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Septoplasty Without Packings Or Splints

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.

 

Ask Dr. Park: How To Clear Your Stuffy Nose (5/10/11)

In this Ask Dr. Park teleseminar, I answer your questions about how to clear your stuffy nose. Here are some topics I’ll cover:

- How to clear your stuffy nose

- The real reason why allergies can ruin your sleep

- The truth about septoplasty and what you must know before any nasal surgery

- Turbinates: The forgotten nasal structure

- Why your sinus pain and headache may not be an infection

- Do Breathe Right Strips work?

- Nasal saline irrigation: Helpful or hurtful?

- Nasal problems with CPAP

 

Click here to order the MP3 recording ($17)

No Packing Septoplasty: Is It Possible?

When I was 6 years old, I was broke my nose while trying to see how far I could jump off a swing. After my nose was reset in the operating room, my nose was completely stuffed. I do remember it being very uncomfortable and did have trouble sleeping. During my one week post-op visit, I was shocked when my surgeon puled out 3-4 feet of gauze packs from each nostril.

When patients hear about a septoplasty procedure, one of the first things that come to mind is the miserable feeling of having your nose packed for a few days after the procedure and the extreme discomfort and pain when the packs have to be removed.

When I first began in private practice about 12 years ago, I did what I was taught to do by more senior surgeons during training: I packed the nose routinely after a septoplasty procedure. The reason for using packing is to prevent blood from accumulating between the two layers of the mucous membrane. If the blood supply to the remaining septum is disrupted, then the entire cartilaginous septum can literally melt away, and your nasal tip can droop later on. I've even seen a few septal hematomas after nasal packings were removed during residency training. Ever since I began avoiding using any sort of nasal packing, I've yet to see a septal hematoma. 

Besides the discomfort issue, the other main reason for doing this is that I realized that blocking your nose even to a small degree can aggravate apneas. Studies have shown that nasal congestion can significantly increase your rate of obstructions and arousals. 

What's my technique? I use a small needle and a quilting suture to go back and forth from one side to the other. This quilting suture is what keeps the mucous membrane layer pressed together. I don't even use splints or silastic sheets. It takes some extra time to do, but it's well worth it for the patient's sake. I'm not the first one to use this technique, and I'm sure that there may be other surgeons that do this, but so far, I haven't personally met any. 

If you underwent a septoplasty procedure in the past, what was your experience? Was your nose packed?

Ask Dr. Park: How to Unstuff Your Stuffy Nose

In this Ask Dr. Park teleseminar, I answer one of the most common questions I get in general, which is, "How can I breathe better through my nose?" 

In this 60 minute live teleseminar, I'll reveal:

- The one thing that most doctors miss

- Why not breathing through your nose can drop your oxygen intake by 20%

- Myths and truths about septoplasty

- How nasal saline can be helpful AND harmful

- How your nose affects snoring and obstructive sleep apnea

- And much more.

Click here to purchase the 65 minute mp3 download.

An Insider’s Guide to Septoplasty

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.

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