Septoplasty Without Packings Or Splints
June 12, 2011
One of the most uncomfortable things you can do to another person is to place nasal packs in their nose after nasal surgery. What’s even worse is when you have to take it out. I know what it feels like, as I had nasal packs after I broke my nose when I was six. I still remember waking up after surgery, with my nose completely stuffed up, and my sleep was terrible.
Unfortunately, ENT surgeons still routinely use nasal packing after nasal surgery, especially during septoplasty. The reason why packing is used is due to a combination of of the nature of the surgery and tradition: The mucous membrane layer on both sides of the midline cartilaginous septum is peeled off, and the deviated portion of the cartilage or bone is removed. Next, the mucous membrane layers are placed back together in the midline. Packs (either long gauge strips or an expandable absorbent sponge are placed on either side of the septum, to compress the mucous membrane layers together. Since cartilage doesn’t have blood vessels for nutrition, it has to receive its’ nutrient supply from diffusion and osmosis from the inner walls of the mucous membrane layers. If you have a blood clot that separates the two mucous membrane layers, nutrient flow to the remaining cartilage will be shut off, and the cartilage will die off, leading to a drooping of your nasal tip.
So if you don’t use nasal packs, what else can you do? Some surgeons place two plastic or silastic sheets in the nose next to the septum, and then tie the two splints together in the front through the nasal septum. You still have to put something in your nose to press the silastic sheets together. Some use rolled up Telfa pads (the nonstick surface that you see on Band Aids), and others place packing around the splints. Most surgeons take out the splints or packing after 2-3 days, but some leave it in up to 7 days.
Many years ago, I came across a paper showing that if you plug healthy college students’ noses and put them through a sleep study, you’ll see apneas. Another study showed that in patients without sleep apnea who undergo nasal packing for nasal or sinus surgery, the AHI increased from 11 to 37, and for patients with sleep apnea, 14 to 39. It’s interesting to note that patients without sleep apnea who need to undergo nasal surgery have mild underlying obstructive sleep apnea. This is in line with a study I performed many years ago showing that up to 80% of people who undergo nasal or sinus surgery and have recurrent or persistent symptoms have significant obstructive sleep apnea.
As I began to realize how important nasal breathing is to the quality of your sleep, I came to the conclusion that nasal packing was sure to cause apneas. If your septum is deviated, by definition, you’re going to be at a much higher risk of having jaw structures that predispose to obstructive sleep apnea. Total nasal congestion can only make things worse. This is also why even if you’re “normal”, having a stuffy nose from a cold or allergies makes you toss and turn more at night—it’s because you stop breathing more often. These obstructions don’t even have to be apneas or hypopneas—they can be short periods of obstruction that still wake you up multiple times per hour.
You’re probably wondering by now how I get away with not using any nasal packs or splints. It’s very simple: After removing the deviated cartilage or bone, I use a little 1/2 inch needle with a dissolvable chromic suture (stitch) and perform a quilting suture, back and forth from one side of the nose to the other, in a zig-zag manner, until all the areas of separated mucous membranes are closed together. In most cases, I do a very conservative shrinking procedures on the nasal turbinates, so there’s little to no risk of scar tissue connecting the raw surfaces of the septum and the turbinates. Some people also need their flimsy nostrils stiffened as well.
When you wake up from anesthesia, you’re breathing really well. But after a few days, it’s expected to get stuffy again, since all the blood, mucous and secretions will block your nose. You’ll go home a few hours after surgery. Two to three days later, I’ll see patients in the office for a 2 minute “cleaning”, after which you can breathe much better again. Most people can go back to work after 2-3 days, and about 2/3 of patients don’t even take any prescription pain medications.
Contrary to conventional perceptions of the misery of undergoing a septoplasty procedure, there are now ways of minimizing pain and discomfort. Surgery is never a walk in the park, but well worth the ability to breathe clearly through your nose again.
11 Responses to “Septoplasty Without Packings Or Splints”
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I totally agree with your first sentence. I had septoplasty + turbinates reduction a few months ago, and removing the packing was the worst part of the whole procedure which would put me off ever having a nasal op ever again :( I’d asked my surgeon if he could do the surgery without the packing, but he said he wouldn’t be happy to, especially with me being on CPAP as there’s no knowing where the blood would end up! Wish you could have done my surgery Dr Park ;)
Dear Dr Park,
I recently underwent a revision septoplasty and turbiniplasty and am recovering well. However, I still believe a significant aspect of my breathing difficulties is due to the effects of the interior structure of my right hand nasal ridge – I’m not sure what you call it – but it is a part of your skull. This seems to protrude, partially obstructing my airway on my right nostril so you end up with a ‘half moon’ shape which is clearly visible under bright light in front of a mirror. I would appreciate your comment on this (unusual?) ailment.
My surgoen (a different one) was much more thorough in what he did this time and I am recovering much better than on the first attempt. Also, there was no packing used but I have stitches in my nose. Nonetheless, the above problem persists and when I have mentioned it, it has been brushed aside in favour of dealing with my turbinates and nasal septum. Whilst these two things have been (rightly, I feel) dealt with, this to my mind does not preclude the possibility of my nose bones’ interior being at fault. I would welcome your thoughts on the matter.
Many thanks,
Charles
Charles,
It sounds like you may have a combination nasal bone/nasal valve collapse issue. I can’t say which one you may have (or it could be both), but wait until you’re completely healed from your last procedure and see if you need to pursue this further. Technically, it’s fixable. Good luck.
Dr. Park, I think the discomfort has been exaggerated. I had septoplasty last year with an older, very traditional doctor who left the packing in for 5 days. It was quite uncomfortable, and prevented me from doing anything but watch movies and listen to audiobooks, but it was not unbearable or particularly painful. I have since talked to at least one person who has refused the surgery because he was afraid of the packing, and this is sad. Really, it’s not that bad.
Joel,
Yes, there are some lucky people like you that do well with nasal packs, but for the majority, it’s an unpleasant experience. Plus it can also worsen any underlying sleep apnea.
G’day Dr. Park,
I just read your downloadable information Re: The truth about Sleep Apnea surgery…..
I am 36yrs old 177 cm’s and 84 kilos.
I totally agree on the confusion factor. I have read many posts and have found only negatives in regards to UPPP. My AHI is 39 My Uvula is long (basically hitting my tongue…tonsils are enlarged but not severely….. My girlfriend kicks me out of bed every second night as I snore like a chainsaw….. I have yet to try and reluctant to try CPAP or a Dental device….
My question is….Would it be worth my deviated septum (many hits due to playing Australian rules football) being repaired first to see how that goes? or having my tonsils removed and my Uvula “trimmed” but not fully removed and not go as far as Palatal surgery??
Thanks for your advice
Regards,
Justin.
Melbourne, Australia
Jutin,
Unfortunately, doing a septoplasty alone is unlikely to cure your sleep apnea, since there are two other areas of collapse (soft palate and tongue). Even if you do undergo a formal UPPP (which includes tonsillectomy), your potential success rate is still only 40%. However, opening up your nose can help with CPAP or oral appliance use. Good luck.
I recently had a septorhinoplasy with turbinate reduction. The packing was absolutely unbearable even with my Tylenol codeine. I have never felt so badly and I gave birth without drugs. The packing my doctor used seemed to dry and stiffen up such that it felt like there were twisted metal rods shoved deep into my sore and swollen face and back into my head. My doctor took them out the next morning at my tearful pleading and I haven’t taken pain medication since. The relief was incredible. I really love my doctor but I would highly recommend that you demand no packing or find a surgeon that doesn’t use it. It’s awful!!
Hi
i had a sepoplasty 2 days ago and was told i had no packing or stitches how can this be im really confused?
Thanks
Hi Dr. I have a question, Im a highly allergic to epinephrine and need a deviated septum fixed, as it is causing me pain to the left side of my face and trouble breathing. Can doctors use something besides this? I also suffer with hyperthyroidism and panic attacks. Please comment. Thank You
Hi,
The septoplasty surgery can be done inside the nose, through the nostril. Typically, there will be no visible scars after surgery. During the septoplasty surgery in New York, the mucosa lining of the septum is carefully separated from the septum. The septum is repositioned or trimmed and then the mucosa lining is carefully replaced. It takes about two weeks for the swelling of the nose to diminish.