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Septoplasty
ALTERNATIVE NAMES: Nasal septoplasty, nasal septal reconstruction.
WHAT IS THE PROCEDURE? Straightening of the nasal septum. The septum is a wall separating the two halves of the nasal cavity. The front portion of this wall is formed by a thin plate of cartilage with the back part formed by a thin bone plate. This procedure is usually indicated if the septum deviates into one or both nasal cavities, thus creating nasal or sinus dysfunction.
WHO IS A CANDIDATE FOR THE PROCEDURE? The most common indication for septoplasty is a septal deviation with nasal obstruction. In this situation the septum deviates to one side; with narrowing of that nasal cavity and lessening airflow. Another reason for performance of this procedure is nosebleeds. The front part of the nasal cavity naturally tends to dry from the air passing through it. If the septum is deviated within the front part of the nose, the airflow along it creates even greater drying, with resultant thinning and cracking of the nasal epithelium, which contains a very dense plexus of blood vessels. If these frequently bleed and respond to conservative measures, such as lubrication and moisturization, then straightening the septum is necessary. Another reason to consider septoplasty would be if there is a deviation in the septum deeper in the nasal cavity which affects drainage of the paranasal sinuses into the nose with subsequent recurrent or chronic sinusitis. The septum may have to be moved into a more normal, mid-line position to facilitate sinus drainage and thus prevent infection. With some individuals in whom the septum tightly contacts other structures inside the nose, such as the turbinates, a chronic head or face pain may result. Septoplasty to move the septum away from the structures helps to resolve the headache. Lastly, some individuals with lessened olfactory capabilities may benefit from straightening a deviated septum.
A septoplasty may be combined with other procedures to try to improve overall nasal volume. On the outside wall of the nose opposite the septum are structures called turbinates. If the septum deviates to one side, then the turbinates on the opposite side of the deviation will enlarge. It may be necessary to either push these out of the way or partially reduce their size to establish good airway on both sides.
HOW IS IT PERFORMED? It can be performed under general or local sedation modes of anesthesia. Access to the cartilage and bony components of the septum is easily obtained through a small 1 to 1.5 cm incision in the lining of the septum just behind its lower edge. The incision is carried down to the cartilage and then the lining on one side of the septum is completely elevated, thus exposing the cartilage and bony components. To get the cartilage portion of the septum to assume a mid-line position, a small strip of it is usually removed from its lowermost aspect, thus freeing it from its attachments along the floor of the nose, and then a vertical strip of cartilage is taken out to free it from its attachment to the bony septum just behind it. In addition to these strips of cartilage, remaining crooked portions of the septum have to be removed. It is very important to maintain an L-shaped piece of septum with the two limbs measuring 7 to 10 mm in width in order to provide adequate support for the tip of the nose. Any crooked portions of the bony septum are likewise removed. Any of the cartilage is then flattened and replaced, not so much to give additional structural integrity to the septum but to act as a spacer between the two mucous membrane coverings of the septum to decrease the risk of perforation formation. To hold the straightened septum in position, small plastic sheets, splints, or packing may be employed for several days postoperatively.
WHAT HAPPENS AFTER THE PROCEDURE? To limit the risk of bleeding, no aspirin-containing products should be used, nor should strenuous exercise or nose blowing be undertaken to limit the possible risk of hemorrhage. Post-operative infections are rare. There is no medical consensus for the need of post-operative antibiotics, but many practitioners employ them to try to prevent the rare occurrence of toxic shock syndrome. To limit the post-operative discomfort, keeping the head elevated above the heart is helpful, in addition to using salt water nasal sprays to keep the intranasal cavity moist. Fortunately, there are few complications. A perforation may result from the surgery, but with the advent of better surgical techniques, this has become less likely. A perforation is a hole that forms in the septum so that now there is communication through the septum from one nasal cavity into the other nasal cavity. Another potential complication is a septal hematoma, which is a collection of blood between the mucosal surfaces on either side of the septum. Not only does this cause fairly significant pain, pressure, and nasal obstruction, but if it gets infected, there can be spread into the cavernous sinus, which could be a life-threatening problem.
WHAT DO THE RESULTS MEAN? Successful outcome would be resolution of the nasal obstruction, cessation of further nosebleeds, headaches, and sinus infection.
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