Septoplasty

Definition

Septoplasty is a surgical procedure to correct the shape of the septum of the nose. The goal of this procedure is to correct defects or deformities of the septum. The nasal septum is the separation between the two nostrils. In adults, the septum is composed partly of cartilage and partly of bone. Septal deviations are either congenital (present from birth) or develop as a result of an injury. Most people with deviated septa do not develop symptoms. It is typically only the most severely deformed septa that produce significant symptoms and require surgical intervention. However, many septoplasties are performed during rhinoplasty procedures, which are most often performed for cosmetic purposes.

Purpose

Septoplasty is performed to correct a crooked (deviated) or dislocated septum, often as part of plastic surgery of the nose (rhinoplasty). The nasal septum has three functions: to support the nose, to regulate air flow, and to support the mucous membranes (mucosa) of the nose. Septoplasty is done to correct the shape of the nose caused by a deformed septum or correct deregulated airflow caused by a deviated septum. Septoplasty is often needed when the patient is having an operation to reduce the size of the nose (reductive rhinoplasty), because this operation usually reduces the amount of breathing space in the nose.

During surgery, the patient's own cartilage that has been removed can be reused to provide support for the nose if needed. External septum supports are not usually needed. Splints may be needed occasionally to support cartilage when extensive cutting has been done. External splints can be used to support the cartilage for the first few days of healing. Tefla gauze is inserted in the nostril to support the flaps and cartilage and to absorb any bleeding or mucus.

Demographics

About one-third of the population may have some degree of nasal obstruction. Among those with nasal obstruction, about one-fourth have deviated septa.

Diagnosis/Preparation

The primary conditions that may suggest a need for septoplasty include:

• nasal air passage obstruction
• nasal septal deformity
• headaches caused by septal spurs
• chronic and uncontrolled nosebleeds
• chronic sinusitis associated with a deviated septum
• obstructive sleep apnea
• polypectomy (polyp removal)
• tumor excision
• turbinate surgery
• ethmoidectomy (removal of all or part of a small bone on the upper part of the nasal cavity)

Septoplasty is used to correct a deviated septum (B). First an incision is made to expose the nasal septum (C). Pieces of septum that are obstructing air flow are removed (D), and the incision is then closed (E). (

Illustration by GGS Inc.

)

Septal deformities can cause nasal airway obstruction. Such airway obstruction can lead to mouth breathing, chronic nasal infections, or obstructive sleep apnea. Septal spurs can produce headaches when these growths lead to increased pressure on the nasal septum. Polypectomy, ethmoidectomy, tumor removal , and turbinate surgical procedures often include septoplasty. Individuals who have used significant quantities of cocaine over a long period of time often require septoplasty because of alterations in the nasal passage structures.

Septal deviation is usually diagnosed by direct observation of the nasal passages. In addition, a computed tomography (CT) scan of the entire nasal passage is often performed. This scan allows the physician to fully assess the structures and functioning of the area. Additional tests that evaluate the movement of air through the nasal passages may also be performed.

Before performing a septoplasty, the surgeon will evaluate the difference in airflow between the two nostrils. In children, this assessment can be done very simply by asking the child to breathe out slowly on a small mirror held in front of the nose.

As with any other operation under general anesthesia, patients are evaluated for any physical conditions that might complicate surgery and for any medications that might affect blood clotting time. If a general anesthetic is used, then the patient is advised not to drink or eat after midnight the night before the surgery. In many cases, septoplasty can be performed on an outpatient basis using local anesthesia. Conditions that might preclude a patient from receiving a septoplasty include excessive cocaine abuse, Wegener's granulomatosis, malignant lymphomas, and an excessively large septal perforation.

Aftercare

Patients who receive septoplasty are usually sent home from the hospital later the same day or in the morning after the surgery. All dressings inside the nose are usually removed before the patient leaves. Aftercare includes a list of detailed instructions for the patient that focus on preventing trauma to the nose.

The head needs to be elevated while resting during the first 24-48 hours after surgery. Patients will have to breathe through the mouth while the nasal packing is still in place. A small amount of bloody discharge is normal but excessive bleeding should be reported to the physician immediately. Antibiotics are usually not prescribed unless the packing is left in place more than 24 hours. Most patients do not suffer significant amounts of pain, but those who do have severe pain are sometimes given narcotic pain relievers. Patients are often advised to place an ice pack on the nose to enhance comfort during the recovery period. Patients who have splint placement usually return seven to 10 days after the surgery for examination and splint removal.

Risks

The risks from septoplasty are similar to those from other operations on the face: postoperative pain with some bleeding, swelling, bruising, or discoloration. A few patients may have allergic reactions to the anesthetics. The operation in itself, however, is relatively low-risk in that it does not involve major blood vessels or vital organs. Infection is unlikely if proper surgical technique is observed. One of the extremely rare but serious complications of septoplasty is cerebrospinal fluid leak. This complication can be treated with proper nasal packing, bed rest, and antibiotic use. Follow-up surgery may be necessary if the nasal obstruction relapses.

Normal results

Normal results include improved breathing and airflow through the nostrils, and an acceptable outward shape of the nose. Most patients have significant improvements in symptoms following surgery.

Morbidity and mortality rates

Significant morbidity associated with septoplasty is rare and is outlined in the Risks section above. Mortality is extremely rare and associated with the risks involving anesthesia. This procedure can be performed using local anesthesia on an outpatient basis or under general anesthesia during a short hospital stay. General anesthesia is associated with a greater mortality rate, but this risk is minimal.

Alternatives

In cases of sinusitis or allergic rhinitis, nasal airway breathing can be improved by using such nasal sprays, as phenylephrine (Neo-Synephrine). Patients with a history of chronic uncontrolled nasal bleeding should receive conservative therapy that includes nasal packing to identify the source of the bleeding before surgery is contemplated. Those who have been diagnosed with obstructive sleep apnea have a variety of conservative alternatives before surgery is seriously considered. These alternatives include weight loss, changes in sleep posture, and the use of appliances during sleep that enlarge the upper airway.

Resources

BOOKS

Muth, Annemarie S., and Karen Bellenir, eds. Surgery Source-book. New York: Omnigraphics, 2002.

Schwartz, Seymour I., ed. Principles of Surgery. New York: McGraw-Hill, 1999.

"Septal deviation and perforation." In The Merck Manual, edited by Keryn A. G. Lane. West Point, PA: Merck & Co., 1999.

OTHER

"Septoplasty." MEDLINEplus Medical Encyclopedia [cited July 7, 2003]. http://www.nlm.nih.gov .

Mark Mitchell

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Septoplasty is performed by a medical doctor (M.D.) who has received additional training in surgery. Typically, septoplasty is performed by a board-certified plastic surgeon, a specialist called an otolaryngologist, or a head and neck surgeon. The procedure can be performed in a hospital or in a specialized surgical clinic.

QUESTIONS TO ASK THE DOCTOR

• What are my alternatives?
• Is surgery the answer for me?
• Can you recommend a surgeon who performs septoplasty?
• If surgery is appropriate for me, what are the next steps?

QUESTIONS TO ASK THE SURGEON

• How many times have you performed septoplasty?
• Are you a board-certified surgeon?
• What type of outcomes have you had?
• What are the most common side effects or complications?
• What should I do to prepare for surgery?
• What should I expect following the surgery?
• Can you refer me to one of your patients who has had this procedure?
• What type of diagnostic procedures are performed to determine if patients require surgery?
• Will I need to see another specialist for the diagnostic procedures?