An Insider’s Guide to Septoplasty

March 25, 2010

The septoplasty operation is one of the most misunderstood surgical procedures that lay people, and even many physicians have. Some people even equate septoplasty with having a nose job, which is not true. Although, some people use having a crooked septum as

an excuse to undergo a rhinoplasty, septoplasty, done correctly, can help patients breathe better, and more importantly, sleep better.

Understanding the Anatomy

In order to fully appreciate if septoplasty is the right procedure for you, you must understand the anatomy of how it’s done.

The nasal septum is the midline cartilaginous structure that divides the two halves of your nasal cavity. The part in the back of the septum is made of bone. Whenever the septum is crooked to a significant degree, your nose can be stuffy, and a septoplasty can be offered if medical therapy doesn't work.

However, having a crooked septum doesn't mean that you'll have a stuffy nose, or that you'll need a septoplasty. No one has a perfectly straight septum. There are other parts of your nasal anatomy that contributes to your ability to breathe, which includes your nasal turbinates and your nostrils. The turbinates are wing-like structures that jut in from the side-walls of your nose that look like wings. They normally warm, filter, smooth and humidify the air that you breathe. Inside this structure is the bone and the outside is a mucous membrane lining. The middle part is made of very vascular tissues that can swell tremendously when filled with blood. This is regulated by your involuntary nervous system. This nervous system normally swells and shrinks the turbinates, alternating from side to side, every few hours (called the nasal cycle).

Do You Have Flimsy Nostrils?

The other structure that is often overlooked is your nostrils. For most people, breathing in causes a mild vacuum effect that causes a mild collapse and a constriction of the nostrils. But in some people with either flimsy or weakened nostrils (from a prior rhinoplasty), they collapse very easily, even with a slight bit of inspiration. If you are one of these people, you may benefit from nasal dilator strips (Breathe-rite is one brand). Sometimes these strips are not strong enough, or it can irritate the skin. Another option is to use internal nasal dilators which work much better. Some of the more common brands are Breathewitheez, Nasal Cones, and Nozovent.

What's Involved with Septal Surgery?

The septoplasty procedure can be done in conjunction with a turbinate procedure. There are many ways to perform a septoplasty, but the most important point is that it should be done well. The septum is covered on both sides by a mucous membrane. After an incision is made inside the nose on the mucous membrane, this layer is peeled away from the septal cartilage. The other side is also entered, which creates two tunnels on either side of the septal cartilage. The crooked part of the septal cartilage is next removed. Some surgeons either soften the cartilage or flatten it out and place it back, and others leave it out completely. In many cases, a small portion of bony spur that juts out at the base of the septal cartilage is also removed. The last part of the operation is where different surgeons use different techniques. Traditionally, thin plastic sheets with or without soft sponge-like packs are placed against the septum on both sides to keep the mucous membrane together for proper healing. If a large clot of blood forms between the two mucous membrane layers, the remaining cartilage may lose it's blood supply and literally melt away.

Because the entire procedure in done inside the nose (or endoscopically), there is no swelling, bruising or changes to the outside of the nose or face (unless a rhinoplasty is done simultaneously).

What to Expect After Surgery

Nasal packing, if placed, are removed anywhere from 1-3 days after the procedure. Many patients report that this is one of the most uncomfortable parts of undergoing this procedure. Some surgeons, like myself, don't use any packs or splints using the following method: compressing the two mucous membrane layers by sewing the two layers together using an absorbable suture, like a quilting stitch. This way, nothing needs to be removed, and you're breathing much better right after the surgery. It's expected with this procedure that your nose will get clogged up after a day or two with accumulation of blood, mucous and debris.

This operation is usually performed as an outpatient procedure, so you'll go home a few hours after surgery. It's usually performed under general anesthesia, but can also de done under local anesthesia with sedation for certain situations. Most people can go back to work after a day or two. Heavy straining or lifting should be restricted for about one week. In my practice, I see the patients about 2 days after the surgery, when the nose is cleaned of all the accumulated debris. Some people need a second cleaning 1-2 weeks later.

Typically, it may take a few weeks to months to feel the full benefits of this operation. During the first few weeks, crusts will build up and fall out as wounds heal. This is also the time when the swelling from the surgery goes away. Afterwards, scarring and tightening of the soft tissues can take weeks to months. You may have your ups and downs in the first few weeks, but you should see consistent improvement by 3-4 weeks.

Most people don't use any pain medications, but one is prescribed just in case. You'll probably be more bothered by the sore throat from having a breathing tube placed during intubation.

What Are The Risks?

Complications are rare, but with any surgical procedure, there is a small chance of infection or bleeding. There is also a small risk any time someone undergoes general anesthesia, which includes, allergic or medication reactions or airway problems. In terms of overall risk, it's riskier when you cross the street. Other very rare complications such as smell loss or a hole in your septum have been reported.

A septoplasty, if done properly, is one of the most gratifying procedures for both the patient and the surgeon. Success rates are very high. However, there are a few percent of patients where nasal congestion still persists, or it comes back after a few weeks to months. In this situation, there are two main possible reasons: there is persistent turbinate swelling due to inflammation, or you have flimsy nostrils. There are treatment options for both theses conditions.

Written by Steven Park · Filed Under Articles, obstructive sleep apnea, Sleep Apnea Surgery, Sleep Health | 2 Comments

Health Consequences of Routine Medical Procedures

January 28, 2010

The New York Times recently ran an exposé on the lack of quality control systems that have lead to a surprisingly high number of radiation overdoses, in some cases leading to death. This reminded me of what they used to do in the 1950s to 60s, where they used x-rays to treat everything from pimples to large tonsils to ringworm. Many women's ovaries were irradiated for depression. What they did in the past may seem barbaric by today's standards, but I'm confident that many of the things we do today may seem barbaric to future generations.

There are two procedures that are still being routinely performed that have negative consequences years, if not decades later, and these are rhinoplasty, and dental extractions for orthodontic work. I see at least 4-5 patients a week that come to see me for routine problems, only to find that their "routine" procedure 10 to 25 years ago probably aggravated their current condition.

During routine rhinoplasty, especially when you're trying to narrow a wide tip, surgeons by definition have to weaken or remove a portion of the support structures (or cartilages) that keep the nostrils open. Current surgical methods take this into consideration to compensate for this fact, but many surgeons are still weakening the lower lateral cartilages without strengthening the remaining structures. This leads to flimsy nostrils that cave in with every inspiration.

As a result of this weakening, patients will have stuffy noses, unrelieved by allergy medications or decongestants. Medicines won't work for structural problems. Sometimes, someone with this condition accidentally tries a Breathe Rite nasal dilator strip, and swears by how wonderful it is.

Dental extractions are still being performed as part of routine orthodontic treatment. If there's too little space for the teeth, then it's logical that removing a few teeth can create enough space for the remaining teeth, right? What's missed entirely is that the jaw's too small. The teeth, especially the molars, act as support structures for the soft tissues of the throat. Once removed, the space behind the tongue collapses, leading to significantly lessened quality of sleep. Even simple orthodontic adjustments can have a major impact on sleep quality, since the space that that the tongue is contained in can change dramatically.

Fortunately, forward-thinking dentists are recognizing the fact that the position of your teeth and size of your jaws have a major impact on your breathing, and your health. Some of these dentists have leapfrogged ahead of the medical profession in terms of understanding the holistic implications of proper facial form and function.

Did you have rhinoplasty years ago, only to have continued nasal congestion, or did you undergo dental extractions before undergoing braces? If so, please describe your experience below.

Written by Steven Park · Filed Under Blog | 1 Comment

Attention All Mouth Breathers – 5 Important Reasons Why You Must Breathe Through Your Nose

December 1, 2009

If you’re a chronic mouth breather because of a stuffy nose, you’re not alone. As the weather chills and allergies and colds abound, and nasal congestion becomes a common trend, mouth breathing inevitably follows-especially when you’re sleeping. I’m sure you’ve seen many passengers asleep on the subways and trains, head and pitched back, mouth wide open, and snoring louder than a diesel engine. Mouth breathing can surely ruin your social image, but that’s nothing compared to the havoc it can wreak on your health.

5 Potent Benefits of Breathing through Your nose

One of the most important reasons to breathe through your nose is because of a gas called nitric oxide that’s made by your nose and sinus mucous membranes. This gas is produced in small amounts, but when inhaled into the lungs, it significantly enhances your lung’s capacity to absorb oxygen, increasing oxygen absorption in your lungs by 10-25%. Nitric oxide also can kill bacteria, viruses and other germs. This is why you often hear fitness and yoga instructors emphasize inhaling and exhaling through your nose during workouts.

Also, if you can’t breathe well through your nose, your sense of smell will suffer and therefore your sense of taste, since your smell and taste buds are connected. This can lead to disturbances in your appetite and satiation levels, wreaking havoc on those struggling with weight issues.

Your nose also has vital nervous system connections to your lungs and heart. Not breathing well through your nose can alter your heart rate and blood pressure, as well as increase your stress responses.

Your nose makes about 2 pints of mucous every day. If your nose isn’t working properly and mucous isn’t cleared, the stagnant mucous can lead to infections such as sinusitis or ear infections, not to mention bad breath.

Lastly, not breathing well through your nose can aggravate snoring or obstructive sleep apnea. Nasal congestion alone doesn’t cause obstructive sleep apnea, but it can definitely aggravate it. If your palate and tongue structures are predisposed to falling back easily due to sleeping on your back and muscle relaxation in deep sleep, then having a stuffy nose can aggravate further collapse downstream. Untreated obstructive sleep apnea can lead to chronic fatigue, depression, anxiety, weight gain, high blood pressure, heart disease, heart attack and stroke.

Knowing all these benefits of breathing through your nose, however, doesn’t help much if you don’t know why you’re not able to do so. To stop mouth breathing, the first thing you must do is to figure out what’s blocking up your nose.

What Can Stop Up Your Nose

Nasal congestion is something everyone experiences now and again. Yet, if you’re trying to prevent this from happening it’s important to explore the various reasons behind why and when this occurs.

Here are five of the most common reasons for a stuffy nose:

"I Have a Deviated Septum"

By definition everyone has a slightly crooked (deviated) nasal septum. There are various reasons for having a deviated septum, including trauma, but the most common reason is no reason at all. It’s just the way your nose developed. What’s more important than how deviated your septum is is what’s happening in front of an around your septum.

Wings in Your Nose

Turbinates are wing-like structures that attach to the sidewalls of the nasal cavity, opposite the midline nasal septum. They normally smooth, warm, humidify, and filter the air that you breathe, but they also become enlarged and produce mucous when inflamed. Turbinates also swell and shrink alternating from side to side, which is a normal neurologic process called the nasal cycle.

Is It An Infection or Allergies?

If you have allergies, a cold or any kind of infection, then your turbinates will swell up, clogging your nose with lots of mucous production. Contrary to popular belief, the color of the mucous has no relation to bacterial vs. viral infections.

Flimsy Nostrils

Once you have inflammation and swelling inside your nose, for some people, depending on the configuration of your nose, your nostrils can literally cave in as you inhale. Different noses have differently shaped nostrils with various nostril thicknesses. The more narrow your nose, the more likely your nostrils can cave in. People who undergo cosmetic rhinoplasty are more at risk years later, since narrowing the nose can weaken the support structures of the nose.

A Nervous Nose?

Some people’s noses are extra sensitive, especially to weather changes, like temperature, humidity, and pressure changes. Certain chemicals, scents and odors can set off a reaction as well. Many people mistakenly think this reaction is an allergy, but it’s really your nasal nervous system over-reacting to the weather or to odors. One of the most common reasons is from poor quality sleep, which causes a low-grade stress response, which can heighten your senses.

It’s All Under Your Nose

A chronically stuffy nose doesn’t happen by itself. Usually it’s part of a bigger picture, where the entire upper and lower jaws are more narrow and constricted, in addition to more narrow nasal cavities. I’ve described this process in my book, Sleep Interrupted, where due to modern human’s eating soft, mushy, processed foods, our jaws are much more narrow than normal, with dental crowding. Bottle-feeding, which is another modern, Western phenomenon, is also thought to aggravate this problem.

If you have a stuffy nose, it can also aggravate soft palate and tongue collapse when in deep sleep, due to muscle relaxation. With more obstruction, more stomach juices are suctioned up into the throat and nose, causing more swelling and more nasal congestion. All this from smaller and more narrow jaws.

Written by Steven Park · Filed Under Articles, obstructive sleep apnea, Sleep Health | 13 Comments