Nasal Blockage and Congestion
Nasal blockage and obstruction can have many causes. In some patients, allergies (“hay fever”) lead to swelling of the nasal and sinus lining, which in turn causes congestion and blockage. In other patients, blockage can be due to simple anatomic obstruction. Take the adenoids, for instance, which are masses of lymphoid tissue in the nasopharynx at the back of the nasal passage. These can be overgrown in some patients which can block the free flow of air in and out of the nose. Other patients might have polyps, which are grape-like masses that typically grow in the sinus areas and expand into the nasal passage. While still others might have blockage due to a deviated septum.
Anatomy of the Septum
The septum is the internal “dividing wall” between the right and left sides of the nose. The back or posterior two-thirds of the septum is comprised of bone, while the front or anterior one-third is made up of cartilage surrounded by a mucosal lining. Anatomically, the bones and cartilage are connected to the maxilla and palatine bone on the bottom and the skull-base on the top. Separating the bone/cartilage and the mucosal lining is an additional lining – the periosteum (for the bone) and the perichondrium (for the cartilage) – which provides a rich blood supply to the bone and cartilage. Along the floor of the nose, the septum is held in the midline by grooves in the bone. The septum is also held in the midline by a variety of supporting connective tissues in the tip of the nose.
In a situation where a deviated nasal septum is determined to be a significant causative factor of nasal obstruction, surgical correction of the deviation may be recommended. Below please find descriptions of septal surgery (septoplasty) along with answers for associated frequently asked questions.
The Benefits of Septoplasty (Nasal Septal Surgery)
Patients with persistent nasal obstruction, blockage and congestion which has been poorly responsive to medical interventions and therapies, and who have a deviated septum as part of their blockage, may benefit from septoplasty. It is our experience that after septoplasty, patients typically report improved nasal breathing and airflow, decreased blockage and congestion, diminished “dry mouth,” and a more complete and restful sleep. Opening the nasal passage with a septoplasty does not treat allergies, but it does allow for improved delivery of nasal sprays (nasal steroids, nasal antihistamines) which are designed to treat allergies. Also, in many patients with persistent nose bleeds, the improved airflow and diminished congestion after septal surgery leads to a decrease in the constant sniffling and nose blowing which contribute to irritation of the front part of the nose where nose bleeds most commonly occur.
Who is a Candidate for a Septoplasty?
Septoplasty is an option for patients with septal deviation and persistent nasal obstruction that has not responded to medical therapy. Nasal blockage often has a component due to swelling of the nose and sinus lining, and it is beneficial to see what degree of improvement can be obtained by trying to minimize this swelling. Nasal steroid sprays, nasal antihistamine sprays, saline sprays and irrigations, and oral antihistamines may be prescribed in an attempt to diminish nasal blockage and congestion. Over the counter medications such as Mucinex (Guafenesin) may be tried. However, decongestants such as Afrin (Oxymetazoline) and Sudafed (Pseudophedrine HCL) are typically not recommended for long-term use due to their side-effect profiles. In some cases, allergy testing may be recommended as well to try to identify the specific allergens and irritants which stimulate swelling and edema. When a patient has persistent nasal obstruction which has not responded to medical therapy, and where the deviated septum is determined to have a notable contribution to the obstruction, septoplasty may be considered as a means to help open the nasal passage and allow for improved nasal airflow.
Simply having a deviated septum does not mean you need a septoplasty. Septoplasty is indicated in patients with symptoms of nasal blockage and congestion where medical therapies have been unsuccessful and in whom the septum is determined to play a significant role in the symptoms. In these appropriately selected patients, septoplasty can have a major, positive impact on nasal breathing, congestion and quality of life.
Your Septoplasty Consultation
Your consultation will begin by your ENT physician listening carefully to your history in order to understand what symptoms you seek improvement with, as well as what treatments and medications you have tried in the past. A thorough exam will be performed. This will often include a nasal endoscopy in which a small, 4mm lighted endoscope is used to visualize the entire nasal cavity from the front all the way to the adenoid area in the nasopharynx. In some cases, testing such as a CT scan and/or allergy test may be ordered. You are encouraged to ask questions during this visit as you should have a full understanding of what next steps your ENT doctor recommends and why he or she recommends these steps. Sometimes, the next step may be surgical septoplasty, while in other cases your physician may recommend other medications to try to see if you can obtain improvement without surgical intervention.
What is septoplasty and how is it performed?
Septoplasty is a surgical procedure designed to correct a deviated (or “off-center”) septum which is contributing to nasal blockage. While septoplasty can be performed with a patient “awake” under local anesthesia, it is most commonly performed as an outpatient procedure in a hospital or Ambulatory Surgical Center operating room under general anesthesia. In this controlled setting, a standard septoplasty is typically completed in about an hour. During the procedure, your surgeon will usually make a small incision on the inside of the nose in the nasal lining.
Through the incision, the septum will be exposed and the deviated components identified and isolated so that they may be shaped, sculpted, and/or removed. Once this is complete, the mucosal “flaps” are sewn back together, leaving a straightened septum and an open, unobstructed nasal passage.
In some cases whereby the deviation is concentrated in a single isolated area of the septum, an “Endoscopic Septoplasty” may be performed. Using a small, 4mm endoscope, the deviated area is identified and a small incision is made just in front of the focal deviation. With specialized instrumentation, flaps are elevated and the “septal spur” is removed in a targeted fashion. In other cases, the entire septum is removed, rebuilt and re-implanted. This is more common after a trauma when the septum is deviated or broken in multiple spots and lacks the integrity to provide meaningful support. This “Extracorporeal Septoplasty” is a more involved procedure and is usually accompanied by a longer recovery period.
In some cases, the septum is just one of several anatomic factors contributing to nasal blockage, and it may be best to address some of these other abnormalities at the same time as septoplasty. The inferior turbinates, for instance, are tube-like structures along the sides of the nasal passage which swell and shrink. In patients where these turbinates are enlarged, it may be beneficial to reduce the size of the turbinates to improve nasal airflow. This is discussed in more detail elsewhere on this website. Other structures which may contribute to nasal blockage and congestion include nasal and sinus polyps, enlarged adenoids, hypertrophied middle turbinates (concha bullosa), masses and tumors. Functional blockage (e.g., nasal valve collapse) occurs when the outside of the nose collapses inwards with inspiration. This may also be surgically addressed at the time of septoplasty, or at another time as a separate procedure.
Can I be awake for my septoplasty?
In most instances, septoplasty is performed under general anesthesia. In some cases, the procedure may be performed with the patient “awake” under local anesthesia. You should discuss this with your surgeon so that the best decision can be made for your circumstances.
Is there nasal packing?
Several years ago, it was standard for patients to have several feet of Vaseline-infused gauze “packed” into their nose at the end of surgery and left there for one week while the patient healed. This was unpleasant and uncomfortable. Fortunately, very few surgeons use packing any more. Some use “septal splints” in place of packing; however, this is also noted to be quite uncomfortable and studies have shown that splints and packing do not provide improved outcomes. With this in mind, many surgeons perform septoplasty without packing or splints. It is advisable to ask your surgeon what their standard practice is.
Does a septoplasty change the appearance of my nose or face?
No. A simple septoplasty does not change the outside appearance of the nose or face. In cases where a patient would like a change in appearance of their nose, this may be performed along with a cosmetic rhinoplasty. If it is your aim to have a change in your nasal appearance as well as function, you should discuss this with your surgeon.
Will I have black eyes or bruises after surgery?
In a standard septoplasty, a patient will not have black eyes or facial bruising. In some cases, when septoplasty is combined with other procedures (e.g., nasal fracture repair, functional or cosmetic rhinoplasty), a patient may have black eyes depending on the techniques used and procedures performed. You should ask what to expect from your surgeon.
Are there stitches?
In most cases, sutures are used to sew the incision site and flaps together at the end of surgery. Sutures are typically dissolvable and do not require removal. In some cases (e.g., Endoscopic Septoplasty), no sutures are used.
How painful is the surgery?
While every patient is unique, most patients will find that their post-operative pain in easily managed with low-dose narcotic medications (e.g., Tylenol with codeine) for 1-2 days, after which they transition to regular or extra-strength Tylenol for another week or so.
How long will I need to take off from work?
Septoplasty is typically a minor, minimally-invasive outpatient procedure. Patients will typically take several days to a week off from work. This can vary based on individual recovery and details of each person’s unique surgery, as well as recovery from general anesthesia. Most patients are advised to refrain from heavy lifting or vigorous activity for 1-2 weeks, although specific details should be discussed with your surgeon.
When can I eat and shower after surgery?
After surgery, there is no restriction on eating or bathing. There is typically a list of blood-thinning medications to refrain from for a brief period after surgery, but you should discuss this with your surgeon. In general, however, you may eat whatever you feel like eating.