Deviated septum

In this article:

• Treatment
• Managing symptoms
• Surgical repair (septoplasty)
• What is new in nasal septum surgery?
• What is recovery like after septoplasty?
• Reshaping your nose
• Deviated Septum Surgery Risks
• References

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Treatment

It is important to see an ENT specialist to diagnose the septal deviation and establish the stage of deformity. This will allow you to make a correct decision about the deviated septum treatment. while many people can use only supportive and anti-allergy measures for years, others will need an urgent surgical correction of the problem. Only an expert can help you to decide which treatment is right in your case.

Managing symptoms

Small septal deviation is extremely common. For years you might not even know you got a deviated septum. Septal deformity can be an “accidental” discovery by an ENT or Allergy specialist during nose exam. 

Now, if you are already visiting a specialist, you must be having some health problems that bother you. Most common symptoms of the deviated septum are congestion, inability to breathe through one side of the nose, sinus headache and problems with breathing at night (snoring, apnea).

As one of the most frequent reasons for the deviated septum is allergy, it is important to treat allergic rhinitis. Even when the septum is surgically corrected, all symptoms may persist due to underlying allergic inflammation. Here are few suggestions for taking care of your nasal septum:

• Consultation with an Allergist is important to get a proper diagnosis and allergy test. then you will not what is responsible for your symptoms
• Take care of your indoor environment. HEPA filter, dust mite protection and good air ventilation to prevent excessive humidity and mold growth
• Control pet dander. Pet allergies are very frequent, but that does not mean you need to get rid of your dog or cat. There are plenty of things you can do to reduce shedding and vacuum it away. 
• Immunotherapy is the best way to treat allergy without medications. Talk to your Allergist if this treatment will work for you
• Nasal wash is safe and effective. Saline will wash away allergen particles and moisturize your nasal cavity.
• Nasal saline spray. This is a gel that can heal nasal ulcers by providing a protective coating of the mucus membranes.
• Nasal steroidal sprays are effective in treating inflammation and reducing swelling, which helps to breathe and may reduce the sleep breathing problems. While some sprays are over the counter (OTC), you should first talk to your doctor to see if you will need to use this medication and if it will work

Same measures are recommended to heal nose after the surgical correction of the septum (if it is necessary).

As the question of whether surgery is needed to treat deviated septum is sometimes controversial, and some doctors prefer to manage this problem only with supportive treatments and allergy control. There are ongoing trials that compare different type of approaches:

• Nasal Airway Obstruction Study (NAIROS): a phase III, open-label, mixed-methods, multicentre randomised controlled trial of septoplasty versus medical management of a septal deviation with nasal obstruction. (https://pubmed.ncbi.nlm.nih.gov/32054508/ )
• Effectiveness of septoplasty versus non-surgical management for nasal obstruction due to a deviated nasal septum in adults: study protocol for a randomized controlled trial. van Egmond MM, Rovers MM, Hendriks CT, van Heerbeek N.Trials. 2015 Nov 4;16:500. doi: 10.1186/s13063-015-1031-4.PMID: 26537948 Free PMC article. Clinical Trial.
• Septoplasty with or without concurrent turbinate surgery versus non-surgical management for nasal obstruction in adults with a deviated septum: a pragmatic, randomised controlled trial. van Egmond MMHT, Rovers MM, Hannink G, Hendriks CTM, van Heerbeek N.Lancet. 2019 Jul 27;394(10195):314-321. doi: 10.1016/S0140-6736(19)30354-X. Epub 2019 Jun 18.PMID: 31227374 Clinical Trial.
• A randomised trial comparing the subjective outcomes following septoplasty with or without inferior turbinoplasty. Samarei R, Mabarian S.Eur Ann Otorhinolaryngol Head Neck Dis. 2020 Sep;137(4):277-283. doi: 10.1016/j.anorl.2020.01.024. Epub 2020 May 29.PMID: 32482570 Clinical Trial.

Surgical repair (septoplasty)

Septoplasty (surgery to straighten a deviation in the nasal septum) is a frequently performed operation worldwide, with approximately 250,000 performed every year in the US and 22,000 in the UK. Most septoplasties are done to improve nasal obstruction (blockage).

Septoplasty is a standard treatment for deviated septum performed by most of the ENT surgeons. There are many different procedure variations used for individual cases. Basic technique is often adequate for individuals with mild to moderate mid to posterior septal deviation Unique challenges arise with caudal septal deviation. Anterior (frontal) septal reconstruction has been shown to be a safe and effective for severe caudal septal deviation.

Septoplasty can also be performed alongside or in addition to rhinoplasty, turbinoplasty, or as part of functional endoscopic sinus surgery for access. Operative recovery is usually a few weeks, and serious complications are rare. Appropriate patients must be selected for surgery to improve patient outcomes.

Post-operative outcomes are commonly evaluated by patient satisfaction, quality of life outcomes, and symptom improvement. It is difficult to evaluate symptom improvement, given it is often very subjective, and objective measurements do not always align with patient perception. 

Some studies have shown a decline in long-term outcomes for patients. One study showed that 26% of patients had no nasal obstruction after 9 years, by comparison to 51% 9 months post-operatively. Another study reported that 53% of patients were symptom-free at 6 months post-operatively, but only 18% remained symptom-free at 34 to 70 months. This may demonstrate that the effects of surgery are short-lived for some patients.

What is new in nasal septum surgery?

Doctors from the Department of Otolaryngology-Head and Neck Surgery Ulsan University Hospital, University of Ulsan College of Medicine Ulsan South Korea published a study describing a new procedure in 2021:

A novel surgical technique to correct caudal and high dorsal septal deviations: L-shape cutting and suturing on the septal L-strut (L-septoplasty). Tae-Hoon Lee, Tae-Koon Kim, Soon-Joon Kim, Jung Gwon Nam

This study aimed to develop a technique to correct the L-strut while preserving nasal support effectively and introduce the L-septoplasty technique and its effects. Patients with caudal and high dorsal septal deviations who underwent the L-septoplasty technique were retrospectively analyzed. Preoperative and three-month postoperative comparative assessments included the Nasal Obstruction Symptom Evaluation (NOSE) scale and minimal cross-sectional area (MCA). 

Results: Thirty patients seen at a tertiary care center were included. NOSE scale scores improved from 47.2 to 13.6, which was statistically significant (P < .001). MCA increased from 0.43 cm2 to 0.74 cm2 (P < .001). During the 3-month follow-up period, deviation correction was well maintained in all patients, and no surgical complications, such as saddle nose deformity, occurred.

Conclusion: The L-septoplasty technique is effective in simultaneously correcting caudal and high dorsal septal deviations without any complications.

 Here is another study published in 2019. It fully describes the technique and results of the novel method that reduces complications:

A novel and cost-effective technique for securing the nasal septum to the anterior nasal spine in septoplasty and/or rhinoplasty surgery. Bhamra N, Darr A, Neamonitou F, Barraclough J.JPRAS Open. 2019 Jul 3;21:43-47. doi: 10.1016/j.jpra.2019.06.001. eCollection 2019 Sep.PMID: 32158885 Free PMC article.

What is recovery like after septoplasty?

The recovery after the septoplasty can take from one week to 2 months. It all depends on the complexity of the surgery. Nowadays the simple septum correction may be done outpatient, and it takes few days to feel fine. It is always a good idea to talk to your surgeon to get an estimated recovery time after the septoplasty. 

As nose is a central part of your face, you might want to take few weeks off, just to make sure the swelling and redness goes away. The surgery can be usually scheduled to fit your work/vacation plans. In some situations, there is no time to wait – that is usually the case for the broken nose and in children.

Get prepared for the pain control and some nasal bleeding. You will be scheduled for frequent visits with the surgeon to have a nasal septum examined and cleaned. If you have excessive bleeding, you will be given directions what to do, and when to go to the ER (if bleeding cannot be stopped).

The nasal toilet is important. Usually, an ENT practitioner will give you precise directions, including a nasal packing, nasal wash and nasal care.

The healing of the nasal septum continues for 3-6 months following the surgery. So, you will need to schedule follow-up appointments with the ENT clinic to make sure there are no complications.

Also, if your initial symptoms did not resolve or returned after the surgery, you may need to see other specialists. Sometimes, it is important to cure allergies in order to restore a normal breathing and avoid symptoms coming back in a long run.

Reshaping your nose

Nasal plastic procedure can be performed for medical reasons (it qualifies for insurance coverage as a medically necessary procedure), or for personal reasons (a person dislikes the shape of the nose). While in many situations the decision to change nose shape is justified, it is important to realize that the whole image of the face will shape.

There is no “redo it back” after surgery is done and healed, as it may be associated with severe complications. So, think twice before you decide. Even when it is approved by the doctor as a recommended treatment, it is important to consider all pros and cons. Sometimes it is not a bad idea to get couple of opinions from surgical experts.

On the other hand, some septal deformities are so prominent that they affect nasal breathing and quality of life. Then it is time to schedule the surgery and prepare for recovery period.

Here is an article describing the results of one type of the surgery to correct a significant septal deformity:

Role of Extracorporeal Septoplasty in Deviated Noses Virendra Ghaisas, Sapna Ramkrishna Parab

Severe gross septal deviations present big surgical challenges for operating surgeon. Septal deviations has direct effect on aesthetic and functional part of nose. Correcting septal deviations during rhinoplasty is basic procedure. 

Extreme deviations of septum especially on dorsal and caudal end of cartilaginous septum are difficult to treat. The classical septoplasty approach becomes unsuitable for such severe deviations. Gubisch has first reported in 1995 about extracorporeal septoplasty. 

To report the experience of Extracorporeal septoplasty and the complication rates with the technique. Retrospective study of 112 patients who underwent extracorporeal septoplasty in primary rhinoplasty from May 2009 to June 2014. Patient’s pre and postoperatively evaluation was done by photographs, nasal endoscopy and subjective by symptoms evaluation satisfaction scale 6 and 12 months postoperatively. 

Nasal endoscopy revealed significant improvement in nasal airway and nasal valve and subjective evaluation satisfaction score was very encouraging. Complications like septal perforation, bleeding, aesthetic complications were minimal (9%). On basis of results obtained, shows that this technique, increases patients nasal airway and aesthetic look of the patients.

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Deviated Septum Surgery Risks

Several complications may occur due to septoplasty procedures, so your surgeon will fully describe and explain all possible risks. The most common problems are:

• excessive bleeding; some oozing is expected, but more extensive bleeding can be managed by nasal packing and may require cautery in rare circumstances. 
• Septal hematomas can occur where bleeding occurs beneath the mucus membrane. This will need to be drained to prevent a septal perforation. 
• Perforations can also occur due to bilateral mucosal perforations intra-operatively, causing reduced vascular supply; if a perforation causes dorsal collapse, then a saddle nose deformity may develop, and this will inevitably require revision surgery.
• Infection, blocked nose, and prolonged healing can occur in a proportion of patients. This can be treated with antibiotics, and the vast majority of patients will have a full recovery within a few weeks. 
• Hyposmia has been described in some patients (more frequently with concurrent turboplasty procedures; this usually resolves within 6 months
•  Intranasal adhesions can occur, but the use of silastic splints minimizes the risk of this. 
• Patients may experience numbness to the upper teeth or lips due to accidental nerve damage; this is usually short-lived, and normal sensation returns within a few months.

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References

Septoplasty. Watters C, Brar S, Yapa S.2020 Dec 23. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan–.PMID: 33620795 Free Books & Documents. Review.

The Role of Extracorporeal Septoplasty in Severely Deviated Nasal Septum. Baser B, Patel DK, Mishra A.Indian J Otolaryngol Head Neck Surg. 2019 Jun;71(2):271-277. doi: 10.1007/s12070-017-1237-8. Epub 2017 Nov 28.PMID: 31275843 Free PMC article.

Nasal septal deviation and external nasal deformity: a correlative study of 100 cases. Sam A, Deshmukh PT, Patil C, Jain S, Patil R.Indian J Otolaryngol Head Neck Surg. 2012 Dec;64(4):312-8. doi: 10.1007/s12070-011-0311-x. Epub 2011 Oct 5.PMID: 24294569 Free PMC article.

Effect of non-surgical maxillary expansion on the nasal septum deviation: a systematic review. Aziz T, Ansari K, Lagravere MO, Major MP, Flores-Mir C.Prog Orthod. 2015;16:15. doi: 10.1186/s40510-015-0084-y. Epub 2015 Jun 4.PMID: 26061988 Free PMC article. Review.

Effect of septoplasty on left ventricular myocardial performance in patients with nasal septum deviation. Kaya H, Kurt E, Koparal M, Tibilli H, Hosoglu Y, Kafadar S, Suner A, Türkmen S.Braz J Otorhinolaryngol. 2020 Sep 26:S1808-8694(20)30151-8. doi: 10.1016/j.bjorl.2020.08.004. Online ahead of print.PMID: 33067133 Free article.