Nasal Septoplasty: How It’s Done for those Curious Minds

Figure 1

Here's some fun stuff--surgery for the DIYer.  That was meant as a joke.  Seriously though, you shouldn't do this yourself or any self-surgery because unpleasant things such as pain and uncontrollable bleeding can occur leading to even more unpleasant things such as panic and death.  The last post (TheDeviated Nasal Septum, June 24, 2018) described the anatomy of the nasal septum.  Sometimes surgery is required to fix a deviated septum, called a nasal septoplasty, often referred to simply as “septoplasty,” where the suffix -plasty is medical lingo meaning “to mold or shape.”  As always, ask a surgeon to do surgery.

The prior post described some of the problems related to a deviated septum, but the main indication is for nasal obstruction—that is, difficulty breathing from the nose.  I usually recommend surgery based on how bothersome this is for the patient and if it significantly affects his/her quality of life.

The Procedure:
This often is a fun surgery and usually under general anesthesia since the sound of scraping and bone crunching inside one’s head is kind of unsettling, to say the least.  And so the majority of patients want to be “out completely, and don’t wake me up until it’s all done.”  After the patient is asleep, cotton pledgets with a dilute cocaine solution are placed inside the nose.  Yes, the same cocaine people snort for recreational purposes, but the medical form is much less concentrated and unfortunately won’t make you high.  Too bad.  Cocaine however has a dual purpose: it anesthetizes or numbs the inside of the nose but also decongests the tissues, meaning the mucosal tissues shrink down.  This allows better visualization and significantly reduces bleeding, as cocaine vasoconstricts (narrows) small blood vessels.  For surgery such as this, it’s a wonderful drug, and if used properly has little in the way of adverse side effects.

Anyway, don’t decided upon surgery just so you can get a little hit of cocaine, ‘cause you won’t experience what you’d think you’d experience if you were using the powdered, street stuff which is much stronger and also illegal, if you hadn’t known.  Keep yourself and your doctor out of trouble and don’t request a gallon of cocaine for your surgery (it only comes in little bottles and is diluted to a 4% strength).

After the cocaine is allowed to do its thing, lidocaine with epinephrine is injected deep to the mucosa and along the cartilage and bone of the septum.  This acts the same way as cocaine, allowing for additional numbing and vasoconstriction, but serves another cool purpose, creating an avascular plane, which allows for later lifting and separating of the soft tissue from the underlying cartilage and bone. 

An incision is made along the front (anterior) part of the mucosa covering the cartilage and a plane of dissection is identified (see Figure 1 at the top).  The mucosa is that moist pink tissue lining the inside of the nose (as well as the mouth, throat, etc) and secretes fluid and mucous to keep the inner nose moist.  Deep to the mucosa is a tough fibrous layer called the perichondrium, which is tightly adherent to the underlying cartilage.  This layer along with the overlying mucosa is collectively called the mucoperichondrium.  Once this plane is identified, it separates readily in most cases (unless there was prior trauma or prior surgery and thus dense scar tissue is encountered); this is made easier with the prior injection of lidocaine and epinephrine into this plane (Figure 2).  Figure 2 (and Figure 3 that follows) is a coronal view, or a slice through the frontal plane of the inner nose.  Notice the septum is deviated to the left and the mucoperichondrial flap is elevated off the right side of the septum.

Figure 2

This mucoperichondrial flap is then elevated from front to back (from anterior to posterior) until bone is encountered.  The junction between the cartilage and bone (known as the bony-cartilaginous junction and the reason medical training takes a long time so that ultra-long words like this can be said with a straight face) is then separated.  Then periosteum is encountered, which is the fibrous layer covering the bone, and mucoperiosteal flaps are elevated on both sides of the bony septum (Figure 3).  Cool, eh?  The deviated part of the bony septum is carefully removed with a variety of different instruments.  Since the bone of the septum for the most part sits more posteriorly, it does not provide structural support to the external nose, and thus as much bone as needed can be removed.

Figure 3

Once the required bone removal is done, the cartilage is allowed to swing back to the midline, much like a door hinged from above.  As much cartilage is preserved as possible, since it is more anteriorly and provides support to the external nose and contributes to some aspects of the shape and contour of the nose.  If the cartilage is significantly bent or curved, relaxing incisions are made on the concaved side of the cartilage in order to relax that curvature.

Once the septum is back in the midline, the incision is closed with an absorbable suture that usually falls out 1-2 weeks later.  The opposing flaps of tissue must be compressed together; otherwise, blood and fluid will form between them, causing a bulging and widening of the repaired tissue, leading to nasal obstruction and defeating the entire purpose of this surgery.  In the old days, this was accomplished by tightly packing 3 feet of ribbon gauze on each side of the nose in a layered fashion, which was removed a week later.  Patients couldn’t breathe at all from the nose and the pain and discomfort could be unbearable for some.  This was the worse part of the surgery.  Also, removing the gauze was very painful.  Nowadays, there are fortunately more comfortable methods to keep pressure on the septum, usually by means of thin plastic splints sewn through and through the septum (i.e. suture is placed from one side through the splint, septum and splint on the opposite side, and then passed again through the splint, septum and opposite splint and then tied into a tight knot) to keep it tightly in place (see Figure 4).  Think of the septum tightly sandwiched between these splints and you get the picture.  As Figure 4 shows, some splints have a semi-cylindric breathing tube that allows for better passage of air since the tissue of the nasal sidewalls often swells after surgery  and can lead to temporary nasal congestion or blockage. 

Figure 4

The splints are removed about a week later.  The nose is first sprayed with a decongestant and anesthetic spray to reduce discomfort.  The suture is cut and removed and the splints slide out.  This is far more comfortable and quicker than the old style packing.

After surgery (both with and later without the splints) patients need to keep the nose moist by gently spraying both sides with a nasal saline spray, 3 or more times a day.  Also, for about two weeks one should avoid any pressure to the nose, avoid manipulating it, and avoid vigorous nose blowing, heavy exertion, sports or exercise; otherwise, a severe nosebleed or disruption of the surgical repair can occur, not to mention a good deal of pain.

Many patients use a narcotic pain medication but often stop about 2-3 days postop (after surgery) using over-the-counter acetaminophen (Tylenol) instead.  Sometimes there is a bit of cartilaginous memory, where a residual curve is noted of the cartilage.  This often can be massage straighter with a cotton tipped applicator on follow-up appointments, and often this eventually becomes straighter as further healing and natural scar tissue forms.

Though there is no bone between the opposed mucoperiosteal flaps farther back in the nose, this tissue eventually scars and firms up with time.  A septoplasty results in a more normal, straighter partition between the left and right nasal passages, leading to easier nasal breathing.  Hope this helps.  Now go out and smell the roses.

©Randall S. Fong, M.D.


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