The nasal septum is the wall between the nostrils that separates the two nasal passages. It supports the nose and directs airflow. The septum is made of thin bone in the back and cartilage in the front. A deviated septum occurs when the cartilage or bone is not straight. A crooked septum can make breathing difficult. The condition also can lead to snoring and sleep apnea.
The septum can bend to one side or another as a part of normal growth during childhood and puberty. Also, the septum can be deviated at birth (congenital) or because of an injury, such as a broken nose. Very few people have a perfectly straight septum.
Surgery to straighten the septum is called septoplasty, submucous resection of the septum, or septal reconstruction. The surgery may be done along with other procedures to treat chronic sinusitis, inflammation, or bleeding, or to correct sleep apnea. Septoplasty also may be done to allow access into the nose to remove nasal polyps. In general, septoplasty is needed only when breathing problems or snoring do not get better without surgery. For more information on surgery to treat chronic sinusitis, see the topic Sinusitis.
Before surgery, the doctor may use a thin, lighted instrument (endoscope) to look at your nasal passages and to see the shape of your septum. In some cases, the endoscope may be used during surgery. You will receive local or general anesthesia for the 60- to 90-minute operation, which is usually done in an outpatient surgery center.
The septum and nasal passages are lined with a layer of soft tissue called the nasal mucosa. To repair the septum, the surgeon works through the nostrils, making an incision to separate the mucosa from the underlying cartilage and bone. The doctor trims or straightens the bent cartilage and then replaces the mucosa over the cartilage and bone.
Inferior Turbinate Reduction
Inferior turbinoplasty is a minor surgical procedure to decrease the size of the inferior turbinates in those patients who have not responded to medical therapy. In the past, reduction of the turbinates was performed by using a variety of methods including cautery or laser reduction, injection with steroids, cryotherapy (freezing) or surgical resection. These methods were either incapable of providing long-term relief (steroid injection and cryotherapy) or were associated with prolonged recovery or chronic nasal crusting (surgical resection, cautery and laser). Recently, techniques were developed to preserve the important function of the mucus membrane overlying the turbinate while still allowing for turbinate reduction.
Powered inferior turbinoplasty uses a specialized instrument called a microdebrider, which is also used in sinus surgery (FESS). This small rotating blade is placed underneath the turbinate mucus membrane to remove the extra bulk of the turbinate from within. This technique has many advantages including more complete removal of turbinate bulk from the back part of the turbinate and a quicker healing time than other techniques. Powered inferior turbinoplasty is performed in a surgery center as a twenty-minute outpatient procedure.
Coblation of the inferior turbinates is performed by inserting a radiofrequency probe underneath the turbinate mucus membrane to shrink the underlying tissue. This ten-minute procedure has the advantage of being able to be performed in an office setting.
Both Coblation and powered inferior turbinoplasty are associated with minimal discomfort post-operatively. These procedures can produce a dramatic improvement in nasal breathing for patients who have previously been unable to get relief. They are also helpful for patients who have difficulty utilizing CPAP for their sleep apnea secondary to nasal obstruction.
Standard Surgical Treatments for Nasal Obstruction
Cautery (burning) of enlarged turbinates can be done with an electrosurgical probe or a laser and is usually performed as an office procedure. Both electrocautery and laser surgery are performed on either the surface of the turbinate tissue or sub-mucosally. Surface cautery results in edema and crusting in the nose which can last three weeks or longer, while sub-mucosal cautery can cause swelling for up to 10 days.
Another method for improving nasal obstruction is outward fracture of the turbinate bone(s), which moves the turbinate away from its obstructive position in the airway. This approach, however, does not address the usual source of obstruction—enlarged sub-mucosal tissue, and the fractured turbinate often returns to its previous position. Turbinate resection (removal of the bone and/or soft tissue) and excision (removal of the soft tissue only) can be performed with surgical scissors or a laser. Physicians can reduce nasal obstruction by cutting away excess tissue from the surface of the turbinate with angled scissors. Following treatment, the nose must be packed for several days with gauze containing anantibiotic ointment.
Risks Associated with Standard Surgeries for Nasal Obstruction
Bleeding, which can usually be managed by packing the nose, is the greatest risk for patients undergoing standard turbinate resection. Over-resection of the turbinates has been reported as the cause of excessive, irreversible drying of the turbinates. Resection, excision and surface cautery can all be associated with prolonged crusting and healing, which occurs over a four- to six-week period.
Laser resection of the turbinates uses light energy that reaches temperatures of 750°C to 900°C (1,400°F to 1,700°F) to vaporize the turbinate mucosa. Safety issues related to the use of the laser require specialized training and experience in laser procedures. The crusting and bleeding rates with laser surgery are similar to cautery procedures.