*** What follows is a general discussion of the indications, techniques, and expected outcomes for two of the more commonly performed nasal surgeries: septoplasty and turbinate reduction procedures. This handout is not intended to replace the advice of the physician but rather to help you organize your thoughts, answer some general and common questions, and perhaps generate further questions for discussion.
General Background & Anatomy
Nasal obstruction or congestion is one of the more common complaints that ENT surgeons encounter in their practice. Most patients describe a sensation of not being able to “get enough air” through one or both sides of their nose. Others may describe snoring, decreased sense of smell, or noisy respirations. Some patients experience an increased frequency of nasal bleeding and irritation as the sole manifestation of a septal deformity. Quite frequently there is a history of nasal trauma or injury that may have occurred many years in the past.
The nasal septum is a bony and cartilaginous divider separating the nose into two distinct nasal cavities. It begins behind the skin between your nostrils and ends at the very back of your nasal cavity. Rarely is it perfectly straight, but the more deviated (or crooked) it is, the more likely it is to cause symptoms. Severely deviated septums not only cause difficulties with nasal breathing, but can contribute to problems with sinus function by “crowding” the narrow channels that normally drain the sinuses. The turbinates are other structures inside the nose that help to control the size of the nasal airway and to moisturize/humidify and filter the air entering the nose. They are capable of dramatic changes in size by virtue of the fact that they contain erectile tissue that expands with increased blood flow. Most of us are familiar with the congestion that accompanies a common cold. This is what some people experience all of the time because of either a septal deviation or hypertrophy (enlargement) of the turbinates. Oftentimes, both problems coexist.
One of the mainstays for medical treatment for nasal obstruction and congestion is a trial of nasal sprays. The most commonly prescribed intranasal medication is a nasal steroid (such as Flonase, Nasonex, or Veramyst). Nasal antihistamines are also routinely used (such as Astepro or Astelin). If patients have allergies, oral antihistamines are usually added to the regimen. Over-the-counter decongestants, such as Sudafed, will help on a short-term basis.
Mechanical splints (Breathe-Rite strips) can be helpful to some patients. They basically enlarge the passageway by enlarging the intranasal valve.
Intranasal decongestants (such as Afrin, Neo-synephrine, Vicks intranasal spray, etc.) are to be used on a very limited basis for no more than 2 days. Longer use will result in a condition known as rhinitis medicamentosa, which is a condition where the nasal passageways exhibit more swelling after the medication effect wears off. This leads to a vicious cycle where a patient feels the need to spray the intranasal decongestant more and more often, thus leading to more severe rebound swelling.
Non-medicinal irrigations utilize saline (such as the Neilmed Sinus Rinse and/or Netipot) to help clean the nasal passages. I heavily encourage all of my patients who suffer from nasal congestion and obstruction to use these products.
Some patients will experience improvement in their symptoms with a combination of these therapies while others may not. These non-responders are potential candidates for surgical intervention.
A septoplasty is a term that actually defines a number of different procedures with a common denominator: the septum is manipulated or reshaped to improve its position in the nose and thus improve the nasal airway. I utilize minimally-invasive endoscopic techniques to perform this surgery. A small, hidden incision is placed inside the nostril (usually the left). The skin and lining that covers the septal bone and cartilage is elevated on both sides, and the deviated section is removed. The skin and lining are then replaced and the incision is closed with absorbable sutures. In this manner, the septum is repositioned in the midline and the nasal airway is improved.
Turbinate reduction procedures (sometimes referred to as submucous resection of the turbinates) serve to improve the nasal airway by reducing the lower portion of the inferior turbinate closest to the floor of the nose. I use a small instrument known as a turbinate microdebrider to selectively reduce the tissue below the surface of the turbinate. Turbinate reduction procedures are often performed in conjunction with a septoplasty.
I rarely use packing for these procedures. In the past, large splints and gauze were placed inside the nasal cavities to hold things in place. With the invention of modern, endoscopic techniques, packing has become obsolete. Let me reiterate – I almost never place packing in a patient’s nose. There are meticulously placed sutures that are supporting the repair, and for this reason, I ask all of my patients to not blow their nose for the first week following surgery. When you wake up from surgery, there will be nothing hindering airflow in and out of the nose.
Post-operative Care and Recovery
This is usually very straightforward. The pain that accompanies a septoplasty and turbinate reduction is usually mild to moderate discomfort, and most patients require little more than Tylenol or Advil after the first few days. All of my patients receive a narcotic pain prescription in case there is intense pain – again, this is rare. Activity is restricted only in that vigorous and strenuous activities are discouraged for the first 7 days after surgery. Patients are generally seen about a week following their operation and then again about 3 weeks later. The whole healing process takes anywhere from 4-6 weeks. It is very common to experience some nasal congestion and stuffiness in the days following your surgery. This is due to the swelling that occurs as well as scabbing and crusting within the nose. The single most important thing patients can do to assure proper healing is to keep the nose moist – starting on the day after surgery, I have patients spray nasal saline up each nostril at least four times a day (it can be done more often).
Nose-blowing is discouraged for the first week. Since I don’t use splints/packing, I keep things in place with carefully placed sutures. Blowing the nose can disrupt these sutures and result in less than optimal healing. If nasal congestion is severe, one trick I tell patients is to use cold nasal saline (keep it in the refrigerator). This will decongest the nasal tissues.
Bleeding from the nose is to be expected for the first 24 hours after surgery. You will be discharged from the recovery room with a drip pad beneath the nose. This can be changed as often as needed, and it helps collect blood and reduce a patient’s need to wipe their nose. Sleeping with the head elevated is encouraged – this will keep the oozing from the nose from trickling down the back of the throat. If bleeding is severe, I ask patients to spray Afrin up each nasal cavity (2-3 squirts up each nostril twice daily, not to be used for more than two days).
Complications are fortunately rare following septoplasty and turbinate reduction. Below is a list of problems that patients may encounter:
Bleeding – again, some bleeding is to be expected. If severe, a post-operative packing may need to be placed if the bleeding does not subside. A return to the operating room would only be done as a last resort.
Infection – patients are kept on antibiotics for one week following surgery to minimize the risk of infection. If you feel that you may have an infection leading up to the surgery, please notify me as soon as possible. A severe infection may postpone surgery for safety reasons.
Septal perforation – modern, endoscopic techniques significantly reduce the risk of septal perforation, a.k.a. “hole in the septum”. If this does occur, it is usually small and of no significance. Rarely, a whistling sound can be heard from the perforation.
Risk of anesthesia – this will be a procedure done under general anesthesia. In other words, you will be completely asleep for the duration of the surgery. Surgery generally lasts for approximately one hour. The anesthesiologist will discuss the anesthesia process in more detail with you.
Scarring – scarring is unusual, but when seen, it can usually be addressed in the post-op visits. Persistent scarring could result in decreased airflow.
Loss of smell – this is usually a transient phenomenon that resolves once the swelling from surgery subsides.
Nasal deformity – in rare circumstances, nasal collapse can happen. If too much cartilage is resected, or if trauma to the nose occurs in the post-op period, this complication is theoretically possible. I have never had this complication occur in a patient, and I go to great lengths to perform a conservative septoplasty that accomplishes the goal of improved nasal airflow and reduces the chances of this complication.