SEPTAL DEVIATION

Nasal Septal Deviation and 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 turbinaes 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 more narrow 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 is 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 determined, surgical planning is complete and the procedure may be scheduled. If surgery is performed well and all conditions affecting airway resistance are considered, the rate of success should be very high. Septal surgery, turbinate reduction, and repair of vestibular stenosis is typically covered by insurance plans and is considered reconstructive because it restores function; Surgery to change the appearance of the nose is cosmetic and is not covered by insurance.

Septal surgery

Septal surgery is performed in a hospital or a surgical center and in most cases under a general anesthetic. 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 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 and Dr. Denys usually sews the septal structures back together in a way that packing is rarely required, about one in every fifty patients. Immediately after surgery, most people can breathe well. 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. 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.

Risks of surgery

Although the goal of the surgery is to improve breathing it is possible you will not obtain an airway as good as you hope for. People's bodies are different and the surgeon cannot control all aspects of the healing process-scar tissue may form or events after the surgeyr may alter the nose. For best results it is important to follow post-opertaive directions or call if you have questions. There are risks and potential complications for evey surgical procedue 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, dryness inside the nose, chronic pain, numbness of the upper front teeth, scarring, and continued obstruction of the nose.

Post-operative care

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.