Deviated Nasal Septum : Def, Causes, Clinical Features, Investigation, Treatment

By S.M. Abu Jar Gifari Papon / In Otolaryngology (ENT) / June 17, 2013 at 8:01 pm

Introduction:
A deviated septum is a condition in which the nasal septum the bone and cartilage that divide the nasal cavity of the nose in half is significantly off center, or crooked, making breathing difficult. Most people have some sort of imbalance in the size of their breathing passages. In fact, estimates indicate that 80% of people, most unknowingly, have some sort of misalignment to their nasal septum. Only the more severe imbalances cause significant breathing problems and require treatment.

Def:
Shifting of nasal septum from midline in one side partially or totally.

Causes:
1. Trauma: a. Brith trauma due to prolonged labour, forceps delevery. b. RTA. c. Assult.

d. Sports injury. 2. Developmental, disproportionate growth of different facial skeleton. 3. Genetic connective tissue disorders such as Marfan syndrome, Homocystinuria and Ehlers Danlos syndrome. 4. Racial. 5. Thumb sucking. 6. Nose picking. 7. Idiopathic.

Types:
1. Anterior caudal deviation. 2. C shaped deviation. 3. S shaped deviation. 4. Septal spur (Maxillary crest from the floor is projected like a spike).

5. Thickend septum.

Clinical Features:
Most septal deformities result in no symptoms, and you may not even know you have a deviated septum. Some septal deformities, however, may cause the following signs and symptoms:

Symptoms:
1. Nasal obstruction. 2. Post nasal drip, nasal discharge. 3. Nosebleeds. 4. Facial pain due to sinusitis. 5. Headache due to sinusitis. 6. Postnasal drip. 7. Loud breathing and snoring during sleep. 8. Recurrent or persistent sore throat due to pharyngitis or tonsillitis. 9. Earache or conductive deafness. 10. Hoarseness due to laryngitis. 11. Repetitive sneezing. 12. Difficulty with breathing. 13. Mild to severe loss of the ability to smell.

Signs:
1. There may be external deformity of the nose. 2. Anterior rhinoscopy shows narrow nasal cavity on the deviated side and roomy nasal cavity on the opposite side. 3. The inferior turbinate may be hypertrophied on the opposite side. 4. there may be some other findings of effects of DNS such as sinusitis, granular pharyngitis, otitis media with effusion.

Investigations:
1. Routine investigation for GA fitness. 2. X-ray paranasal sinus occipito-mental view to see any evidence of sinusitis. 3. Coronal CT scan of PNS if functional endoscopic sinus surgery is planned with septal surgery.

Treatment:
No treatment if no symptoms or mild deviation. In mild cases, symptoms can simply be treated with medications such as decongestants, antihistamines, and nasal spray. Medication temporarily relieves symptoms, but does not correct the underlying condition. Surgical treatment-For pts with typical symptoms and gross deviation there are two surgical options for deviated nasal septum such as Septoplasty or Submucous resection. Septoplasty is mostly practise now a days as it has a cosmatic value . During septoplasty, a surgeon, working through the inside of the nose, makes a small incision in the septum and then removes the excess bone or cartilage required to even out the breathing space of the nostrils. Sometimes, a rhinoplasty, or nose job, is combined with septoplasty to improve the appearance of the nose. This procedure is called septorhinoplasty. Septoplasty may also be combined with sinus surgery. Surgery to repair a deviated septum is usually performed in an outpatient setting under local or general anesthesia and takes about one to one and a half hours, depending on the amount of work being done. You should be able to go home three to four hours after surgery. Internal splints or soft packing material may be put in the nose to stabilize the septum as it heals. If a septoplasty is the only procedure performed, there should be little to no swelling or bruising after surgery. However, if a septorhinoplasty is performed, a week or two of swelling and bruising is normal following the procedure. If possible, it is best to wait until after the nose has stopped growing, around age 15, to have surgery. Newer procedures are becoming available that use balloon septoplasty techniques that avoid actual surgery and are done in the office setting. These are being done for milder cases.

Complications:
Hypertrophy of inferior turbinate. Hypertrophy of middle turbinate. Sinusitis. Pharyngitis. laryngitis. Tonsillitis.

Nasal deformity. Chronic supporutive otitis media.

Deviated Septum Surgery Risks:

No surgery is completely risk-free and the benefits from undergoing surgery in this case, being able to breathe better must outweigh the risks. Septoplasty and septorhinoplasty are common and safe procedures and the chance of having a dangerous side effect is rare. Still, talk with your doctor about the possible risks of surgery before you make a treatment decision. Although rare, risks of septoplasty and/or rhinoplasty may include: infection bleeding hole (perforation) of the septum loss of the ability to smell

If you are having nasal symptoms and think you may have a deviated septum, make an appointment to see an ear, nose, and throat doctor, or ENT. There are a number of reasons why you may be experiencing these symptoms, including chronic sinusitis or nasal allergies. Make sure you get the right diagnosis so that you can get the treatment you need.

Prevention:
You may be able to prevent the injuries to your nose that can cause deviated septum with these precautions: Wear a helmet when playing contact sports, such as football and hockey. Wear a seat belt when riding in a motorized vehicle.

Source: Review of Otolaryngology, Head and Neck Surgery by Dr. M. A. Matin

Deviated Septum
e h t n i o J W M y a D e h t f d r o t s L g n l i a

Definition
The nasal septum is a thin structure, separating the two sides of the nose. If it is not in the middle of the nose, then it is deviated.

Description
The nasal septum is composed of two parts. Toward the back of the head the nasal septum is rigid bone, but further forward the bone becomes cartilage. With one finger in each nostril this cartilage can easily be bent back and forth. If the nasal septum is sufficiently displaced to one side, it will impede the flow of air and mucus through the nose. This condition, called a deviated septum, can cause symptoms and disease.

Causes and symptoms

A deviated septum can be a simple variation in normal structure or the result of a broken nose. Any narrowing of the nasal passageway that it causes will threaten the drainage of secretions from the sinuses, which must pass through the nose. It is a general rule of medicine that when flow is obstructed, whether it is mucus from the sinuses or bile from the gall bladder, infection results. People with allergic rhinitis (hay fever) are at greater risk of obstruction because their nasal passageways are already narrowed by the swollen membranes lining them. The result is sinusitis, which can be acute and severe or chronic and lingering.

Diagnosis
It is easy to see that a septum is deviated. It is more difficult to determine if that deviation needs correction. It is common for a patient to complain that he/she can breathe through only one nostril. Then the diagnosis is easy. A deviated septum may also contribute to snoring, sleep apnea, and other breathing disorders.

Treatment
The definitive treatment is surgical repositioning of the septum, accomplished by breaking it loose and fixing it in a proper place while it heals. Decongestants like pseudoephedrine or phenylpropanolamine will shrink the membranes and thereby enlarge the passages. Antihistamines, nasal cortisone spray, and other allergy treatments may also be temporarily beneficial.

Alternative treatment
As a palliative, saline drops and sprays are very helpful in loosening mucus in the obstructed side and preventing drying in the other side, where all the air blows. Hot peppers, such as jalapenos, can produce enough tears and discharge to flush out a stopped-up nose. An even more effective treatment is called a nasal lavage, often done using a small pot with a spout. Saline solution is poured into one nostril and allowed to flow out the other nostril. Then, the process is repeated in reverse. These therapies are all useful to take care of symptoms, but do not correct the problem. Nasospecific, a procedure where a deflated balloon is inserted in the nostril and inflated to a large enough degree to adjust the septal deviation, can be an alternative to surgery. A trained practitioner in the nasospecific procedure is necessary.

Prognosis
Surgical repair is curative and carries little risk. Chronic infection can be painful and lead to complications until it is resolved. If there is continued obstruction, the infection will very likely return.

Prevention
Avoidance of virus colds, airborne dusts, air pollution, and known allergens will minimize the irritation

and swelling of the membranes lining the nasal passages.

Resources
Books Ballenger, John Jacob. Disorders of the Nose, Throat, Ear, Head, and Neck. Philadelphia: Lea & Febiger, 1991.

Key terms
Allergen Any substance that irritates people sensitive (allergic) to it. Allergic rhinitis Swelling and inflammation of the nasal membranes caused by sensitivity to airborne matter like pollen or cat hair. Saline A salt solution in water. Normal saline has the same salt concentration as the body, 0.9%. Sinuses The nasal sinuses, air-filled cavities surrounding the eyes and nose, like the nose itself are lined with mucus-producing membranes. They provide cleansing to the nose, resonance to the voice, and structure to the face. Sinusitis Infection of the sinuses. Sleep apnea A condition in which breathing is temporarily interrupted during sleep. It leads to high blood pressure, sleepiness, and a variety of other problems.

The Incidence of Concha Bullosa and Its Relationship to Nasal Septal Deviation and Paranasal Sinus Disease
BACKGROUND AND PURPOSE: The incidence of middle turbinate pneumatization, or concha bullosa, has been well described in the literature. However, to our knowledge, no study has evaluated concha bullosa in relation to nasal septal deviation. We sought to analyze the incidence of concha bullosa and any correlation with nasal septal deviation and paranasal sinus disease. METHODS: Three neuroradiologists retrospectively reviewed findings of 1095 consecutive paranasal sinus CT studies conducted between 2001 and 2002. All examinations were performed for evaluation of a symptom referable to the sinonasal region. Paranasal sinus inflammatory disease was identified and graded as mild, moderate, or severe. Sphenoid, ethmoid, maxillary, and frontal sinuses were each graded separately on both sides. If a concha bullosa was present, it was graded in size as small, moderate, or large. If bilateral concha were present, sizes were compared and when one was larger, it was identified as dominant. When nasal septal deviation was present, it was graded as mild, moderate, or severe. The direction of nasal septal deviation was identified as the face of the convex surface. RESULTS: There was a clear association between the presence of a unilateral concha, or a dominant concha (in the case of bilateral concha), and the presence of nasal septal deviation ( P < .0001). Moreover, there was a significant relationship between the presence of concha bullosa and deviation of the nasal septal to the contralateral side (P < .0001). This inverse association was present regardless of the size of the concha bullosa or degree of septal deviation. In every case, there was some preservation of air channels between the dominant concha and the nasal septum. Seventy-three percent of patients with concha bullosa had paranasal sinus inflammatory disease; 78% of patients without concha bullosa also had some form of inflammatory disease. CONCLUSION: Concha bullosa is a common anatomic variant. There is a strong association between the presence of a concha bullosa and contralateral deviation of the nasal septum. Nasal septal deviation away from the dominant concha, with preserved adjacent air channels, suggests that the deviation is not a direct result of mass effect from the concha. No increased incidence of paranasal sinus disease exists in patients with concha bullosa.

Several authors have assessed the relationship between sinonasal anatomic variants and the incidence of sinusitis. The incidence of Haller cells has been reported to vary from 2 45%, and although some reports have found a statistically significant relationship between maxillary sinusitis and medium or large Haller cells (1), it is generally believed that the presence of a Haller cell is not related to sinusitis (2, 3). The incidence of agger nasi cells has been reported to vary from 3% to almost 100%, and its presence has been firmly associated with frontal sinusitis ( 2). The incidence of Onodi cells varies from 3.451%. Although not associated with sinusitis, its presence does pose an increased incidence of surgical complications (2, 4). There are two anatomic variants, the middle turbinate concha bullosa and nasal septal deviation; however, adequate documentation of their anatomy and etiology has not appeared in the literature either to support or refute their roles in sinusitis. The incidence of CT findings positive for concha bullosa has varied from 14 53%, and the relationship of concha bullosa to paranasal sinus disease continues to be debated ( 5, 6). Similarly, the role of nasal septal deviation in the etiology of sinusitis remains unclear. Our empirical observations regarding CT signs of paranasal sinus have suggested that when a concha bullosa was present, the nasal septum was deviated with a convexity to the opposite side and the airway between the concha and septum maintained. Herein we evaluate these observations to assess the relationship among concha bullosa, nasal septal deviation, and sinusitis in a large series that would yield statistically relevant data.

Methods
We retrospectively searched our radiology database for all paranasal sinus CT findings obtained between January 1, 2000, and December 31, 2002. The study was performed with institutional review board and HIPAA approval number GCO 030407. CT was performed on three CT scanners (GE Medical Systems HiSpeed CT/I or GE Medical Systems LightSpeed Ultra, GE Medical Systems, Milwaukee, WI; and Siemens Sensation 4, Siemens, Erlangen, Germany) to obtain 2.53.0-mm axial and coronal studies of the paranasal sinuses. Nasal vasoconstrictors were not administered. All patients were referred for CT owing to a clinical symptom presumably referable to the sinonasal region. Patient histories were not taken into account. Therefore, the data were not sorted by specific patient complaints or symptoms. A total of 1095 consecutive CT studies were identified. Of these cases, 97 studies were eliminated because either a tumor or prior surgery had destroyed some or most of the anatomic structures being studied. Of the 998 cases included in this study, the examinations were reviewed by three neuroradiologists (J.S.S., J.N.L., P.M.S.) and any differences in opinions were resolved by consensus. The left and right sides of each of the frontal, ethmoid, sphenoid, and maxillary sinuses were assessed separately for the presence of mucosal disease. This disease was evaluated as either being present or absent. A concha bullosa was defined as being present when more than 50% of the vertical height (measured from superior to inferior in the coronal plane) of the middle turbinate was pneumatized. A concha was subjectively assessed as being absent, small, moderate, or large. If bilateral concha were present, they were assessed as being equal in size or one was designated as the dominant concha. Deviation of the nasal septum was subjectively assessed as being absent, mild, moderate, or severe, and the direction of deviation was described by the convexity of the septal curvature. The preservation or obliteration of the air channel between a concha (unilateral or dominant concha) and the nasal septum was also assessed. SAS statistical software (Institute Incorporated, Cary, NC) was used to summarize the data. Analysis was performed with chi-square and Wilcoxon ranked sum techniques.

Results
The median age of the patients was 44 years (range, 0 98 years). There were 598 female (60%) and 400 male (40%) patients. Of the 998 patients, 648/998 (65%) had nasal septal deviation; 343 (51%) had a convexity to the right, 320 (49%) had the convexity to the left, and 15 (2%) had biconvex nasal septal deviation. Because these 15 patients with biconvex deviation technically had deviation in both directions, they were included in both the left and right convexity groups, leading to a total of 102% for the three groups.

Of the 998 patients, 436 (44%) had at least one concha bullosa, 227 (23%) patients had a unilateral concha, and

209 (21%) had bilateral concha. Of the patients with bilateral concha, 85/209 (41%) had equal sized concha and 124 (59%) were judged as having a larger, dominant concha. Overall, 351/998 (35%) patients had either a unilateral or dominant (if bilateral) concha. Of these 351 patients, 149 (42%) had a small concha, 156 (44%) had a medium-sized concha, and 46 (13%) had a large concha. Of all 998 patients, 647 (65%) had either no concha or bilateral concha of equal size (Table 1). TABLE 1: Summary of incidence, unilateral or bilateral occurrence, and size of concha bullosa

When considering patients with either a unilateral or dominant concha and the presence or absence of nasal septal deviation, 276/351 (79%) of patients with a unilateral or dominant concha had nasal septal deviation, but only 75 (21%) with a unilateral or dominant concha did not have nasal septal deviation; 357/647 (55%) of patients without a unilateral or dominant concha had nasal septal deviation, and a similar number, 275/647 (43%), of patients without a unilateral or dominant concha did not have nasal septal deviation (Table 2). In patients with a left-sided unilateral or dominant concha, 117/166 (70%) had right-sided nasal septal deviation, 11 (7%) had left-sided nasal septal deviation, and 38 (23%) had no nasal septal deviation. In patients with a rightsided unilateral or dominant concha, 127/185 (69%) had left-sided nasal septal deviation, 21 (11%) had rightsided nasal septal deviation, and 37 (20%) had no nasal septal deviation (Table 3). There was a strong association between a unilateral or dominant concha and contralateral nasal septal deviation ( P < .0001). TABLE 2: Incidence of nasal septal deviation in patients with and without unilateral or dominant, if bilateral concha bullosa

TABLE 3: Incidence of nasal septal deviation broken down by convexity compared to the presence and location of unilateral or dominant, if bilateral concha bullosa When considering patients with a unilateral or dominant concha and nasal septal deviation, the association of septal deviation was greater in patients with medium or large concha than in those with small concha. Forty-one of 46 (89%) patients with a large unilateral or dominant concha had associated septal deviation; 136/156 (87%) patients with a medium unilateral or dominant concha had associated septal deviation; and 100/149 (67%) patients with a small unilateral or dominant concha had associated septal deviation ( P < 001). When considering the relationship of sinus disease and nasal septal deviation, 504/648 (78%) of patients with nasal septal deviation had some sinus disease, and 253/350 (72%) without nasal septal deviation had some sinus disease (P = .0531)(Table 4). Of all 998 patients, 757 (76%) had some sinus disease; 318/436 (73%) of patients with a concha had sinus disease, and 439/562 (78%) of patients without a concha also had some sinus disease (P = .44). The relationship between a unilateral or dominant concha and right-sided sinus disease was not significant (P = .78), and the relationship between a unilateral or dominant concha and left-sided sinus disease was not significant (P = .53). TABLE 4: Distribution of nasal septal deviation and concha bullosa in the patient population studied

There was no association between a unilateral or dominant concha and disease in any single sinus (eg, right or left frontal, right or left ethmoid, etc). P values ranged from 0.26 to 0.90. Specifically, there was no association between the presence of a concha bullosa and an increased incidence of disease in any ipsilateral sinus. There was no relationship between a deviated septum ( P = .41) or a unilateral or dominant concha (P = .72) and the side of any sinus inflammatory disease based on the Wilcoxon ranked sum

test. Previous SectionNext Section

Discussion
One of the explanations given for the wide reported incidence (14 53%) of concha bullosa, as assessed on the basis of CT findings, is that the definition of a concha bullosa has varied among studies. Some reports have defined a concha as any aeration of the middle turbinate, even if the aeration is restricted to the upper nonbulbous portion of the turbinate. Other reports have restricted the definition of a concha bullosa to those cases wherein the aeration extends caudally into the bulbous portion of the middle turbinate (2, 3, 513). Because most otolaryngologic surgeons restrict the diagnosis of a concha to those cases that have pneumatization of the bulbous portion of the middle turbinate, we adapted the definition of a concha as a middle turbinate with pneumatization extending caudally at least 50% of the vertical height of the middle turbinate. This invariably brought the aeration into the bulbous portion of the turbinate and was an easily measured criterion on coronal CT studies (Fig 1). In our study, a concha was present in 44% of the cases and was unilateral or dominant in 35% of patients. Of these conchae, 42% were small, 44% were moderate, and 13% were large.

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FIG 1. Coronal CT scans showing the definition of a concha bullosa.

A, Coronal CT scan of the paranasal sinuses shows pneumatization ( arrow) of just under 50% of the vertical height of the right middle turbinate. This was not considered to be a concha bullosa in this study. There is no deviation of the nasal septum. There is inflammatory mucosal thickening obstructing the left infundibulum. B, Coronal CT scan of the paranasal sinuses shows pneumatization ( arrow) of more than 50% of the vertical height of the right middle turbinate. This pneumatization extends into the caudal bulbous portion of the turbinate. This was considered to be a small concha bullosa in this study. Also note that the nasal septum is moderately deviated convexity to the left and there is preservation of the air channel between the concha and the nasal septum. There is some mucosal thickening in both maxillary sinuses.

The population studied was referred for CT owing to a specific symptom presumably related to potential disease in the sinonasal region. Therefore, statistical inference of our results applies only to a symptomatic population. The incidence of concha bullosa, sinusitis, nasal septal deviation, and associations thereof apply only to patients who present to a healthcare provider with complaints potentially caused by sinonasal disease. No conclusion about the general population is made from the results of this study.

Some reports have suggested a relationship between the presence of a concha bullosa and sinusitis (14, 15), but other reports have found no direct relationship (16,17). We found no correlation between the presence of a concha bullosa and sinus disease. Seventy-two percent of patients with a concha had sinus disease, but 78% of patients had sinus disease without a concha. This relationship held true for unilateral and contralateral sinusitis. With regard to nasal septal deviation, it is reported in 2031% of the population and severe deviation has been

noted as a contributing factor for sinusitis (14, 18, 19). Another study reported a possible causal relationship between concha bullosa or septal deviation and sinus disease (15). Conversely, one study did not demonstrate a causal relationship between nasal septal deviation and sinusitis (20).

We defined nasal septal deviation as any bending of the nasal septal contour as evaluated on coronal CT studies. The direction of the deviation was defined by the side of the convexity of the curvature. Subjectively, we classified the deviation as absent, mild, moderate, or severe. We found that nasal septal deviation of some degree was present in 65% of the cases. There was no relationship found between nasal septal deviation and sinus disease.

We also found that there was a strong relationship between the presence of a concha (unilateral or a dominant concha) and deviation of the nasal septal convexity away from the concha ( P < .0001). We also found, however, that there was always maintenance of the nasal air channel between the medial aspect of the concha (unilateral or dominant concha) and the adjacent surface of the nasal septum (Figs 24). This implies that the deviation of the septum away from the concha is not the result of the concha pushing the septum. Rather, there appears to be some as yet unknown developmental relationship between a concha and the nasal septum. It is analogous to the chicken and the egg conundrum. We could find no information that suggested whether the concha develops first and the nasal septum somehow senses the mass effect of the concha and correspondingly developed away from this side, or if the septal deviation develops first and then the concha enlarges to partially fill the expanded air channel. In either case, the septal deviation is often so great that there is compromise of the contralateral nasal air channels.

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FIG 2. Coronal CT scan of the paranasal sinuses shows a moderate-sized left concha bullosa with moderate deviation of the nasal septum convexity to the right. Note that there is preservation of the air channel between the concha and the nasal septum. There is mucosal disease in both ethmoid sinuses.

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FIG 3. Coronal CT scan of the paranasal sinuses shows a large left concha bullosa with severe deviation of the nasal septum convexity to the right. Note that there is preservation of the air channel between the concha and the nasal

septum. There is mucosal disease in both maxillary sinuses.

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FIG 4. Coronal CT scans showing variation in concha size wth preservation of nasal air channels.

A, Coronal CT scan of the paranasal sinuses shows moderate-sized concha bullosa bilaterally, with the one on the left side being slightly larger, or dominant. There is mild deviation of the nasal septum convexity to the right. Note that there is preservation of the air channel between the dominant concha and the nasal septum. There is, however, some loss of the air channel between the nasal septum and the right concha. There is mucosal disease in both ethmoid and maxillary sinuses. B, Coronal CT scan of the paranasal sinuses shows moderate-sized concha bullosa bilaterally, with the one on the left side being slightly larger, or dominant. There is mild deviation of the nasal septum convexity to the right. Note that there is preservation of the air channels between each concha and the nasal septum. There is mucosal disease in both maxillary sinuses. C, Coronal CT scan of the paranasal sinuses shows a moderate-sized bilateral concha bullosa with mild deviation of the nasal septum convexity to the right. Neither concha was considered to be dominant. Note that there is preservation of the air channels between each concha and the nasal septum. There is mucosal disease in both maxillary sinuses.

Conclusion
When a unilateral or dominant concha bullosa is present, there is no statistical relationship with any sinus disease (on either side). There is, however, a strong relationship between the presence of a unilateral or dominant concha and contralateral nasal septal deviation while the air channel between the concha and the nasal septum is preserved. There is no statistical relationship between nasal septal deviation and the presence of any sinus disease.

Septoplasty

Septoplasty surgery is intended to correct what is called a deviated nasal septum, or deviated septum for short. The nasal septum refers to the structure that separates the left and right nasal passageways. It is comprised of both cartilage and bone. In the adjacent diagram the cartilage component of the nasal septum is shaded light yellow while the bony portion of the septum is shaded light purple.

Normally the nasal septum is relatively straight as it extends back into the nasal cavity. We say relatively straight because there is usually some degree of even mild deviation, or displacement, in everyone. When this deviation in the septum is excessive, as it is in many patients, it can cause a symptomatic blockage of airflow through the nose. This feeling of blockage can occur on one side or both depending on how the septum is deviated and to what degree it is blocking the inside of the nose. In most patients with a symptomatic deviated septum the difficulty breathing through the nose is somewhat fixed meaning, it does not change much on a day to day basis. This should make logical sense because we are dealing with an anatomical, or structural, problem inside of the nose that will not change until it is surgically corrected.

Origins of a Deviated Nasal Septum

In a great majority of patients seeking correction for a deviated septum, or septoplasty, there is no prior history of trauma (injury) to the nose. A good majority of these patients were simply born with the problem. It may not have manifested itself early on in life, but as the nose continued to grow through adolescence the nasal septum began to deviate in one or more directions.

In other patients, there is a definite history of trauma to the nose as a result of an injury. For instance, many patients with a deviated septum began noting problems after suffering a blow to the nose while playing sports. In these instances, the septum (like the external nose) can be fractured resulting in displacement of the septum from its normal midline position. These patients will note an obvious decline in the nasal function soon after the injury with greater difficulty breathing through the nose on one side and/or the other.

Diagnosis of a Deviated Nasal Septum

Diagnosis of a deviated nasal septum is made by a nose specialist (Facial Plastic & Reconstructive Surgeon or Otolaryngologist) upon close examination of the nose in the office setting. A specialized diagnostic instrument, called a nasal speculum, is inserted into the nostril and the nose specialist can readily determine whether or not the nasal septum is crooked, or deviated. In the adjacent diagram you can see what this might look like in real life. This particular patient presented with a complaint of difficulty breathing through their left nostril (your right side when examining them). On examination in the office you can see there is an obvious blockage inside of the nose. Normally you should see more black shadowing indicative of an open nasal cavity going directly back into the nose. In this particular case, the septum is bulging into the nasal cavity causing a blockage. This is directly responsible for this patients inability to breathe properly through the left side of their nose.

In some cases, your nose specialist may order a computed tomography (CT) scan of the area to confirm the diagnosis. In many of these instances, it is simply to satisfy the requirements of your health insurance company, which often times requests additional studies to provide objective evidence of a medical condition. In other cases, a CT scan can help rule out other associated medical conditions, such as chronic sinusitis, nasal polyps and more.

Septoplasty for a Deviated Nasal Septum

Septoplasty surgery, or septal reconstruction, is a reconstructive procedure that is intended to correct a deviated nasal septum. The surgery is most commonly performed through the nostrils without having to make any external incisions on the nose. In some complex cases of a deviated septum, your nose specialist may recommend an open rhinoplastyapproach. This means they require more exposure to accomplish the surgical goals and need to make an external incision to lift the skin up over the nasal tip. The septoplasty surgery involves elevating the internal lining of the nose on both sides to properly expose the cartilage and bone that comprise the septum. Once the deviated portions have been adequately visualized, the crooked segments of cartilage and bone are typically removed, or resected. However, it is of vital importance that

the surgeon preserve what is called an L-strut of septal cartilage.

The L-strut is

depicted in the adjacent diagram as a blue shaded area. As you can see, this outer border of septal cartilage plays an important role in maintaining the external shape of the nose. This includes providing support for the nasal bridge and the tip. As long as an L-strut of septal cartilage that is approximately 1.5-2 cm wide is preserved along the bridge and tip, there should be no change in the external shape of the nose. Many patients often ask if their nose will change in appearance following standard septoplasty surgery. The answer is not typically especially if a proper L-strut is preserved during the surgery.

Septoplasty surgery is usually done under a general anesthetic in the operating room. A general anesthetic is typically recommended more for safety than any issue with patient comfort. When lying down on your back for surgery like this, you will inevitably have some drainage down the back of your throat. If this drainage happens to find its way down to your vocal cords and into the lungs, it can cause severe problems with breathing termed aspiration. This can essentially be avoided by having a general anesthetic where a tube is placed for breathing purposes, thereby, minimizing any chances of drainage getting into your lungs.

Recovery from Septoplasty Surgery

In my practice, I rarely pack the nose following septoplasty surgery. This is one of the most feared issues when it comes to septoplasty recovery as many nose surgeons commonly pack the nose at the conclusion of the surgery. Gauze packing is placed alongside of the septum on both sides to compress the internal lining and minimize chances of bleeding after surgery. Unfortunately, this nasal packing can be incredibly uncomfortable and a source of considerable anxiety following septoplasty surgery. In my experience as a nose specialist, I have been able to avoid packing the nose in a great majority of septoplasty cases by, instead, using an absorbable suture to compress the internal lining. By doing so, my septoplasty patients can avoid the pain and misery of having gauze packing placed inside of the nose without compromising the actual surgical results.

Most septoplasty patients do fine on low dose narcotic medications, such as Vicodin, that are taken for a few days after surgery. After this time period, many patients switch to Tylenol over-the-counter for residual discomfort that is typically mild.

Saline sprays inside of the nose during the early recovery period (10-14 days) will help keep the area well

moisturized and decrease chances of internal scabbing, which will delay wound healing.

Most septoplasty patients will begin to appreciate the improvements in nasal breathing within 5-10 days of the surgery with further improvements noted upwards of several months out.