Overview of Septoplasty
Nasal septoplasty is a common operation carried out by ear, nose, and throat (ENT) and plastic surgeons. This surgery, which is not just for looks but primarily to improve function, is often done to correct a crooked or deviated septum. The septum is the structure that separates your nostrils, and if it’s bent or shifted to one side, it can make it harder for you to breathe through your nose.
There are a variety of methods to perform this surgery, including techniques that can be done through the nostrils, using a camera (endoscopic), or through a small cut on the outside of the nose (open). Sometimes, nasal septoplasty is done together with nose reshaping (rhinoplasty), surgery on the nasal turbinates (turbinoplasty) – these are structures on the side of your nose that help filter and humidify the air you breathe in, or as part of a surgery to improve your sinuses.
The recovery period from nasal septoplasty usually lasts a few weeks, and severe complications are not common. It’s very important to select the right patients for this operation, as this greatly helps in achieving the best results.
Anatomy and Physiology of Septoplasty
The success of septoplasty, which is a surgery to correct the shape of the septum in the nose, depends on understanding the nose’s particular anatomy. The septum is a significant structure in the nose; it gives support to different sections and divides the nasal cavity into two separate pathways. These allow the smooth flow of air and help to warm and moisten the air we breathe. If the septum curves or deviates, it can lead to obstructed airflow that can result in symptoms, such as difficulty breathing or even worsened sleep apnea in some cases. Bony outgrowths resulting from a deviated septum could also cause nosebleeds, headaches, or facial pain.
The septum is composed of three main parts: membranous, cartilaginous, and bony. The membranous septum is made up of fibrous tissue and is found at the very front of the septum. The cartilaginous septum, which is quadrangular or four-sided, is found behind the membranous septum. The bony section is at the back, made up of the vomer and perpendicular plate of the ethmoid.
Another crucial aspect of the nose’s anatomy is the nasal valve, which is the smallest part of the nasal passage. If seen from one side, in about half of the people, there may be a wider section of the upper side at the level of the internal nasal valve, which can be mistaken as a deviated septum.
The septum’s two significant junction points, which relate to surgical intervention, are its connection with the front part of the maxilla (upper jaw bone) and the “keystone area”, a crucial area for maintaining the nose’s structure and stability. It’s important that surgeons are careful during septoplasty to avoid damaging the support for the upper nose. If this area is disrupted, it could lead to a saddle nose deformity, which is a nose that has lost its bridge.
Both the cartilage and bone of the septum are encased in a sort of fibrous skin, which enables blood flow and innervation (the supplying of nerves). This network of blood vessels is responsible for warming and moisturizing the air we breathe in through the nasal cavity. The lining of the septum consists mostly of a specific kind of respiratory epithelium, whereas, higher up, near the smell-sensing region of the nasal cavity, the olfactory epithelium is found.
The vasculature of the septum is made up of a combination of arteries from the internal and external carotid arteries. These arteries supply oxygenated blood to different areas of the septum. The blood vessels merge into a plexus, which is often the main source of nosebleeds.
The nerves supplying the external and internal nose belong to the ophthalmic and maxillary branches of a larger nerve called the trigeminal nerve. Different branches of these nerves supply sensations to different parts of the septum. The olfactory nerve senses smells and takes these sensory inputs from the olfactory epithelium to the area of the brain responsible for processing them.
Why do People Need Septoplasty
Septoplasty, a type of nose surgery, is usually done because the wall between the nostrils, known as the nasal septum, is not shaped correctly. This incorrect shape, which might be due to an injury, can cause the septum to move into one or both of the nostrils. This makes the area inside the nostrils smaller, making it harder to breathe through the nose and causing a feeling of a blocked nose. People may notice this blocked feeling particularly when they’re exercising or being active. This surgery is usually only considered if the person is having unpleasant symptoms like difficulty breathing through the nose.
There are different ways to measure how much someone’s nose is blocked. The Nasal Obstruction Symptom Evaluation (NOSE) scale is a common and reliable way to measure this. People who have low scores on this test might not get much improvement after surgery. It’s also important to remember that there might be other reasons for a blocked nose, like allergies, sinus infections, regular use of nasal sprays to unblock the nose, autoimmune diseases, or cancer. If these conditions are the main reason for the blocked nose, medicine or other treatments might be the first choice, rather than surgery.
Septoplasty might be also done for other reasons too, such as regular nosebleeds, sleep apnea (where breathing stops during sleep), sinus infections, and facial pain or headaches due to the septum touching the inside of the nose (Sluder’s syndrome). Sometimes, septoplasty is carried out as part of surgery on the sinuses, the base of the skull, or the eye socket areas to allow the surgeon easier access.
When a Person Should Avoid Septoplasty
Surgery may not be suitable for everyone. Conditions like rhinosinusitis or vasculitis (inflammation of the nose and blood vessels respectively), or situations where other medical treatments haven’t been fully explored may make surgery options unviable. While nasal sprays won’t fix a bent nasal passage (deviated septum), they may reduce long-term swelling enough to make surgery unnecessary. Also, insurance providers may not cover the cost of a pricey surgical procedure if other non-surgical treatments have not been tried first.
Using recreational drugs, especially snorting cocaine close to surgery time, is strongly discouraged. The nose-narrowing and tissue damaging effects of cocaine can cause issues like a hole in the nasal septum, slow healing, or even a collapsed nasal bridge which results in a flattened nose shape. It is recommended that patients have not used such drugs for at least 6-12 months before the operation. Testing may be needed to confirm this. Similar care should be taken with patients showing signs of rhinitis medicamentosa – a condition caused by overuse of certain types of nose sprays. All use of such sprays should be stopped for a long period before surgery, though they can help control bleeding during and after the operation. Smoking is generally bad for one’s health, but current research does not show that it worsens the outcomes of this specific nasal surgery.
Patients who have unrealistic expectations about how they will look or feel after functional septoplasty (surgery to correct a deviated septum) should not be considered for the operation until extensive pre-surgery counselling has been conducted. This applies even more to those who are also having concurrent nose reshaping surgery. Both the surgeon and the patient need to have a common understanding of possible results. This can help improve satisfaction levels for both after the operation. Those who have a deviated or deformed septum but have only limited functional issues may not benefit much from the surgery.
Other factors such as existing health conditions, functional status (an ASA grade, which assesses physical status before anaesthetic), and a patient’s age all need to be considered in determining whether general anaesthesia will be safe or if the patient would be able to cope with the recovery process after surgery.
Equipment used for Septoplasty
A standard surgery to correct a deviated septum (septoplasty) usually involves a certain set of tools and equipment. However, surgeons might not use all of these, depending on the technique they prefer to use.
The basic tools include:
A Headlight – This helps the doctor see inside your nose during the operation.
A variety of nasal speculums
– Hartmann/Vienna,
– Cottle, and
– Killian (in 3 different sizes).
These tools help to keep your nostrils open during the procedure.
The surgeon might also use different types of scissors (such as Cottle curved scissors and Gorney nasal shears) and forceps (like Blakesley nasal forceps, Takahashi nasal forceps, and others) to cut and manipulate tissues within your nose. A scalpel (#15 blade on a #7 Bard-Parker scalpel handle) is used for incisions.
Suction tips (like Ferguson or Frazier suction tip) help to remove fluid from your nose during surgery. Other tools may be used as needed, such as a bipolar diathermy forceps which is used to cauterize (stop blood flow) in the tissues.
Then there are a variety of elevators and chisels, including the McKenty raspatory, Freer chisel, Freer elevator, and others. These are specialized tools that help to separate and/or reshape the tissues in your nose.
The list also includes a cotton applicator for applying medication, a needle holder for suturing, and a medicine cup. If endoscopic techniques are used, the surgeon will need a Hopkins rod with a light source.
After the procedure, special dressing or splints may be used to help your nose maintain its new shape while it heals. To prevent infection, a Mupirocin ointment may be applied, and the wound may be closed using sutures – stitching material – (5-0 and 4-0 chromic gut suture).
Who is needed to perform Septoplasty?
Ears, Nose, and Throat (ENT) specialists typically carry out a medical procedure known as septoplasty. Septoplasty is a common procedure amongst these doctors. More complicated versions of this procedure, which might include a second surgery or even involve a nose-job, are usually handled by very specialized doctors who focus on the nose or facial plastic surgery. Even some plastic surgeons can perform septoplasty.
Different medical experts are required to assist in performing the surgery. These include an anesthetist (a doctor specialized in giving medications to ensure you don’t feel pain during the surgery), a scrub nurse (a nurse who helps the surgeon during the operation), a surgical technologist (a specialist well-trained to handle surgical tools and equipment), as well as nurses in the operating room and in the recovery area after your surgery. Coordinators are also there to ensure all these professionals work together seamlessly to guarantee a successful operation.
Preparing for Septoplasty
Doctors will ask about your experience with anything that affects your nose, looking for any signs of illness in your sinus region or allergies. A scoring system, such as the NOSE scale, can be used to rate symptoms that may be caused by blocked nasal passages. Doctors will also need to know your medication history, sidelining nasal medications like decongestants and corticosteroids, as well as any recreational drugs you may have taken. If you smoke, it might be best to quit, even though it hasn’t been proven to negatively affect the results of nasal surgery.
It’s important for your doctor to know if you’ve previously had nose or sinus surgery, any issues with anesthesia in the past, or any bleeding disorders.
The doctor will then examine your head and neck in detail, starting with a simple front-end nose check using a tool called a nasal speculum. If needed, they may use an instrument called a flexible nasendoscope to check the back part of your nose for any signs of disease or unusual growths, especially if they found nothing in the front of the nose that could explain your symptoms (for example, if you have severe problems with a blocked nose but the nose structures look normal).
When assessing the nasal septum (the wall dividing the two nostrils), the doctor will look at the skin covering the nasal septum for any inflammation and check the size and condition of the structures inside the nose. If these are too large and blocking the nose, a surgery called turbinoplasty may be needed.
The doctor will also touch and feel the nasal septum to understand the nature of the deviation, its size, location, and whether it was the cartilage or bone which is deviated. They’ll check for any holes in the nasal septum, any dislocations, and any bone overgrowths. If you’ve had a septoplasty before (a surgery to fix a deviated nasal septum), the doctor may use a special tool to feel how much cartilage is left in the septum.
The external part of the nose will also be checked for any additional deformities, any inward movement of the outer sides of the nostrils during breathing in and the degree of support for the tip your nose. A test known as Cottle’s maneuver may be conducted to check for any narrowing of the internal nasal valve.
This detailed examination will help your doctor decide whether surgery is the right choice for you, how complicated it might be, and the best surgical approach and technique for you.
How is Septoplasty performed
The procedure we’re discussing is called an endonasal operation, which happens inside your nose. It’s usually done to help correct issues with the shape of your nose or to improve your breathing. Here’s how it happens:
First, you’ll be lying flat for this operation with your head slightly tilted towards one side. Your doctor might then trim some of the hairs in your nose for a better view of the area. They might also use a special solution to reduce any swelling in there. After that, they’ll numb the area inside your nose using a local anesthetic so that you don’t feel pain during the procedure. The medicine helps to hydrate the parts of your nose and make sure your blood isn’t flowing too fast in that area which helps the surgery to be smoother.
Next, they’ll use a tool called a nasal speculum to wide open your nostril to reveal the edge of the cartilage inside your nose. A small cut is then made to expose it. From there, the doctor will use specialized instruments to carefully and gently separate the skin from the cartilage in your nose. This technique makes sure that the cartilage stays healthy and keeps its normal color. They’ll be very careful not to tear the skin inside the nose, especially if there are bumps or deformities on the cartilage.
After that, the doctor will check where the deformity is in the nose, which could be a part of the cartilage or even a bone. They’ll then use certain tools to cut and remove this deviation, while making sure that a solid structure remains to support the nose. This process needs to be done with precision and care to avoid complications.
The discarded cartilage that was taken out during surgery is usually kept in a saline solution or wet sterile gauze. This is because it might need to be reshaped and used later to strengthen the remaining cartilage structure or to contribute to grafts if needed.
Once that’s done, the skin flaps inside your nose are gently put back to their original position against the nasal cartilage. The incision is then stitched up. The stitches used are usually absorbable, meaning they’ll go away on their own with time. Dressings and splints might be placed inside your nose, to aid with the healing process.
After the operation is done, you’ll typically be able to go home that same day. The doctor might prescribe a cream to prevent infection and medicine for pain relief. Saline or Oxymetazoline sprays could be useful to help keep the inside of your nose clean during recovery. You’ll need to come back to the hospital for a follow-up visit after 1-2 weeks, to assess your healing process and have any nasal splints removed if they were placed.
Sometimes, rather than a traditional procedure, your doctor might choose to perform an endoscopic septoplasty. In this technique, instead of a nasal speculum and headlight, a tiny camera is used to view the inside of your nose. This might be chosen if you also need another type of endonasal surgery, or in specific cases where the deformity in your septum is localized or hard to reach. This technique gives the doctors a better magnified view of your nasal structure.
This procedure might be a bit more technically difficult than the traditional method and might take longer to perform properly. If the deformity is towards the front of your nose, this method might be particularly challenging. And, for complicated deformity or previous fractures, there’s another option called extracorporeal, which refers to an operation where the structures of the nose are manipulated outside the body and then reinserted.
Possible Complications of Septoplasty
When undergoing a procedure called septoplasty, which is a surgery to straighten the bone and cartilage divide in the nose, there might be various side-effects or complications you should be aware of. Here’s what you need to know:
The most common issue after the surgery is bleeding, which is generally mild and expected. However, in rare instances, if the bleeding is extensive, the doctor might need to use nasal packing or cautery, a technique where heat is used to control the bleeding. A rare complication called septal hematomas might also occur, where blood collects within the layers of nose tissue. In such cases, doctors will need to drain the blood to prevent further complications such as infection or nose deformity.
In addition to this, you might experience infection, trouble breathing through the nose, or a delayed healing process. But don’t worry; these infections are actually quite rare and can usually be treated easily with oral antibiotics. In most cases, patients recover fully within a few weeks. It is also possible that after the surgery, some people experience hyposmia, which is a reduced ability to smell. This typically gets better within six months.
It’s worth mentioning that you might also feel some numbness or sensitivity in your upper teeth or lip. This happens due to the doctors needing to manipulate the nasopalatine nerve during the surgery. But you should not worry too much about this complication as it typically resolves within a short span of time and the normal sensation returns within a few months.
The most widespread complaint amongst patients after septoplasty is that their nasal breathing did not improve as much as they expected. This could be caused by a variety of factors including repeated injury to the nose, weight gain, change in the position of cartilage over time, or surgical error. Doctors will discuss this risk prior to surgery.
What Else Should I Know About Septoplasty?
Septoplasty, a common ear, nose, and throat (ENT) surgery, mainly fixes a deviated septum, which can obstruct breathing through the nose. This surgery usually works well, and many patients find their nose blockages are significantly improved afterwards. However, some people may notice their nasal problems come back after the procedure, and the satisfaction rate can vary a lot.
Doctors usually assess the success of the surgery by asking patients how satisfied they are afterward, how much their quality of life has improved, and how much their symptoms have improved. But assessing symptom improvement can be tricky because it often varies and depends on the individual’s perception. Sometimes, what medical tools measure doesn’t match how the patient feels. This could be one reason why some studies have reported a gradual decline in long-term success rates after septoplasty.
Despite these sometimes-variable results, it’s important to carefully consider surgical candidates and make decisions based on potential for successful results. An effective approach could involve a mix of personal accounts and objective tests to determine patient suitability for surgery. In countries like the UK, where healthcare is funded by the state, surgeries like septoplasty should clearly show that they significantly improve patient quality of life and reduce symptoms to qualify for funding.
In the end, it’s crucial that the decision to proceed with such a surgery must be evidence-based, predicting a good chance of success after surgery, and improve the patient’s quality of life.
