Overview of Septoplasty
Nasal septoplasty is a common procedure conducted by ear, nose, and throat doctors or plastic surgeons. It’s essentially a surgery done to fix a deviated septum – a condition where the thin wall between your nostrils leans into one side causing difficulty in breathing. The surgery’s main objective is to improve airflow in your nose, rather than changing its appearance.
There are several ways to perform this procedure, such as through the nostrils, using an endoscope (a special tool with a camera on the end), or by making a small cut on the nose. Sometimes, this procedure can also be performed alongside other nose surgeries like rhinoplasty (reshaping the nose), turbinoplasty (reducing the size of the nasal turbinates for better air passage), or as part of functional endoscopic sinus surgery to have better surgical access.
Recovery from this operation usually takes a few weeks, and serious complications happening are quite rare. Deciding on the right candidates for the surgery is critical to get optimal results. An ideal candidate is a patient with a significantly deviated septum that severely affects their breathing.
Anatomy and Physiology of Septoplasty
The septum is a key part of your nose, providing support to the structure and dividing your nasal cavity into two separate airflow paths. This division in the septum helps warming and humidifying the air we breathe in. However, if your septum is not straight or ‘deviated’, it can cause problems like blocking the airflow in your nose. This can lead to symptoms such as a blocked nasal passage and in severe cases, it can make sleep apnea symptoms worse. A deviated septum can also produce bony growths, or ‘spurs’ that can cause nosebleeds, headaches, and facial pain.
The septum is made up of three main parts: a membrane, cartilage, and bone. The membrane section is at the front, made of fibrous tissue. The cartilage part, which has a four-sided shape, sits behind the membrane. Bone makes up the rest of the septum and is located behind the cartilage. This entire structure of the septum provides stability to your nose.
The nasal valve, a small triangular-shaped area inside your nose, is the narrowest part of the nasal passage and helps in controlling the airflow. Certain tissues can make the nose look deviated, however, they are usually even on both sides.
Special attention is needed during a surgical procedure on the septum to two critical points: the junction with the anterior nasal spine of the maxilla and the “keystone area”. This “keystone area” is essentially the central area of your nose. If this area is disturbed during surgery, it can potentially lead to deformities.
The cartilage and bone parts of the septum are wrapped in tissues that provide a good blood supply and innervation. These networks help in regulating the temperature and humidity of the air passing through the nasal cavity.
The blood supply to your nasal septum is via arteries sourced from the internal and external carotid arteries. These arteries provide blood to all parts of the septum, from top to bottom and front to back, ensuring the entire septum is well supplied.
Different parts of your nose and septum are supplied by branches of the trigeminal nerve, which is a major sensory nerve of the face. The smallest part of the nose gets feeling from the olfactory nerve, enabling the sense of smell.
Why do People Need Septoplasty
A septoplasty is a surgery done to fix a misshapen nasal septum. The septum is the wall dividing the nostrils, and a deformity could involve a bent or twisted septum that takes up space in one or both nostrils. This could make airflow through your nose difficult, giving you the feeling that your nose is blocked. This is usually more noticeable when you’re working out or exerting yourself. The most common reason for a deformed septum is injury. However, you need to be experiencing constant nasal blockage for this surgery to be considered necessary.
There are several ways to measure how badly your nose is blocked. One of these is the NOSE (Nasal Obstruction Symptom Evaluation) scale, a scoring method that helps determine how severe your blockage is. If your score is low, surgery probably won’t help. Before considering surgery, your doctor will take a detailed medical history to check if other factors might be causing or contributing to nasal obstruction. These could include nose injury, rhinosinusitis (a type of sinus infection), allergies, blood vessel inflammation, illegal drug use, chronic use of nasal decongestants, autoimmune diseases, or even cancer. If any of these are the problem, you would first be offered relevant treatment (like nasal steroids for chronic allergic rhinitis) before surgery is thought of.
Septoplasty may also be recommended for recurrent nosebleeds, obstructive sleep apnea, sinusitis, and facial pain or headaches caused by septal spurs touching a turbinate (a condition called Sluder’s syndrome). Additionally, a septoplasty may become necessary as part of certain surgeries on the sinuses, skull base, or orbits (eye sockets). This is done to give surgeons better access to the area they need to operate on.
When a Person Should Avoid Septoplasty
There are several reasons why a doctor may decide not to perform surgery. These can include if a person has other diseases like rhinosinusitis (an infection or inflammation of the sinuses) or vasculitis (inflammation of blood vessels) or if the person hasn’t tried other medical treatments yet. Using nasal sprays won’t fix a crooked septum, but they might reduce long-term inflammation enough to improve a blocked nose without needing surgery. Also, health insurance companies usually require that all non-surgical treatments be tried first before they’ll agree to cover a costly surgical procedure.
It’s also strongly recommended to avoid using recreational drugs, especially cocaine, during the time before and after surgery. Cocaine can cause blood vessels to constrict and damage the lining of the nose, which can then lead to complications such as a hole in the septum, delayed healing, and a collapsed nose. It’s generally best to make sure patients haven’t used these drugs for at least 6 to 12 months before surgery, and drug testing might be needed to double-check this. Similar care should be taken with patients who show signs of rhinitis medicamentosa, which is a condition involving congestion that occurs after long-term use of nasal decongestants. These sprays can also cause constricting blood vessels, so they should be avoided for a significant amount of time before surgery. However, they can be helpful to minimize bleeding during and after surgery. Despite its negative effects on health, smoking doesn’t seem to affect how successful this type of surgery can be.
Patients with unrealistic expectations about the outcome of septoplasty surgery (surgery to fix a deviated septum) should receive extensive counseling before being offered surgery. This is particularly true for those who also wish to undergo rhinoplasty (cosmetic nose surgery). The surgeon and patient need to have a common understanding about what results are achievable, as this can lead to both the patient and the surgeon being more satisfied after surgery. Likewise, patients with a crooked or deformed septum, but without substantial functional symptoms, may not see much improvement from surgery.
Lastly, a patient’s other illnesses, functionality (ASA grade – a system used to evaluate a patient’s fitness before surgery), and age all need to be taken into account when deciding whether the patient would be safe to go under general anesthesia, which makes the patient unconscious during surgery, and whether the patient would be able to manage the recovery process after surgery.
Equipment used for Septoplasty
A usual kit for a septoplasty surgery, which is done to fix a deviated septum in your nose, includes a variety of tools. However, the doctor may only end up using some of these, based on what methods they like best for doing this procedure.
The kit might include a headlight for the surgeon to see clearly in your nose. It could also have few types of speculums – the Hartmann/Vienna, Cottle, and Killian types. A speculum is a tool that doctors use to hold your nostrils open during the surgery. There are also various kinds of forceps, which are like tweezers that the surgeon uses to hold or move tissues. Types of forceps might include the Jansen-Middleton, Blakesley, Takahashi, Blakesley-Wilde, Lubet-Barbon, Adson-Brown, Cushing-Brown bayonet, Jansen nasal dressing, and Cottle lower lateral models.
Also in the kit could be a #15 blade on a #7 Bard-Parker scalpel handle, which is a surgical knife used to make incisions. Other tools could include the Hills elevator, Cottle curved scissors, and Gorney nasal shears, which are used for cutting tissue; Ferguson or Frazier suction tip, which is used to remove fluid or debris; bipolar diathermy forceps, which uses electricity to stop bleeding; and a cotton applicator for applying medicine.
The kit might also include a variety of elevators – tools used to lift or move tissues – such as the Freer, Pierce, Cottle, and Woodson types. On top of that, there may be a Cottle chisel and metal mallet, which are used for breaking and shaping bone; Backhaus towel forceps, used for handling sterile towels or drapes; a needle holder for suturing; and a medicine cup.
If your surgeon is using an endoscope (a thin tube with a light and camera at the end) for the surgery, the kit could also include the Hopkins rod, light source, and stack. Silastic splints, which support the nose as it heals, and different sizes of chromic gut suture, a type of thread that dissolves over time, might also be part of the set. And finally, there might be Mupirocin ointment, used to prevent bacterial infections.
Who is needed to perform Septoplasty?
Surgeons who specialize in Ear, Nose, and Throat (ENT) often do a surgery called septoplasty. This operation is quite common among these types of surgeons. Some septoplasty surgeries are more complicated and may need to be done by a surgeon who specializes in the nose (rhinology) or facial plastic surgery. Some plastic surgeons also do septoplasty surgeries.
The operation is not a one-man job; several medical professionals are involved. An anesthetist, who makes sure you don’t feel any pain during the surgery, a scrub nurse, who assists the surgeon, a surgical technologist, who handles the technical aspect of the operation, along with nurses who take care of you before and after the operation and coordinators who ensure everything runs smoothly.
Preparing for Septoplasty
Doctors will need to get a full understanding of your nasal symptoms and how they affect you. This includes any other nose-related or overall health symptoms, like allergies. There are certain tools like the NOSE scale that help doctors grade how severe your nasal blocking symptoms are. It’s also important to discuss any medication you’re taking, especially nose sprays that reduce congestion or inflammation and any recreational drugs. If you smoke, stopping might be recommended, even though it’s not proven that smoking makes nose surgery outcomes worse. If you’ve had nose or sinus surgery before, had issues with anaesthesia, or have bleeding problems, these are also important to note.
During your checkup, the doctor will do a thorough examination. This starts with a complete check of your head and neck, followed by an inspection of the front part of your nose with a special tool called a nasal speculum. The doctor might also use a flexible tool to inspect the back of your nasal passage for any signs of nose disease or unusual growths, especially when your symptoms don’t match what they see. When they look at your nasal septum, which is the wall that separates the two sides of your nose, they are checking the quality and nature of the tissue and the large structures in your nose.
If these structures are too big and making it difficult to see, a procedure to reduce their size may be needed. The doctor will also feel the part of your nose to evaluate the size, location, and nature of any deviations to help understand if it’s mainly caused by soft tissue or bone and detect any holes, dislocations, or sharp points in it. If previous nasal septum surgery has been done, the doctor will also check how much of the original tissue is still there.
An external examination will also be conducted to note any other deformities, if your nostrils collapse when you breathe in, and how well your nasal tip is being supported. Finally, a test named Cottle’s maneuver could be performed to check for any internal blockages in your nose.
By doing a thorough examination, the doctor will be able to determine if surgery is the right step, how challenging it might be, and what surgical method would be best for you.
How is Septoplasty performed
When preparing for an endonasal surgical procedure, here is what typically happens:
You will lie on your back with your head slightly tilted towards the surgeon. Any prominent nose hairs will be trimmed. The surgeon may choose to reduce the blood flow to your nose with a specific medication. Then an anesthetic is applied to both sides of the nose to numb the area, help with tissue separation, and control bleeding during the surgical process.
Next, the surgeon uses a tool called a nasal speculum to get a better view of the lower edge of the cartilage in your nose. An incision, or cut, is made along this edge to expose the cartilage. The surgeon uses different tools to carefully separate the tissue layers, working towards the back of the nose to expose the cartilage and other parts of the nasal bone framework.
Once the cartilage and bone structures are revealed, the surgeon will assess the location and direction of any abnormalities or deformities. They will then use a variety of tools to cut and dissect the tiny structures as needed. The goal is to keep a certain amount of cartilage and bone intact for support.
Next, the detached tissue layers are folded back against the cartilage, and then the incision is stitched up. The surgeon may use additional strategies to stop the tissues from separating again post-surgery and to prevent any blood build-up. A small surgical device known as a septal stapler might be used in place of traditional sutures.
After the procedure, you can typically go home on the same day. You’ll get a prescription for a topical antibiotic cream and pain medication. The use of a saltwater spray and other medications might also be suggested to help keep the nasal passages clean while you recover.
You may have to come in for a post-operation check-up in one to two weeks, especially if the surgeon used splints, or braces, that need to be removed. Antibiotics are usually not required. If you had any small gauze packing placed during the surgery, antibiotics might be needed to avoid any infection risk.
The steps used in an endoscopic procedure are generally the same as the traditional endonasal method, simply done with the help of an endoscope, a small camera that helps to visualize the structures inside the nose. This method can be particularly handy in cases where the surgeon needs a better view of certain parts of the nasal cavity. It is important to understand that endoscopic techniques present some challenges and might take a longer time for beginners.
If the deformities inside your nose are complex, involve all the components of the bone and cartilage framework or you have had a previous nasal surgery, a different approach known as extracorporeal surgery might be employed.
Possible Complications of Septoplasty
When you have a septoplasty, which is surgery to fix a deviated septum in your nose, there can be complications or side effects. It’s important to understand these issues may occur before you agree to the procedure. Bleeding is the most common complication. A little bleeding or oozing can be expected, but heavier bleeding can occur and it can be controlled with nasal packing – a procedure where material is placed in the nose to stop the bleeding. In rare occasions, heat or electricity (cautery) may be used to control the bleeding.
Another issue that can occur is called a septal hematoma, which is when blood collects beneath a layer of tissue in your nose. This needs to be drained to prevent other problems like an infection or changes to the shape of your nose, like a ‘saddle nose’ deformity. A ‘saddle nose’ is a condition where the bridge of the nose collapses. Perforations, or holes in the septum, can also occur due to cuts made during the operation.
Some people can have an infection, a blocked nose or find that it takes a long time to recover. Infections are rare and can typically be treated with oral antibiotics – most patients recover fully within a few weeks. Some people might experience a decrease in their sense of smell, especially if they have another procedure done at the same time. This usually improves within six months. In some cases, scar tissue may build up in the nose, but the use of silicon-based splints can help to reduce this risk. Some people may also experience numbness or extra sensitivity in their upper teeth or lip due to handling of a nerve during surgery; these sensations normally recover within a few months.
One common long-term issue is that some people might not feel like their breathing has improved enough. This can happen for various reasons including repeated nose injuries, weight gain, natural cartilage changes, surgical errors and others. It’s important to understand this risk before you have the operation.
What Else Should I Know About Septoplasty?
Septoplasty is a common type of nose surgery (also known as an ENT procedure), often performed to fix a deviated septum. This operation can greatly improve the quality of life for most people who have had difficulty breathing because of this nose structure problem. However, some people still face recurring problems even after surgery, and satisfaction from the procedure can vary greatly, with rates ranging from 50% to 100%.
To understand how successful the operation is, doctors typically look at three things: patient satisfaction, improvement in quality of life, and improvement in symptoms. The tricky part about evaluating symptom relief is that it can vary from person to person, and even fluctuate throughout the day. Sometimes, objective tools, like acoustic rhinometry and rhinomanometry, might not match up with a patient’s own perception of their breathing.
Research shows that the long-term results may not be maintained for some patients. For example, one study found that nine years after surgery, only 26% of patients had no nose blockages, compared to 51% at nine months post-op. Another study revealed that while 53% of patients were free of symptoms six months after surgery, the number dropped to 18% after 34 to 70 months.
It’s tough to predict which patients will have successful outcomes after surgery. Many factors may impact this, including: nose injuries, recurring nose allergies or combining septoplasty with another nose surgery (inferior turbinoplasty).
Doctors need to examine each patient individually to decide if the surgery should go ahead. The decision is based on both objective measures and the patient’s own experience of their symptoms. In places like the UK, where healthcare is funded by the government, it’s important to show that the operation will indeed improve the patient’s quality of life and reduce their symptoms, to justify the spending. Therefore, careful patient evaluation is crucial to predict a good outcome after the surgery.