Septoplasty and Nasal Valvuloplasty

Deviated Septum

The shape of your nasal cavity can lead to symptoms of nasal obstruction. The nasal septum is the wall dividing the nasal cavity into halves; it is composed of a central supporting skeleton covered on each side by mucous membrane. The front portion of this dividing wall is a firm but pliable structure made mostly of cartilage and is covered by mucosa that has a substantial supply of blood vessels.

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.  Within the nose there are additional structures composed of erectile tissue called turbinates.  These swellings will shrink and expand frequently throughout the day in order to regulate the humidity in the nose.  However, sometimes they are chronically swollen in a condition called turbinate hypertrophy.

A ‘deviated septum’ occurs when the septum is severely shifted away from the midline. The most common symptom from a badly deviated or crooked septum is difficulty breathing through the nose. The symptoms are usually worse on one side, and sometimes actually occur on the side opposite the bend.  However, the side that is less narrow can also be obstructed by the turbinates, which will swell to compensate for the excessive space.  In some cases, the swollen turbinates can be the sole source of nasal obstruction.

Lastly, the sidewalls of the nose are made out of cartilage, soft tissue and bone.  These can lead to obstruction if they collapse into the nose while breathing.  A good analogy is a tent, if the tents pole is crooked or if the tents walls are narrow this can decrease the space in the tent leaving less room for the camper (or air for breathing).   Symptoms of a deviated septum can also include nose bleeds, noisy breathing, recurrent sinus infections or cosmetic alteration of the nose.

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

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.

Your First Visit

After discussing your symptoms, the primary care physician or specialist 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. Surgery may be the recommended treatment if the deviated septum is causing troublesome nosebleeds or recurrent sinus infections. Additional testing may be required in some circumstances.

Septoplasty

Septoplasty is a surgical procedure performed entirely through the nostrils, accordingly, no bruising or external signs occur. 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. The time required for the operation averages about one to one and a half hours, depending on the deviation. It can be done with a local or a general anesthetic, and is usually done on an outpatient basis. After the surgery, nasal packing is 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. If a deviated nasal septum is the sole cause for your chronic sinusitis, relief from this severe disorder will be achieved.

Nasal Valvuloplasty

When the sidewalls of the nose are collapsing excessively, then reinforcing these areas to prevent nasal obstruction may be required.  This may only be noticed after an initial septal surgery has already been performed.  To reinforce these areas, a batten graft of cartilage is placed into the area of weakness in the sidewalls of the nose.  This is like an extra pole placed in the sides walls of a tent to prevent it from collapsing on the sleeping campers.  It creates more space.  It often requires an extra incision to place these suspension poles and the cartilage is taken from the septum or the ear to support the structures.  Additionally, the bony sidewalls of the nose may be deviated in a direction that requires rebreaking or moving them into a position that allows for better breathing.  These particular procedures can change or widen the outside appearance of the nose, but this may be needed to create more space.

What happens during surgery?

On the day of surgery, you’ll arrive at the surgery center on an empty stomach. You will have to avoid aspirin products and blood thinning medications prior to this.  You will meet with the anesthesiologist, surgeon and nurses to prepare you to go to sleep for the surgery.  It is performed under general anesthesia, which means a breathing tube is used and you are completely asleep.  You will not be able to wake up until surgery is completed.  Surgery takes somewhere between 1 and 2 hours typically.

Most of the time, no external incision are used unless a nasal valvuloplasty is performed, and this may require one external incision that is very small and heals well.  Cartilage is cut and repositioned to create more breathing space and the sidewalls may be reinforced or fractured to reduce obstruction.  Stents of silastic or very soft flexible plastic are placed in your nose to hold structures in place while healing.  These are very important and will be removed in 3-5 days.  After surgery is completed, you will wake up and be brought to the recovery area.  After 1-2 hours you will go home with a bandage under your nose to catch any slowly oozing blood.

What is recovery like?

Unless the nasal bones have to be rebroken there will be no black and blue eyes.  Typically, it is recommended to take 1 week off of work and avoid exercise for 2 weeks.  You will have moderate pain which typically lasts 3 days and you will be provided pain medication to help tolerate the recovery period.  Icing is recommended but not required.  You may have some bleeding the first 24 hours, but this tapers off quickly.  The first several days are marked by considerably worse nasal obstruction due to swelling and blood clots in the nose.  After the nasal splints are removed the breathing dramatically improves, and you are well on your way to recovery.