What is a deviated septum?
Did you ever feel like one side if your nose is always stuffed up or blocked? That may indicate you have a deviated septum which is the most common cause of a continual nasal obstruction. It can be uncomfortable and even change your sleep patterns. Some patients find they need to sleep with the blocked side down towards the pillow to allow the more open nostril to breathe. Sleeping with the blocked side up can mean trouble breathing and problems sleeping.
The culprit is the septum, the wall between the two sides of the nose. It can become crooked, or ” deviated” for any number of reasons. While some people can pinpoint an incident that pushed their septum out of shape, most of us just have no recollection of a cause. Maybe you fell on your nose as a child, playing a sport, or perhaps your nose was traumatized during birth. Either way, it turns out that many people have mildly deviated septums that cause no problems whatsoever. If there is no nasal blockage, obstruction or frequent sinusitis, then a mildly deviated septum doesn’t need to be fixed unless you are considering rhinoplasty (this will be discussed below).
But if you are finding you have trouble breathing either during the day or at night, with one side of your nose constantly feeling blocked, that can be fixed. First, A deviated septum needs to be diagnosed by a careful examination of the inside of the nose. Most nose specialists will use a headlight and a small device called a nasal speculum to inspect the inside of your nose. If your nose is congested or swollen turbinates are obscuring a full view of the inside of the nose, the nose can be decongested using a medicated nasal spray to improve visibility. For a deeper inspection of the nasal cavity, openings of the sinuses and the back of the nasal airway, a flexible or rigid nasal endoscope can also be used.
Every patient being considered for nasal surgery, even cosmetic rhinoplasty (commonly called “nose jobs”) should have a thorough examination of the inside of the nose to check for a deviated septum. That’s because any nasal surgery could make a deviated septum more symptomatic and suddenly create nasal blockage. Even a few millimeters of narrowing of the sidewalls of the nose that usually occurs with rhinoplasty could make this small deviation of the septum more important and now cause obstruction. This is based on the physics of Bernoulli’s Law pertaining to air flowing through a column. So, if I see a deviated septum, I will fix it, even if the patient came in for a cosmetic rhinoplasty. I don’t want to create a new problem. Some patients may not even realize that they have been breathing predominantly out of only one nostril until it’s pointed out at the time of examination. It also amazes me when I see patients for a revision rhinoplasty with breathing issues how often they report that their surgeon never even looked inside their nose because it was just a cosmetic rhinoplasty.
While most deviated septums can be diagnosed by a thorough nasal examination, CT scans are sometimes obtained to better visualize the back of the nose and the sinuses. If you have recurrent sinusitis, a CT scan will add more information on the status of your sinuses that can’t be seen, even with a nasal endoscope. Some insurance companies actually require or highly recommend a CT scan to further document a deviated septum. Recently, we have been using intra-nasal photographs taken with an nasal endoscopic camera to circumvent the need for a CT scan.
The nasal septum is the wall in the center of the nose that divides it into two sides. The front 2/3 is made of cartilage and the back portion is thin bone. The septum, as well as the entire nasal cavity is lined by smooth shiny skin called mucosa that covers the cartilage and bone. The septum sits on a small groove of bone called the maxillary crest that is the top of the bone that makes the palate (roof of the mouth). The septum extends from the floor of the nose to the bridge above and all the way down to the nasal tip below. If you put your finger in your nose and feel a wall in the middle, that’s your nasal septum.
Other structures in the nose that also contribute to the nasal airway are called turbinates. There are three turbinates on each side of the nose: lower, middle and upper. They are curly bones that are also covered by mucosa. The turbinates help channel the air we breathe along a direct path from the nostril to the back of the throat then down into our lungs; this is called laminar flow. The turbinates also swell to warm and humidify the air we breathe and as a reaction to colds and allergies. You could be outside in cold, dry air, by the time the air gets to your lungs it is 98% humidity and body temperature. This is mostly a function of swelling of the turbinates. The turbinates also have a natural cycle where one side swells and 6 to 8 hours it alternates to the other side. If you cover one of your nostrils and the airflow is good, but when you switch, the other is less. This cycle will alternate sides. Rarely do people breathe fully through both nostrils at the same time. The nasal cycle is also affected during sleep. The downhill nostril will swell by gravity and you breathe more through the uphill nostril. This is why when you turn over; there is a brief wave of air you feel. It’s the uphill nostril opening up.
Fixing a deviated septum
Septoplasty, or fixing a deviated septum alone is usually performed from inside the nose by a closed or endonasal approach. That means crooked cartilage and bone is moved, scored, reshaped or removed. As long as your surgeon leaves a strong support along the bridge and bottom of the nose, there should NOT be any changes to the way your nose looks from the outside. There also shouldn’t be any “black and blue” under the eyes or even an external cast necessary. As I tell all my septoplasty patients, your mother couldn’t tell you had anything done 2 days after surgery. Only in very extreme circumstances (less than 1 in many hundreds) does the nose need to be “opened” to correct a deviated septum.
Septoplasty vs. Rhinoplasty
|Achieves||Functional restoration (improves breathing)||Cosmetic improvement (enhances appearance)|
|Alters||The septum (the bone and cartilage separating the left and right airways in the nose)||The outer shape, size, and projection of the nose and/or nostrils|
|Open or Closed Approach||Closed (endonasal)||Open or closed|
|Covered by Insurance||All or partial (depending on your insurance policy and the surgeon’s practice policy)||Not generally|
Septoplasty and Rhinoplasty
If you have a deviated septum and would like to improve the appearance of your nose, septoplasty and rhinoplasty can be performed together as one operation known as septorhinoplasty. Part of the operating room and anesthesia fees may be covered for the functional aspect of the procedure, but patients should be aware that most insurance companies do not cover the surgical fees for rhinoplasty, even when it is performed with a septoplasty.
Other causes of nasal blockages: A deviated septum is not the only reason your nose could be continually feeling stuffed or blocked, and there are procedures to help these as well:
Sinusitis, Endoscopic Sinus Surgery
The sinuses drain into the nose through tiny passages or corridors between the turbinates. When these small ports get blocked by a cold or allergies, the mucus backs up and bacteria can pool. This acts like a stagnant pond. It then becomes a cycle of more bacteria, more toxins and more swelling. Antibiotics and sometimes nasal sprays and/or decongestants are necessary to sterilize the sinuses. Then they can drain better. However, if you have very tiny sinus openings, this cycle may keep on repeating.
Endoscopic sinus surgery uses tiny surgical telescopes called endoscopes to explore inside the sinus openings. They can then be surgically enlarged to enhance fluid drainage from the sinuses and prevent backup of mucus and bacteria. Surgery of the sinuses may be simple opening of the sinus outflow tracts called the middle meatus or more aggressive cleaning out of the sinuses depending on the extent of sinus disease. CT scans and correlation with the response to medical treatment will help determine how extensive sinus surgery needs to be.
Endoscopic sinus surgery is frequently performed at the same time as septoplasty since a deviated septum is often a significant contributing factor. It can also be safely done in conjunction with cosmetic rhinoplasty.
The Nasal Valve
The nasal valve is the narrowest part of the nose. It is actually divided into two parts: internal valve and external valve. When you have nasal obstruction, it is sometimes from nasal valve issues in addition to, or instead of, a deviated septum or enlarged nasal turbinates. The internal nasal valve is in the middle third of the nose. The cartilages called the upper lateral cartilages insert into the nasal bones above and intersect with the top of the nasal septum in the midline. If you run your finger down the side of your nose, you will likely feel a drop off below the top third of the nose. This is where the upper lateral cartilage is inserting under the nasal bone. When a nasal hump is removed and the gap closed, the upper lateral cartilages may get even narrower.
Internal valve issues of excessive narrowing of the upper lateral cartilages after cosmetic rhinoplasty is one of the most common issues addressed in revision rhinoplasty. The treatment is placement of grafts of your own cartilage to support that internal nasal valve, called spreader grafts. These grafts are usually taken from nasal septal cartilage. Since we found that this issue was occurring so often, most rhinoplasty surgeons, including myself actually place spreader grafts in primary rhinoplasty to prevent internal valve issues in the first place in many patients.
The external nasal valve is lower down in the nose and comes from strength and support of the nostrils by the tip cartilages called the lower lateral cartilages. The external nasal valve can be compromised or narrowed by a number of causes: too much cartilage is removed from the nasal tip during rhinoplasty, sutures used to narrow the nasal tip are too tight or the shape and position of the lower lateral cartilages are such that they don’t offer sufficient support for the nasal airway. The treatment for a narrow nasal valve in revision rhinoplasty, or even preventing one in the first place during primary rhinoplasty is also by the use of cartilage grafts. These are called alar strut or batten grafts.
The bottom line is that Dr. Pearlman has a procedure to help you breathe easier and feel better with very little down time.
Answers to frequently asked questions about the procedure
If you have blockage of your breathing and documented treatment for nasal obstruction, insurance often can pay for surgery. This will be only for the functional procedure of septoplasty and not rhinoplasty.
Septoplasty alone has no effect on the appearance of your nose. There is no external splint or cast. Some patients choose to have cosmetic surgery at the same time.
Septoplasty will permanently straighten a deviated septum. However, nasal obstruction may also be due to other anatomic and functional issues. For most patients, they experience permanent improvement in breathing.