What is septoplasty?

Septoplasty is a surgical procedure, performed mainly by Ear, Nose and Throat surgeon to correct and realign nasal septum deviation.

Nasal septum deviation

The nasal septum consists of three main parts: membranous, bony, and cartilaginous. The septum divides the nasal cavity into two equal parts. If the nasal septum deviation was mild, this usually will not cause any major or noticeable problems. If the deviation was moderate or severe, the patient may complain of multiple problems like:

• • Difficulty breathing especially while sleeping
  • Snoring and dry mouth
  • Sleep apnea
  • Repetitive sinus infections
  • Recurrent epistaxis

What causes the deviated nasal septum?

Nasal septum deviation can present at birth or at any stage of life. For the newborn, a trauma during delivery could be the reason for the deviated septum, or as a part of other congenital malformations.

In older children and adults, the septum of the nose can be deviated after face or nasal trauma as may happen in:

• • Car accidents
  • Intense sports that may cause a blow to the nose
  • Fall injury

In older age the deviated septum could be part of the aging process, as the deviation may worsens while getting old.

Prevalence of nasal septum deviation

Nasal septum deviation is a common complaint among the populations. Some papers and studies suggest that septal deviation and nasal obstruction are reported by nearly 70% of the general populations.

How nasal septum deviation is diagnosed?

Although a deviated septum isn’t a serious condition, but it compromises the patient daily activity, and prevents him from deep sleep, leading to restless sleep and lack of energy and concentration the following day.

All of this makes diagnosis of deviated septum important to start treatment and improve patient’s quality of life.

History

The history of the patient usually gives important clues about his condition like:

• Recent trauma to the face or the nose
• Recent serious accident
• Recurrent sinusitis
• Breathing problems that do not responds to the usual medical treatments
• Sleep apnea and snoring

Physical examination of the nose

The nose should be examined thoroughly to give a clear picture about the condition of the septum. If it has a perforation or other abnormality, and to measure the deviation level. Also, to inspect all the internal structure of the nose. The examination is usually done using the conventional examination tools or by using more specific and accurate tools as fiber-optic nasal endoscopy.

Images

In the normal circumstances, there is no benefit in using imaging while diagnosing deviated septum. In severe trauma like in car accidents, the patient may undergo a CT scan to figure out the extent of the damage exactly.

The medical treatment of the deviated nasal septum

In case of mild deviated septum, the medical treatment should be tried first before shifting to the surgical options. The medical treatment aims to alleviating the distressing symptoms. These treatments include:

• Inhaled nasal steroids:Those inhalers can decrease the symptoms, as steroids have anti-inflammatory effects, so it relieves nasal swelling, and enhance breathing. The use of steroids must be kept under doctor supervision.
• Antihistamines:another class of drugs that can be used in treatment of nasal congestion in patients with mild septum deviation.
• Decongestants:this class of drugs are used to relive nasal mucosal swelling; this may help in decrease the airflow obstruction that makes breathing difficult. The use of decongestant must be cautious as long-term use may worsen the symptoms due to rebound congestion.

Despite these medications are used to decrease the patient’s symptoms, there is no available medication can correct the deviated septum, and the only available solution is in surgical wards.

Indication of septoplasty

According to the American academy of otolaryngology, head and neck surgery, the clinical indicators for septoplasty surgery includes:

• Difficulty breathingdue to unilateral or bilateral nasal airway obstruction.
• Recurrent nasal bleedingdue to deviation of nasal septum and not responsive to medical treatment.
• Structural deformityto nasal structure which may interfere with other surgical interference in the nose.
• As a part of rhinoplasty surgery
• In cases of unusual persistent pain in the gums, teeth, and face, which can be treated only by applying local anesthesia to deviated nasal septum.
• Breathing difficultieswith absence of any other possible cause such as nasal polyps, tumor, or nasal turbinate hypertrophy.

Septoplasty surgery could be part of other surgical procedures such as: sinus ostium obstruction surgery, tumor excision, treatment of recurrent persistent epistaxis.

Who performs the septoplasty surgery?

Usually Ear, Nose, and Ear surgeons are the surgeons who perform the surgery, and in some cases, the plastic surgeons can do the septoplasty as a part of rhino septoplasty surgery.

Contraindication of septoplasty

Although septoplasty is a common surgical procedure, there is a few conditions where the septoplasty procedure may be contraindicated such as in cases of acute sinusitis or active nasal infection.

Some conditions that coexist with the deviated septum and worsens its symptoms as vasculitis, or rhinosinusitis may benefit from some medications like the decongestants to decrease the breathing difficulties without undergoing the surgical procedures as first line treatment.

Some drug use may compromise the septoplasty surgery like intranasal cocaine. Cocaine inhalation must be stopped one year before undergoing the surgery, as the intranasal cocaine has a severe vasoconstriction effect, and causes mucosal atrophy. These effects on the nose may increase the possibility of serious complications as:

• • Perforation of the nasal septum
  • Delaying the healing process
  • May results in some nasal deformity like saddle nose deformity

Vasoconstrictor sprays that can be used as OTC treatment of rhinitis or rhinosinusitis, and should be avoided for extended period before the septoplasty surgery.

Large septal perforation is one of the septoplasty contraindications as the complete closure, and the healing of the defect could not be achieved.

Patients diagnosed of lymphomas, because the local healing following the procedure would be delayed, and even impaired due to the effect of the tumor itself or from the effect of radiotherapy.

In some systemic diseases as Wegener granulomatosis, the aim of the treatment is to treat the nasal septal perforation, but the disease activity should be kept in total remission, because the disease activity may interfere with the healing of the wound. The size of the perforation is also a key as the perforation tends to be large in patients with Wegener granulomatosis, and the septoplasty surgery may fail in treating large septal perforations.

Other contraindications include uncontrolled systemic diseases as hypertension and diabetes mellitus.

The septoplasty procedure

Septoplasty is usually an outpatient procedure where the patient can be discharged on the same day. The procedure can be executed under local or general anesthesia:

• • Local anesthesia: where the patient undergoes the operation while is awake
  • General anesthesia: where the patient is sedated during the procedure

During the procedure, the surgeon enters the nose through one of the nostrils aiming to correct the deviated septum, and removing any extra bones or cartilage, and realigning the septum in the middle of the nose.

According to the condition of the patient, the surgeon may insert packing in the nose to stop bleeding, and to prevent further hemorrhage. Splints also may be inserted to support the septum for a brief period postoperatively.

A stitch or two may be needed during the surgery, and those stitches will be dissolved on their own later during the healing process.

Post- operative patient recovery

Septoplasty is a minor surgery and can be done in an outpatient facility, and most cases do not require hospitalization.

If the nose was packed during the surgery, the patient would be asked to be a mouth breather until the nose packs are removed, which is usually done after a day or two.

The patient would be asked to keep his head elevated, especially in the first few days. Here is a list of the most common post-operative symptoms and how to treat them:

• Swelling: The swelling that results post-operatively in septoplasty surgery is usually mild. This swelling is part of the healing process, as the body helps in healing by increasing the blood supply to the wound. This swelling is also responsible for the mild discoloration that follows the procedure. With healing,the body reabsorbs all the extra fluid which gradually disappears after a few days, and to help in relieving swelling, the patient would be advised to
  • Keep his head elevated especially at night for a few days
  • Avoid lifting heavy objects post-operatively
  • Applying cold compressing pads to decrease inflammation and lessen swelling
• Packing: If the nose waspacked, the patient would be asked to keep it dry and clean until be removed on his first post-operative surgeon visit.
• Epistaxis: Epistaxis is a bloody tinged mucus discharge is expected in the first two to three days following the procedures, but in case of heavy bleeding the patient must contact his surgeon, which can treat this bleeding by Cautery and packing the nose. To avoid heavy bleeding post-operatively, the patient would be advised to be away from lifting heavy objects or hitting the face and nose.
• Facial discoloration: As mentioned before, a little pinkish discoloration is expected, it usually fades in the first week post-operatively.
• Stuffy nose: Nasal congestion is quite common side effect following septoplasty surgery. In such case,intranasal saline sprays may relief this congestion.
• Pain: In the first few days following the surgical procedure, the patient may feel mild to moderate pain, which usually is treated with over-the-counter pain suppressing medications. Applying cold compressing may help with pain too. If the patient suffers from severe or persistent pain not responding to the usual OTC drugs, he should seek medical help.

A study by Sclafani et al showed that patients who went septoplasty surgery suffer from moderate pain in the first day postoperative and became milder later.

Patients follow up

Nasal packing is not common in the recent surgeries, if the patient has intranasal packs, it is usually removed day or two post-operatives. If the patient has intranasal splints, it will be removed after one week in the first follow up appointment. In the first post-operative visit, the surgeon would inspect the nasal passage for any sign of infection or any other serious complications.

The patient can resume his normal daily activities after nearly two weeks, while strenuous or intense activities can be resumed after one or two months.

Complications of septoplasty

 

Septoplasty is a minor procedure with relatively less post-operative complications.  From these complications:

• Post-operative infection:Although infection is not common in septoplasty surgery, but the risk of infection increases following the surgery especially in immunocompromised patients. The infection may compromise the healing and causes fever and pain. For treatment, the surgeon would prescribe antibiotics and pus drainage to help relieve infection.
  • Toxic shock syndromeis one of the serious infections, yet exceedingly rare. Fever, diarrhea, and hypotension are common symptoms. To prevent this infection the nasal pack is filled with specific antibiotic. The most common pathogen causing TSS is staph-aureus bacteria.
  • Nasal septal abscesscan be a risk especially in patients with type 2 diabetes mellites. The risk increases if the patient has uncontrolled hyperglycemia.
• Cerebrospinal fluid leak:It is a rare side effect which could be found during the procedure. If the surgeon noticed the cerebrospinal fluid leak, an antibiotic coated pack is inserted in the nose. After the procedure, the patient would be recommended to have rest for a couple of days and to take antibiotics to guard against possible infections as meningitis. Symptoms of meningitis include fever, headache, photophobia, and neck rigidity.
• Nasal septal perforation:One of septoplasty surgery complications, which typically occurs gradually over long-time. Patients with nasal septal perforations may complain of recurrent epistaxis, and noises during respiration. If the septal perforation develops, the patient may need a revision surgery to repair the perforation.
• Epistaxis:Mild nosebleed is expected in the healing time, but heavy bleeding is a reason for concern and contacting the surgeon.
• Nasal congestion or obstruction:The swelling that follows the surgery causes mild nasal congestion that subside after complete healing of the wound. If the congestion does not lessen with time or even worsen, which may be due to the septal deviation was not totally corrected during the procedure. Also, this could be due to a newly formed intranasal adhesions after the surgery. These complications can be prevented by inserting intranasal splints following the surgical procedure and during the healing time.
• Facial pain:A few patients may complain of tooth and gum pain, and numbness in the face following the surgery. This condition may be caused by nerve injuries that could happen during the procedure. Patients should be reassured that this pain and numbness will disappear with time.
• Miscellaneous:A few patients reported decrease or change in smell sense or insomnia, this complication is a temporary side effect of the procedure. Other complications may include:
  • Change in patient’s voice
  • Contusions or black eye
  • Nasal deformity

Results of septoplasty surgery

After undergoing a septoplasty surgery most patients feel drastic improvements in most symptoms, especially nasal congestion.

Pedersen et al. found that 3% of patients with nasal congestion improved after 12 months following the surgery, 81% of these patients had severe nasal obstruction prior to the surgery.

A few factors were associated with improvements such as:

• • Higher age at the time of the surgery
  • Limitations of intense activities after the surgery

Another study conducted by Samad et al. to discuss the efficacy of nasal septal surgery; they found  that the patients symptoms improved following the septoplasty surgery. They reported a success rate of 70%.

On the other hand, a study by Sunnergrenet et al. founded that septoplasty had a few long-term unfavorable side effects. In the study, only 18% of all the participants in the study (111 patients) reported worsening of their symptoms in 34-70 months follow up.

Difference between rhinoplasty and septoplasty

Septoplasty and rhinoplasty are surgical procedures that manage multiple nose issues. Septoplasty surgery treat the deviated nasal septum, while rhinoplasty focus more on the external structure of the nose for better shape and good aesthetic look.

In surgical wards septoplasty is performed as part of rhinoplasty surgery. To achieve the best results in reshaping patient nose, a septoplasty surgery is performed first to help realigning the internal nasal structure, even if the patient does not complain of any structural abnormalities, then a rhinoplasty surgery follows to reach the optimum results for the patient.

Endoscopic septoplasty

While the open septoplasty is a common surgical procedure, the use of endoscope can provide a better view for the nose and better accuracy in comparison to the traditional technique.

Both techniques can treat deviated septum and achieve a better breathing, but the endoscopic septoplasty procedure have less short-term side effects like pain, adhesions, and post-operative bleedings.

In a study conducted by Park DH et al., 14.3% of patients treated by using conventional methods had more post-operative complications in comparison to patients treated with endoscopic septoplasty.

Another study by R Bothra et al. found that complications as bleeding, and sub-orbital edema, and pain were less in the group that treated with endoscopic septoplasty.

Laser-assisted septoplasty

Laser assisted septoplasty is a technique in which the surgeon uses carbon-dioxide laser to perform septoplasty surgery. Laser assisted septoplasty can be used in treatment of chronic nasal obstruction due to septal deviation. Most patients reported improvement following the procedure with minimum side effects, and in less than 10 minutes in outpatient’s clinic.

In a study by Y.V. Kamami, 703 patients underwent laser-assisted septoplasty, and the success rate of the procedure was 90.8% with significant improvements on symptoms like nasal obstruction, sneezing, and chronic rhinitis symptoms.

Another study to evaluate the safety and efficacy of laser-assisted outpatient septoplasty for treatment of snoring, and nasal obstruction. The author concluded that laser-assisted septoplasty is safe and tolerable outpatient clinic procedure for nasal obstruction and snoring.

Pediatrics septoplasty

Septal cartilage of the nose has a key role in the development and growth of the face in children, so most physicians are disquiet about performing nasal surgeries in pediatrics age group.

In recent years, growing evidence suggested that deviated nasal septum can be treated in pediatrics with minimal or no affection to the development of the face.

For children who complain of severe nasal obstruction and subsequent breathing problems. In that case the septoplasty surgery may be adjuvant in therapy, especially after failure to achieve results with medical treatment alone.

In a review article by Cingi et al., septoplasty surgery in children was reviewed, discussing the possibility of affection of pediatrics facial growth. They found that septoplasty would be indicated in children with severe breathing problems, associated with deviated septum after failure of medical treatment to achieve improvements of symptoms.

In a  study by Ori et al., more than a hundred child (111 child), whose age range from 6 to 13 years old underwent a septoplasty surgery from 2005 to 2010. Reviewing long term effects on children facial features, and improvement of symptoms. The study showed that no complications from the surgical procedure were reported, improvement in nasal breathing problems, and no affection to physiological facial and dental growth in subsequent follow up visits.

Pediatric septoplasty surgery can be done at any age, even at birth. Parts of nasal septum (cartilaginous septum) keep growing in children until 18 years old; some physicians argue against doing the septoplasty before 18 years old except in patients with severe symptoms.

A study by Lee.et al. found that undergoing the surgery before 18 years old increases the rate of rediverting again.