Septoplasty: Straightening the Nasal Septum

Septoplasty is an operation in which the nasal septum is straightened. This page will describe in more detail when this operation is recommended, how it is done, and what to expect if you are going to have a septoplasty.

The nasal septum is the part of the nose that divides the right nasal cavity from the left nasal cavity (see diagrams). The septum usually lies directly in the center of the nose and rests on a bony ridge called the maxillary crest.. The septum is made up of several layers. In the front, the central portion of the septum is cartilage, a relatively soft material that is fairly fliexible (colored blue on the diagram). More posteriorly, the central septum is made up of thin bone (light tan in the diagram). Lying on top of the bone and carilage is the lining of the nose, called the mucosa.



The picture to the left shows the internal structure of the nasal shows septum viewed in cross section. The front of the nose is to the left. The cross-hatched region is made up of cartilage (blue). Towards the back, the septum is made up of thin bone (light tan).






A septoplasty is done if the septum is so crooked that it interferes with breathing or causes other problems. Few people actually have a perfectly straight septum, but in most cases the amount of bending is not large enough to be noticed.

This image shows the nose viewed from below. In this case the septum is deviated to the patient's right side. In some cases the front part of the septum is in the proper position, but the rear portion has the deviation. The most common symptom from a badly deviated (crooked) septum is difficult breathing through the nose. The symptoms are usually worse on one side, and sometimes acually occur on the side opposite the bend. In some cases the crooked septum can interfere with the drainage of the sinuses, resulting in repeated sinus infections. The septum may also need to be straightened in individuals undergoing sinus surgery just so that the instruments needed for this operation can be fit into the nasal cavity.

Other Causes for Nasal Stuffiness
It is important to remember that the nose goes through a natural cycle in which the nasal line on one side and then the other slowly expands and contracts. These cycles occur every several hours and may lead to the perception of nasal obstruction. If you have persistent difficult breathing through your nose, you should see an Otolaryngologist for a complete exam. You should NOT use any over-the-counter nasal sprays for more than a few days without contacting your doctor. Many of these products have ingredients that produce rebound nasal swelling when they are stopped. As a result, the user is required to keep using the spray in order to keep his or her nose clear. Long term use like this can cause unjury to the lining of the nose. There are some sprays that can be used for a long time without side-effects; ask your doctor which spray is best for you.

Septoplasty: Performing the Operation
The basic principle in a septoplasty is to straighten the crooked portions of the septum. The operation is almost always done through the nose, without an external incision (there may be an incision if a rhinoplastly is also done at the same time). Badly deviated portions of the septum may be removed entirely, or they may be removed, readjusted, and reinserted into the nose. The operation takes about 1-1.5 hours, depending on the complexity of the deviation. It can be done with a local or a general anesthetic, and is usually done on an outpatient basis. In many cases nasal packing of some sort is placed for one to several days. There almost never is any bruising on the skin for just a septoplasty, though there can be bruising if a rhinoplasty is also done at the same time

Potential complications of a septoplasty
If the operation is done under a general anesthetic, there the usual risks with any general anesthesia. Bleeding is a possible risk, which may require nasal packing. Much more rare is the risk of a hole to developing in the septum after the operation. This may cause nasal crusting or interfere with breathing through the nose. An even rarer complication is postoperative infection of the septum, which could cause the front portion of the nose to bend inward. This would require a second opertion to correct the deformity.

How do I know if I need a septoplasty?
It is best to have a good nasal exam by an Otolaryngologist. Nasal obstruction can be caused by other things besides a crooked septum, so it is important to have a good examination of your nose.

Sinus Disease

The sinuses are air filled spaces within the skull. There are four groups of sinuses:

1. Maxillary sinuses, a paired group located below the eyes and lateral to the nasal cavity.
2. Ethmoid sinuses, typically numbering about 10-15 and arranged in a honeycomb pattern between the eyes.
3. Frontal sinus, a large single or divided cavity above the eyebrows.
4. Sphenoid sinus, a single or divided space located behind the nose, nearly in the center of the skull.

The sinuses are normally lined by a thin layer of tissue called mucosa. Glands within the mucosa produce a secretion called mucous. Mucous helps to moisten and clean the nose, and also helps in the sense of smell. The mucosa cells lining the sinuses have tiny hair-like structures called cilia that sweep the mucous to small openings in the sinus wall.

Under normal circumstances the mucous produced in the sinuses is cleared in a self-cleaning process. However, if the natural openings between the sinuses and the nasal cavity are blocked, the mucous can accumulate in the sinuses. Anything that blocks the outflow of this mucous can lead to sinus pressure, pain, and infections.

 The illustration to the left shows a schematic of this cleaning process. The sinus shown here is the maxillary  sinus, and its opening is actually up high along the wall. The blue arrow represents the path the mucous from  the sinus takes as it passes into the nasal cavity.

 Once the mucous reaches the nasal cavity it is then swept back towards the back of the throat and swallowed.  The average person actually prduces two to four cups of mucous per day.

 Diagnosis of sinus infections
 Diagnosis of sinus infections (called sinusitis) is made based on the symptoms and the physical examination.  Symptoms of a sinus infection include pain and pressure in the facial region or behind the eyes, fever, purulent  nasal discharge with increased post-nasal drainage and nasal congestion. If the infection is quite severe it can  lead to redness and swelling of the skin near the eyes. Headaches can of course be caused by many conditions  other than sinusitis, so it is important to try to confirm the diagnosis of a sinus infection

 Physical examination is useful, but it is difficult to actually see into the sinuses in someone who has not had  previous sinus surgery. In some cases one can actually see pus coming out of the sinuses, which confirms the  diagnosis.

Since the sinuses are difficult to see, the physician may rely on x-rays to help make the diagnosis. The simplest x-ray
is called a plain film and it shows some of the basic structures in the skull. However, to really get a good look at the
sinuses it is often necessary to get an imaging study called a CT scan. The picture to the right shows a CT scan of
normal sinuses. On this scan, the bone is white, and air shows up as black. In the healthy state the sinuses are filled
with air, and therefore will be totally black. The sinuses are normally lined by a thin layer of tissue called mucosa.
This mucosa should not be seen on the CT scan. With chronic sinusitis, there will be thickening on the mucosa and it
will show up as an abnormal gray area on the walls of the sinuses.


 The image to the left shows an example of someone with an acute  sinusitis. The red air is pointing to the patient's right maxillary sinus. (On a  CT scan, the patients right side is on the left side of the image). Notice that  this sinus is filled with a grey material, which probably is a combination of  mucous and pus. The sinus on the opposite side is completely black, indicating that it is filled with air  and therefore healthy. The tip of the red arrow is actually right near the natural opening of the maxillary  sinus. In his case, something is preventing the drainage of the debris and the sinus is therefore  infected.

 Treatment of Sinus Infections
 The first line of treatment for sinus infections is a combination of antibiotics and other medical measures.  There are many antibiotics available which are active against different types of bacteria. In addition to  antibiotics, oral decongestants like pseudoephridine (Sudafed) are useful. Nasal decongestants like  oxymetazoline (Afrin) may be effective for a short time, but should not be used for more than several  days. (Long term use of oxymetazoline can produce what is called a "rebound" effect; after stopping the medication the nasal mucosa becomes even more swollen.) If there is a history of allergies, anti-histamines may be useful.

In addition to these medicines, it is often helpful to irrigate the nasal cavity with a saline solution. This helps to keep the nasal mucosa moist and cleans the nasal cavity.

If sinus infections persist despite maximum medical treatment, surgery may be necessary.