SEPTAL DEVIATION & NASAL OBSTRUCTION
There are several causes for nasal obstruction including structural or anatomic abnormalities, inflammatory conditions, swelling, tumors, and infection. The first step in treatment planning is to obtain a history of the condition and a careful exam of thee nose. The nasal septum is a structure made of cartilage and bone which is located in the midline of the nose and separates the nasal passages. In the back of the nose the septum ends such that a common space is present called the nasopharynx; this is where the adenoids and eustachian tube openings are located. When air flows through the nose, it should pass freely and with little resistance. Outside air is warmed and humidified within the nose before entering the windpipe and lungs. A major function of the nose is to condition air. When airflow through the nose is blocked, most people report considerable discomfort which is why this is a common reason to seek help.
When the nasal septum is crooked or bent it is considered to be deviated and it will cause variable degrees of resistance to air flow. Mild septal deviations require no treatment and are fairly common. Severe obstruction may result in complete airway obstruction of one or both sides of the nose. The most common cause for a septal deviation is congenital, caused by warping of the structure as the face grows forward and down during childhood (the back of the septum is a growth center). Injuries are another common cause for septal deviation which may also result in a crooked nose as well. Typically the first line of treatment is with decongestants or topical nasal steroid sprays. Even though these treatments do not change the septum, they may shrink tissues in the nose enough to improve breathing. If the medications work well, they may be the best treatment; however, some people do not wish to take a medication for the rest of their lives or the medication does not help and prefer surgery. To fix a septal deviation, surgery is required to straighten the structure. Prior to surgery it is important to have a careful exam because even though a septal deviation is present, there may be other causes of nasal obstruction as well.
Another common cause of nasal obstruction is due to large turbinates. Turbinates are structures located inside of the nose on the outside region; there are three sets of turbinates superior (upper), middle, and inferior (lower) turbinates. The upper turbinates are small and rarely cause trouble. The middle turbinates may be large or contain and air cell (concha bullosa) causing the structure to be larger than normal. The inferior turbinates are the most common cause of trouble and may be severely enlarged and may cause mild to complete airway obstruction. Treatment of inferior turbinates is discussed in another section.
Nasal airway obstruction may also be due to collapse of the nasal tissues during breathing. There are two regions of the nose referred to as nasal valves: the external nasal valve and the internal nasal valve. Airway resistance is greatest in these regions. When collapse of the external nasal valve occurs, the nostrils become narrower and even though the nasal airway inside the nose is fine, airflow will be poor. Another name for this condition is dynamic vestibular stenosis because it occurs while breathing and may be minimized by Breathe-Rite strips or by pulling the skin next to the nostril upward. This condition is often overlooked and may be a cause for poor surgical results even when the septum is perfect. The internal nasal valve is affected more by the shape of fixed structures within the nose.
Once the conditions affecting nasal airflow are defined and medical treatment has failed to help, a procedure may be scheduled. If surgery is performed well and all conditions affecting airway resistance are considered, the rate of success should be high. Septal surgery, turbinate reduction, and repair of vestibular stenosis are typically covered by insurance plans and is considered reconstructive because they restore function. Surgery to change the appearance of the nose is cosmetic and is not covered by insurance.
Procedures to reduce the size of the inferior turbinates exist. Turbinates may be enlarged because of abnormal soft tissue, bone, or both. If medical treatment fails to help, a procedure to reduce the size of the turbinates may be offered. Soft tissue reduction may be done in the office or hospital setting. The goal is to create a normal sized structure. Aggressive turbinate reduction may cause chronic nasal dryness. Various techniques are available from surgical resection to use of radiofrequency. The success rate of the procedure is high and the recovery after the procedure includes bleeding but pain is mild. It is common for people who have turbinate hypertrophy to have allergies or Afrin dependence; these conditions should be treated to achieve success.
Septal surgery is performed in a hospital or a surgical center and in most cases under a general anesthetic. Septal surgery is not often offered to younger patients (under age 16) because their facial growth is not yet complete. A typical surgery takes about one hour but may take longer if turbinates are treated or vestibular stenosis is repaired. Modern surgery is performed through an incision created inside the nostril or with a special scope, and either nostril may be used but the left side is the most common side. The goal is to reconstruct the septum such that a crooked structure is changed to a straight structure. This usually requires shaving or removing cartilage and bone or removal and replacing of pieces. It is important to maintain the strength of the nose. The septum has a key role in nasal support, especially the front aspect of the septum. Once complete, the incision is closed. Packing is rarely required but a plastic splint may be placed to help stabilize the septum while it heals. Immediately after surgery, most people can breathe to some degree. Swelling or bruising of the nose and face is not expected. It is also important to know that the shape or appearance of the nose DOES NOT usually change after septal surgery. If your nose is crooked before the surgery, expect it to be crooked after the surgery unless a rhinoplasty is also planned. Over the next few days, the nasal airway will worsen but after a week most people can breathe well and have only mild pain. If a splint was placed, it will be removed after about a week. Pain is greatest in the first three to four days and tapers so that most people do not need pain medication after one week. Bleeding is always present but this is typically mild in degree. A follow-up visit is planned at one and three weeks after surgery.
NASAL VALVE COLLAPSE (Dynamic vestibular stenosis)
The soft tissues of the nose may collapse when air passes through the nose. This condition is more common in those with northern European ancestry. The condition may be noticed by observing the nostrils and then performing a rapid deep sniff. If the condition is present, the nostril will change; at times the entire nostril collapse and becomes a slit. This occurs because the cartilage of the nostril is too weak and is unable to resist the negative pressure created by sniffing. Treatment includes use of Breathe Right nasal strips to support the nostril or surgery. Several surgical techniques can be used to treat the condition depending upon the severity of the condition. The simplest method is the "J" flap. This technique tightens the skin inside the nostril and supports the weak cartilage. This technique may be performed in an office or hospital setting. Another technique is placement of a cartilage graft, often taken from the septum or ear, into the nostril region. The cartilage graft supports the nostril and resists collapse. Other techniques are available and the surgeon must determine the best option.
RISKS OF SURGERY
Although the goal of the surgery is to improve breathing it is possible the airway will still not be ideal. People's bodies are different and the surgeon cannot control all aspects of the healing process. Scar tissue may form or events after the surgery may alter the nose. For best results it is important to follow post-operative directions, or call if you have questions. There are risks and potential complications for every surgical procedure including septoplasty. Fortunately the rate of complications is low for this procedure. Some of the major complications include but are not limited to the following: excessive bleeding, infection, change in the shape of the nose, loss of nasal strength or support, perforation of the nasal septum or scar tissue, dryness inside the nose, chronic pain, and numbness of the upper front teeth, and continued obstruction of the nose.
Many people will have a bandage placed below their nose after surgery which is intended to catch drips of blood and may be replaced as needed. Take care to avoid pressure on the nose. It is best to sleep with head elevated above the level of the heart for the first several days after surgery to reduce swelling and pain. Ice packs may be used over the nose to reduce swelling but take care not to place pressure on the nose or let the ice touch skin. It is best to avoid heavy lifting and strenuous activity for the first week. Highly aerobic activities, swimming, and contact sports should be avoided until cleared by the doctor, usually about two weeks. Excessive activity may provoke bleeding or cause a hematoma to form inside the nasal septum which may require another procedure to treat or result in an infection or alter results. Most activities are permitted right after surgery and it is common for those who have desk jobs and less strenuous work to return after a few days. Pain medication is used by most patients and while taking narcotic type medication, you are not permitted to drive. Motrin is a good substitute and may work well after surgery.