Deviated Septum

deviated-septum-before-afterThe nasal septum is the partition dividing the nasal cavity into two halves; it is composed of a central supporting skeleton covered on each side by mucous membrane. The front portion of this natural partition is a firm but bendable structure made mostly of cartilage and is covered by a mucosal lining that has a substantial supply of blood vessels. The back portion of the nasal septum is bony and offers structural support to the height of the bridge of the nose. The ideal nasal septum is exactly midline, separating the left and right sides of the nose into passageways of equal size.

Estimates are that 80 percent of all nasal septums are off-center, a condition that is generally not noticed. A “deviated septum” occurs when the septum is shifted far enough away from the midline to diminish the airflow from the nostril to the back of the nose. The most common symptom from a badly deviated or crooked septum is difficulty breathing through the nose.  Such airway obstruction can lead to open mouth breathing, chronic nasal infections, loud snoring or obstructive sleep apnea. Nasal sinus surgey and polyp surgery as well as tumor removal often include septoplasty.

The symptoms are usually worse on one side, and sometimes actually occur on the side opposite the bend. In more severe cases the crooked septum can interfere with the drainage of the sinuses, resulting in repeated sinus infections.

Septoplasty is the preferred surgical treatment to correct a deviated septum. This procedure is not generally performed on minors, because the cartilaginous septum grows until around age 18. Septal deviations commonly occur due to nasal trauma.

A deviated septum may cause one or more of the following:

  • Blockage of one or both nostrils
  • Nasal congestion, sometimes one-sided
  • Frequent nosebleeds
  • Frequent sinus infections
  • At times, facial pain, headaches, postnasal drip
  • Noisy breathing during sleep (in infants and young children)

In some cases, a person with a mildly deviated septum has symptoms only when he or she also has a “cold” (an upper respiratory tract infection). In these individuals, the respiratory infection triggers nasal inflammation that temporarily amplifies any mild airflow problems related to the deviated septum. Once the “cold” resolves, and the nasal inflammation subsides, symptoms of a deviated septum often resolve, too.

Diagnosis of A Deviated Septum:

Your First Visit: After discussing your symptoms, Dr. Dagan will inquire if you have ever incurred severe trauma to your nose and if you have had previous nasal surgery. Next, an examination of the general appearance of your nose will occur, including the position of your nasal septum. This will entail the use of a bright light and a nasal speculum (an instrument that gently spreads open your nostril) to inspect the inside surface of each nostril.

Septal deviation is usually diagnosed simpy by direct observation of the nasal passages. In addition, a computed tomography (CT) scan of the entire nasal passage is often performed. This scan allows the physician to fully assess the structures of the nose and sinuses. Additional tests that evaluate the movement of air through the nasal passages may also be performed.

Patients with chronic sinusitis often have nasal congestion, and many have nasal septal deviations. However, for those with this debilitating condition, there may be additional reasons for the nasal airway obstruction. The problem may result from a septal deviation, reactive edema (swelling) from the infected areas, allergic problems, mucosal hypertrophy (increase in size), other anatomic abnormalities, or combinations thereof. A trained specialist in diagnosing and treating ear, nose and throat disorders can determine the cause of your chronic sinusitis and nasal obstruction.

Treatment
There is no medical treatment for septal deviation. Surgical correction of the deviation of the nasal septum is the treatment of choice, also called septoplasty or submucous resection surgery. Septoplasty is a surgical procedure performed entirely through the nostrils, without any external incisions, accordingly, no bruising or external signs occur.

Before performing a septoplasty, Dr. Dagan will evaluate the difference in airflow between the two nostrils. In children, this assessment can be done very simply by asking the child to breathe out slowly on a small mirror held in front of the nose.

As with any other operation under general anesthesia, patients are evaluated for any physical conditions that might complicate surgery and for any medications that might affect blood clotting time. If a general anesthetic is used, then the patient is advised not to drink or eat after midnight the night before the surgery. In many cases, septoplasty can be performed on an outpatient basis using local anesthesia. Conditions that might preclude a patient from receiving a Septoplasty include excessive cocaine abuse, Wegener’s granulomatosis, malignant lymphomas, and an excessively large septal perforation.

Septoplasty surgery does not change the external features of the nose and is meant only to improve nasal breathing. The surgery involves uncovering the cartilage of the septum from its lining inside the nose, removing and re-straightening the cartilage. Next, the bottom part of the septum (the bony crest) which is akin to the track holding a window in place is addressed. Very commonly, the bony crest is off form the center and needs to be flattened in order to allow for the septum to spring back into the center. The cartilage that was re-straightened is usually reinserted, and the lining is stitched closed.

The surgery might be combined with a rhinoplasty, in which case the external appearance of the nose is altered and swelling/bruising of the face is evident. Septoplasty may also be combined with sinus surgery.

After the surgery, nasal packing may be inserted to prevent excessive postoperative bleeding. During the surgery, badly deviated portions of the septum may be removed entirely, or they may be readjusted and reinserted into the nose.

The surgical procedure takes approximately 45 minutes to an hour (including anesthesia) and as already mentioned may be done under local, twilight or general anesthesia.

The surgery might be combined with a rhinoplasty, in which case the external appearance of the nose is altered and swelling/bruising of the face is evident. Septoplasty may also be combined with sinus surgery.

Aftercare
Patients who undergo septoplasty surgery are usually sent home from the hospital later the same day. All dressings inside the nose are usually removed before the patient leaves. Aftercare includes a list of detailed instructions for the patient that focus on preventing bleeding after the surgery.

The head needs to be elevated while resting during the first 24-48 hours after surgery. Patients will have to breathe through the mouth if any nasal packing is still in place. A small gauze “moustache” will be tape under the nose to absorb the small amount of bloody discharge normally expected after surgery. Normally the gauze will absorb a rose colored fluid but excessive bleeding should be reported to the physician immediately. Antibiotics are usually not prescribed unless packing is left in place more than 24 hours. Most patients do not suffer significant amounts of pain, but those who do have severe pain are sometimes given narcotic pain relievers. It is normal to experience some numbness, tingling or discomfort in the first few weeks after surgery in the tip of the nose, the base of the nose or the front teeth. Patients are often advised to place an ice pack on the nose to enhance comfort during the recovery period. Patients who have splint placement usually return seven to 10 days after the surgery for examination and splint removal.

It is advised to avoid blowing the nose or bend over in the first few days after surgery in order to prevent bleeding. When sneezing, it is important to keep the mouth open to reduce the chance of bleeding as well.

Risks
The risks from septoplasty are similar to those from other operations on the face: postoperative pain with some bleeding, swelling, bruising, or discoloration. A few patients may have allergic reactions to the anesthetics. The operation in itself, however, is relatively low-risk in that it does not involve major blood vessels or vital organs. Infection is unlikely if proper surgical technique is observed. One of the extremely rare but serious complications of septoplasty is cerebrospinal fluid leak. This complication can be treated with proper nasal packing, bed rest, and antibiotic use. Although the portion of the nasal septum that is addressed during surgery is not crucial for support of the bridge of the nose, there is a remotely rare chance of loss of heght of the bridge of the nose which is correctible. Follow-up surgery may be necessary if the nasal obstruction relapses.

Normal results
Normal results include improved breathing and airflow through the nostrils, and if combined with a cosmetic rhinoplasty an acceptable outward shape of the nose. Most patients have significant improvements in symptoms following surgery. It usually takes 1-2 weeks to appreciate the improved breathing because swelling and bloody secretions within the nose need to subside and are frequently cleaned during the first post operative visit one week after surgery.

Alternatives
In cases of sinusitis or allergic rhinitis, nasal airway breathing can be improved by using such nasal sprays, as phenylephrine (Neo-Synephrine). Patients with a history of chronic uncontrolled nasal bleeding should receive conservative therapy that includes nasal packing to identify the source of the bleeding before surgery is contemplated. Bleeding episodes can be controlled with cautery in the ENT office. Those who have been diagnosed with obstructive sleep apnea have a variety of conservative alternatives before surgery is seriously considered. These alternatives include weight loss, changes in sleep posture, and the use of appliances during sleep that enlarge the upper airway.

Septoplasty surgery is elective, meant to improve the quality of life as it relates to nasal breathing. The alternative to correcting the septum surgically is of course no treatment at all. Unfortunately there is no means to correct the nasal septum other than surgery.