more or less depression 
of the nose, due to injury. 3. Those in which there is local 
flexion, near the nostril, of the cartilage only. 4. Those in 
which a ridge of considerable size runs upward and back- 
ward, from near the nostril, along the line of articulation of 
the vomer with the cartilage; which ridge is formed mostly 
of bent cartilage, but partly of the bent vomer. 
Judging from my own observation, the affection usually 
occurs in early life, either before or about the age of puberty. 
This deflection may be of traumatic origin, but usually it 
appears to be spontaneous. Some patients attribute it to 
an accident: such for example, as being thrown from a 
horse, or falling upon the ice; but in the majority of cases 
no cause is assigned, or the one given does not satisfactorily 
account for the condition. In searching for the cause of 
* Read before the American Laryngological Association, session 1882. 
Reprinted from the Archives of_Laryngology, Vol. iii, No. 4, Oct., 1882. E. Fletcher Ingals. 
2 
this affection, we usually find that the patient has been 
troubled with catarrhal symptoms for some time before 
obstructed respiration has been noticed, and this is the only 
symptom which is found with any degree of uniformity in 
the early history of these cases. Again, in many persons 
who are affected with chronic coryza, we find considerable 
distortion of the septum, particularly of its cartilaginous 
portion. Both of these facts point to inflammation of the 
nasal mucous membrane as one of the principal factors in 
the production of the deformity. 
I have had no opportunity to observe post-mortem ap- 
pearances, but from a study of clinical cases and from the 
examination of numerous skulls, I am convinced that the 
affection of the septum usually commences in the cartilagi- 
nous portion, and that the flexion of the vomer, which 
often exists, is of mehanical origin due to firm articulation 
of this bone with the cartilage. 
We must bear in mind that we have a vertical septum, 
resting upon an unyielding base and held firmly down by 
the nasal bones and soft tissues of the nose, therefore no ad- 
dition can be made to its edges without causing flexion. In 
cases of spontaneous origin the principal changes appear to 
have been in the edges of the cartilage, increased growth 
from which has caused it to bend upon itself; but in some 
instances there is also considerable thickening of the septum. 
The process I believe generally depends upon congestion 
of the overlying mucous membrane, but its exact nature 
has not been determined. It is probably a simple hyperpla- 
sia of the cartilaginous cells due to hypernutrition; but it 
may possibly be of the nature of rachitis the pathology of 
which is obscure. 
Sir W. Jenner1 says the alterations in the bones in rachi- 
tis consist in an increased preparation for ossification, but an 
incomplete performance of the process. 
P. Henry Green2 states that the zone of cartilaginous tis- 
sue which in health is being transformed into bone is very 
thin, but in rachitis it is greatly increased particularly at 
the ends of the bones, but also beneath the periostium. 
1 “ Green’s Pathology and Morbid Anatomy,” 3d Am. ed., p. 222. 2 Ibid. Deflection of the Septum Narium. 
3 
It would seem, therefore, that at least one step in the 
development of rachitis consists in an abnormal growth of 
cartilage, and it is possible that the same conditions operate 
to enlarge the cartilaginous septum that cause the increase in 
rachitis. However, if we accept the theory that rachitis is 
due to checking of nutrition, it would appear inappropriate to 
class deflections of the septum as one of the manifestations 
of this disease; for in patients in whom deflection is ob- 
served, there is seldom any evidence of imperfect nutrition, 
and thus far I have not seen one presenting other signs of 
rachitis. 
Patients with deflection of the septum generally apply 
for relief, because of obstructed respiration or deformity of 
the nose. But we usually find also that there is excessive 
secretion from the nasal mucous membrane, most of which 
passes behind the velum into the throat. We also observe 
that the voice has something of a nasal twang, but the 
progress of the flexion has usually been so gradual that the 
patient himself does not appreciate the change. 
When distortion of the cartilage is extreme, the point of 
the nose is often pushed to the opposite side so as to cause 
considerable deformity, which is very objectionable, espe- 
cially in ladies. I have found this deformity so often that I 
am led to think that in the majority of cases a crooked nose 
is the direct result of enlargement and deflection of the 
septum. 
Upon inspecting the naris on one side we find a free 
space with more or less concavity of the septum, along 
which a narrow furrow will often be seen corresponding to 
the line of greatest flexure. In the opposite naris we find 
convexity of the septum varying in extent and position in 
different patients, but always greater than would at first be 
expected from examination of the larger naris. 
Contrary to the experience of others, I have observed 
this convexity most frequently on the right side. 
In the first class of cases there is a uniform concavity of 
one side with a corresponding convexity of the other. 
In the second class the deformity depends upon the se- 
verity of the injury, and may consist of simple depression 4 
E. Fletcher Ingals. 
and bending of the septum, or of this conjoined with fract- 
ure of the nasal bones. 
In the third class there may be only a slight flexion of 
the cartilage, near the nostril, both the anterior and pos- 
terior extremities of which may be easily seen; but in 
many instances the bent septum passes obliquely downward, 
from its natural position above, to the ala, and then bends 
sharply upon itself so as to lie almost horizontally across 
the nostril. In this form of distortion the nostril is often 
found to be completely closed, and the point of the nose 
is crowded considerably to the opposite side. In such 
cases thorough inspection may be impossible, but by draw- 
ing the ala well outward we may usually obtain a view of 
the deeper parts of the naris. 
In the fourth class, the deformity usually commences at 
the middle or upper third of the septum, and passes from 
that point outward and downward nearly to the floor of the 
naris. It then bends sharply upon itself, forming a longi- 
tudinal ridge which stands out from the normal plane from 
three to eight millimetres. The ridge thus formed gener- 
ally passes obliquely upward and backward, a distance of 
two or three centimetres in a line corresponding to the ar- 
ticulation of the vomer with the cartilage and nasal plate 
of the ethmoid. 
The most prominent part of the flexure is usually found 
about two millimetres below the normal position of the 
junction of the nasal cartilage with the vomer. In these 
cases, though upon first inspection the inferior plane of the 
bent septum seems to rest upon the floor of the nasal 
cavity, it will generally be found that a space remains 
beneath it sufficient to allow the passage of a probe two or 
three millimetres in diameter. 
There can be no difficulty in making a diagnosis if both 
nostrils are inspected, but it is sometimes impossible to 
determine the extent of the inflexion, in the deeper parts 
of the naris, until the cartilage in front has been removed. 
In cases of spontaneous origin the process of flexion con- 
tinues for a limited though uncertain time, but probably 
in most cases for at least two years. It finally comes to a Deflection of the Septum Narium. 
5 
standstill, and there seems no tendency to recurrence of 
the active increase in the size of the cartilage ; neither is 
there likely to be any atrophy of it; but the deformity 
unless relieved by an operation will continue through life. 
In traumatic cases considerable flexion results immedi- 
ately from the injury, but judging from the extent of dis- 
tortion in cases of this variety which have fallen under my 
observation, the injury is usually followed by considerable 
hypertrophy and subsequent bending of the cartilage. 
Several operations have been recommended for the relief 
of this condition. The most important are; the one recom- 
mended by S. D. Gross, which I believe is the same as that 
proposed by Chassaignac, which consists in paring off a 
portion of the bent septum ; the operation proposed by 
Wm. Adams, for forcible replacement of the bent and de- 
pressed septum ; and Goodwillie’s operation for perforating 
the septum. 
Several modifications have been made in each of these 
operations, which have better adapted them to special 
cases. 
In the first class of cases often no operation is necessary, 
though, perforation by Steel’s instrument, or Adam’s oper- 
ation, would probably correct the deformity, yet even in 
these I should prefer the removal of a slender triangular 
piece from the lower margin of the septum. 
In the second class of cases Adam’s operation,1 or the 
operation suggested by Dr. A. J. Steel, of St. Louis, and 
subsequently practised by Dr. Glasgow,2 seems most likely 
to be followed by favorable results, especially if there is no 
enlargement of the cartilage, in which case, if replaced, it is 
of exactly the proper dimensions to restore the nose to its 
former shape. 
In the third and fourth classes, where there is an increased 
growth of cartilage, no operation is likely to be permanently 
successful which does not include the removal of the re- 
dundant tissue. 
1 British Medical Journal, Oct. 2, 1875. 
2 St. Louis Courier of Medicine, 1879 ; also. Transactions of Am. Laryngo- 
logical Association, 1881, p. 117. 6 
E. Fletcher Ingals. 
Simple perforation of the septum is not sufficient in these 
cases, for although it will doubtless partially relieve the dif- 
ficulty in respiration by allowing air to pass from the ob- 
structed nostril through the enlarged naris, it will not cor- 
rect the deformity of the nose. It will not usually cure the 
obstruction in the back part of the occluded naris, and 
therefore it cannot cure the catarrhal symptoms; besides, 
as suggested at the last meeting by Dr. Glasgow, there is a 
tendency to scabbing of the edges of the perforation, and 
deformity of the nose is liable to result from removal of 
large portions of the septum. 
Paring off portions of the septum will answer the pur- 
pose in some cases, but it is only suitable for a small num- 
ber. By this operation a thin septum would be left of the 
original size, and of insufficient strength to support the 
nose. Such a septum would be peculiarly liable to further 
distortion; consequently, in many cases, the operation 
would not only fail to correct the twisting of the nose, 
but it would favor subsequent depression of the external 
parts. The operation suggested by Dr. Jarvis I have not 
tried, and as it is to be fully discussed in the next paper, I 
will not comment upon it. 
In all cases where the cartilage is much enlarged the oper- 
ation which seems to me most suitable, and which I have 
on two occasions found very satisfactory, consists in sepa- 
rating the mucous membrane and removing the redundant 
tissue, after which the mucous membrane is stitched down 
and the septum retained in proper position until firm union 
has taken place. 
The operation will sometimes require considerable time, 
and therefore in most instances an anaesthetic will be neces- 
sary. 
Ether or chloroform may be employed, but nitrous oxide 
is preferable for short operations, such for example, as that 
to be recommended for cases of the fourth class. 
Before commencing the operation, when possible, a small 
Eustachian catheter should be carried through the ob- 
structed nostril to the pharynx, and through it a catgut or 
a well-waxed silk ligature should be passed for tamponing Deflectioyi of the Septum Narium. 
7 
the posterior naris. This ligature should be attached to a 
suitable tampon of cotton or sponge, and tied in such a 
manner that about two inches of the end of the ligature 
may hang down the pharynx when the tampon has been 
placed in position. This hanging end will greatly facilitate 
the removal of the tampon after the operation. It is usu- 
ally best to introduce the tampon before the anaesthetic is 
administered. 
When the bent septum lies nearly horizontally across the 
nostril the mucous membrane over the septum should be 
incised from above downward and outward near the centre 
of the nostril as indicated by the line ad in drawing, and 
then with the handle of a scalpel or with delicate curved 
spuds, the membrane should be separated from all that por- 
tion of the septum which is to be removed. 
Estimating carefully the amount of tissue which it will 
be necessary to resect in order to secure symmetry of the 
nose and a straight septum, the cartilage should now be cut 
through from the upper to the lower outer angle of the 
obstructing portion a b, as indicated by the dotted lines in 
the drawing and then along the inner border from above 
downward a c. With a little care this incision can be 
made without cutting through the mucous membrane in 
the opposite naris. The cartilage may now be seized 
with forceps by the angle (a) and drawn downward and 8 
E. Fletcher Ingals. 
cut off. If the flexion extends backward along the septum, 
a slender triangular piece also must be removed from its 
lower border by means of scissors, a knife, or a short cut- 
ting hook. 
The incisions should be so planned that when the septum 
is pushed into its normal position the cut edges of the car- 
tilage will be in apposition. The mucous membrane is 
now drawn down and stitched, thus holding the cartilage 
in a proper position ; but it must also be supported by a 
plug or by a pledget of cotton until firm union has taken 
place. I have used cotton for this purpose, but the plugs 
recommended by Adams and Glasgow might possibly an- 
swer a better purpose. After a few days a tubular instru- 
ment of similar form would probably be more comfortable. 
The twisting of the end of the nose will be found to have 
been remedied by replacing the cartilage, and if proper 
care is exercised to keep the septum in position, until 
union is firm, a perfect result may be confidently predicted. 
I-have not made the experiment, but I think the after-treat- 
ment would be more easily carried out if the cartilage were 
either broken or incised at its upper part so as to destroy 
its resiliency, and thus require less pressure to hold it in its 
normal position. 
In addition to the anterior obstruction, a large ridge 
sometimes runs upward and backward a distance of two or 
three centimetres, as in the fourth class; this may be re- 
moved at once or a second operation may be made. 
In the fourth class, not only the cartilage, but usually the 
upper border of the vomer also, is bent; were it not for 
this, the operation might be readily performed by separat- 
ing the mucous membrane and then paring off the cartilage 
with a slender probe-pointed knife. On account of the 
bony tissue which has to be cut through, a slender saw will 
be found useful in operating on these cases. I have used a 
slender metacarpal saw, but I am now having made a much 
smaller instrument which may be worked either by hand or 
by a dental engine, and which will, I think, materially facili- 
tate the operation, and possibly render an anaesthetic un- 
necessary in cases of this class. Deflection of the Septum Nariunt. 
9 
In these cases the mucous membrane should be divided 
perpendicularly at the anterior extremity of the ridge, so as 
to allow the introduction of a spud ; also along the lower 
outer angle of the deflected cartilage, at a point which will 
insure enough tissue to cover the cut surface of the septum. 
The membrane having been separated from the septum, the 
saw is carried beneath the projecting portion close to the 
crest of the maxillary bone, and the cut is made directly 
upward until the bone and cartilage are divided. The 
piece being removed, the mucous membrane falls down upon 
the cut surface, and may be stitched at its anterior extremi- 
ty to the. membrane covering the crest of the maxillary 
bone. 
It is not often necessary to bend the septum after this 
operation, but if the flexion at its upper part is very great, 
it is advisable to restore it to its normal position, as after 
the operation for cases of the third class. ARCHIVES OF LARYNGOLOGY 
LOUIS ELSBERG, M.D., 
EDITED BY 
NEWYORK, 
J. SOLIS COHEN, M.D., FREDERICK J. KNIGHT, M.D., 
PHILADELPHIA, BOSTON, 
GEORGE M. LEFFERTS, M.D. 
NEWYORK, 
IN CONJUNCTION WITH 
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