What is a deviated septum?
The septum is the wall that divides the two sides of your nose on the inside. It is made of cartilage in the front of your nasal cavity and bone farther back as well as high inside the nose. Both sides of the septum are covered with a thin lining called the mucosa which also covers the rest of the nasal cavity and sinuses. A deviated septum is when the wall between the two sides of the nose is crooked or has spurs which block one or both sides of the breathing passage.
How do people get deviated septums?
Few people have perfectly straight septums. Usually it is a little bit bowed into one side or the other or there are small spurs. Typically, these minor deviations do not cause any problems and nothing needs to be done about them. Sometimes people naturally have very deviated septums which cause problems. Others will have a broken nose which shifts the septum into a new position that blocks the airway.
What are the symptoms of a deviated septum?
Generally the main symptom is nasal obstruction (trouble breathing through the nose). Most commonly, one side of the nose is more blocked than the other. The obstruction does not change or fluctuate very much with time.
Deviated septums can also sometimes contribute to recurrent sinus infections. Usually they do not cause headaches or pressure. An exception to this rule is when the septum is so deviated that it touches the opposite side of the nasal cavity (“contact point”). In some patients, this can cause chronic facial pain or headaches which will resolve if the septum is straightened.
Who is a good candidate for surgery to straighten a deviated septum (septoplasty)?
Good candidates for surgery should complain of chronic nasal obstruction most or all of the time which has not improved adequately with nasal medications such as flonase or nasonex. When I look in their nose, the septum should be blocking the side of the nose where they have the most trouble breathing (sometimes it is both sides).
Sometimes patients having sinus surgery need to have a septoplasty because I cannot otherwise get access to their sinuses due to a high septal deviation.
Patients who have other serious medical problems should think carefully before electing to have this surgery. It is a quality of life procedure, not a life or death surgery. In certain patients, I will have their primary care doctor or cardiologist give clearance for surgery to make sure the risk of problems is as low as possible.
Anyone on any blood thinners needs to be off of them for a week before and after this surgery. These medications include aspirin, any NSAIDs (ibuprofen, naproxen, etc), coumadin, plavix, and any other blood thinners.
How is septoplasty performed?
The surgery is done while the patient is completely asleep under general anesthesia. It is done as an outpatient procedure.
Once the patient is asleep, I make an incision inside the nose along the front of the septum. There are no external skin incisions. After the incision, I carefully lift the mucosal lining off the bone and cartilage of the septum on both sides. Then, I remove any deviated portions of bone and cartilage.
At this point, I usually crush most of the cartilage so that it is straight, and then place it back into the septum to add structural support. Finally, I reapproximate the two flaps of mucosal lining and place absorbable stitches to hold everything together and close the incision.
I almost always perform turbinate reduction at the same time as septoplasty.
I usually do not place any packing or splints inside the nose. In certain cases, I may decide to use plastic splints in the nose to provide support for the healing process. I remove these in the office 5 days after surgery. If I do put splints in the nose, a stitch in the front of the nose holds them in the right place.
What should you expect after surgery?
On average, there is a moderate amount of pain after septoplasty. I usually give a prescription for hydrocodone or another narcotic pain medication after the surgery. Pain usually starts improving after 4-5 days.
There may be some bloody oozing after surgery as well as large crusts of dried blood and mucus. It is important to use nasal saline spray 3-4 times a day for several weeks after surgery to help clear out crusting and to aid healing.
Avoid hot drinks and alcohol for 48 hours after surgery as these can increase the risk of bleeding.
Avoid any strenuous exercise, nose blowing, or heavy lifting over 10 pounds for 1 week after surgery. Open your mouth if you have to sneeze.
Patients must have stopped taking prescription pain medication for 24 hours before driving. You can return to work at this time as well, though heavy lifting or strenuous work activity is not permitted until 1 week after surgery.
What are the risks of septoplasty?
The most common risk is that nasal breathing will not be improved enough to satisfy the patient. The vast majority of patients will breathe much better once the septum is straightened, but the surgery does not address underlying allergies or other inflammation inside the nose that causes congestion. Also, the healing process is unpredictable, and sometimes the septum can shift positions and partially block the nose again in the future.
Another risk is bleeding. Bloody oozing is common in the first 24 hours after surgery. Brisk bleeding is not common.
A more rare risk is a septal perforation (hole between the two sides of the nose). This can cause crusting, nosebleeds, a whistling sound, and a sensation of nasal obstruction. If small, these perforations can be closed.
A very rare risk is a fracture of the roof of the nasal cavity causing a leak of spinal fluid from around the brain. I have never seen this happen, but it is a possible risk that patients should be aware of before having septoplasty.