Nasal Obstruction: Septoplasty & Turbinate Reduction

What is the nasal septum?

The nasal septum is a partition made of cartilage and bone that divides the right nasal cavity from the left nasal cavity. The septum is usually straight and lies in the centre of the nose. A deviated septum is an abnormal bend in this partition and this may cause problems with nasal breathing and/or nasal discharge. It may be caused by an injury or birth defect. Inside the nose, the side walls contain small horizontal bones (turbinate) that are lined with nasal tissue. It is important to note that the nose goes through a natural cycle in which the nasal lining of the turbinates on one side (and then the other) slowly expands and contracts. These cycles occur every several hours and may lead to the perception of the nasal obstruction being intermittent and/or changing sides.

Medical treatment of nasal obstruction

In some patients allergy, infection or other irritants may cause the nasal lining to swell and produce nasal obstruction. If there is already a deviated septum or large turbinates, a small amount of swelling can produce symptoms. On the other hand, if the swelling can be reduced with medication, this may be enough to avoid surgery. Thus a trial of medical therapy will often be suggested by Dr Becvarovski.

May consist of:

• Nasal Decongestants: Decongestants should NOT be used for more than 5 days because congestion can actually become worse when using these sprays for a long period of time. If you have high blood pressure or other medical problems contact your family doctor first.
• Salt Water irrigation
• Steroid Nasal Spray: (NASONEX, or RHINOCORT, or BECONASE)

What is a septoplasty?

A septoplasty is an operation in which the nasal septum is straightened. Septoplasty aims to reposition rather than remove the deviated septum, thus allowing strength and support of the nasal framework to be maintained.

When there is a septal deviation there is invariably an associated swelling of tissue arising from the side walls of the nose (the turbinates). Commonly partial removal of this swelling ‑ known as turbinectomy or turbinate reduction (diathermy and/or resection)‑ is combined with the septoplasty operation.

What are the indications for a septoplasty?

A small number of people actually have a perfectly straight midline septum, but in most cases the amount of bending is not large enough to be a problem. A septoplasty is performed if the septum is so bent that it obstructs the breathing or interferes with the drainage of the sinuses, (leading to repeated sinus infections). In some cases the septum may need to be straightened in patients undergoing sinus surgery just so that the instruments needed for the surgery can fit into the nasal cavity.

Pre-operative Care

• DO NOT TAKE ASPIRIN OR ASPIRIN RELATED MEDICATION IN THE 14 DAYS PRIOR TO SURGERY (NB: PANADOL, PANADEINE and PANADEINE FORTE can be taken) - see Back Page– Medications to Avoid
• DO NOT CONSUME ALCOHOL 10 DAYS PRIOR TO SURGERY
• IF YOU HAVE NOSE OR SINUS X-RAYS YOU MUST BRING THESE TO THE HOSPITAL
• You must be adequately fasted on admission to hospital. See pre-admission details.

The Surgery

Septoplasty:

The operation is performed under general anaesthesia. Depending on the complexity of the deviation, the operation may take approximately 1-1.5 hours. The surgery is performed inside the nasal cavity usually with no external incisions. The incisions are hidden from sight just inside the nose. Consequently the area just beneath the tip of the nose is often most tender. Badly deviated portions of the septum may be removed entirely, or they may be removed, readjusted, and reinserted into the nose. Occasionally a thin Teflon plate (known as a splint) may be placed in the nose at the time of surgery to avoid contact and scarring between the septum (central partition) and side walls. This usually stays in place for 4 ‑ 6 days. If the tip area of the nose is widened or lacks support, cartilage from the septum is used to support the nasal tip (tip‑plasty).

Turbinate Reduction:

The turbinates are reduced by diathermy (or cautery) or by cutting excess tissue &/or bone. Diathermy or cautery cause scarring of the tissue thus preventing it from swelling. An out-fracture (or pushing outwards to the side) may be performed at the same time to increase the nasal passage.

At the end of the procedure nasal packing is usually required (this depends on the amount of bleeding).

Post-operative Care

While in hospital

Post-operative pain may require an injection but it is usually only mild by the next day. The degree of pain and headache is variable and unpredictable. Blood will be swallowed after the operation and this may cause some nausea and sometimes vomiting of old blood in the first day after surgery. Most patients will be discharged from hospital on the first or second post-operative day.

Packing placed during the operation within the nose will be removed the next morning before discharge from hospital. There will be a small amount of bleeding at this time. Most patients are up and around within a few days and able to return to work in approximately one week.

After discharge

If splints have been used, you will leave hospital with these still inside the nose and these will be removed in the rooms in 4 ‑ 6 days. The nose will be blocked and runny whilst the splints are in place. There may be some blood staining of the mucus during this time. If the discharge becomes purulent, contact this office or the St George Hospital (T: 9350 1111) after hours. Removal of splints is generally straight forward and because they are made of Teflon they do not stick to the nasal tissue. Breathing improves substantially when the splints are removed in the rooms, but gradual improvement will continue for up to 6 weeks after surgery.

May consist of:

• Nasal douching
• Nasal ointment
• Antibiotics

• Seven days are required off work. No heavy lifting or straining for 2 weeks after discharge. (Sitting in a chair/bed for the first 3-4 days is recommended, then short walks after this)
• Avoid running hot water onto your face during showers for a prolonged period of time.
• Avoid hot drinks in the first few days (Stick to a cool diet).
• PANADOL OR PANADEINE CAN BE TAKEN FOR PAIN.
• DO NOT TAKE ASPIRIN OR ASPIRIN RELATED MEDICATION FOR 3 WEEKS FOLLOWING SURGERY (see Back Page– Medications to Avoid)

Complications of Septoplasty and/or Turbinate reduction surgery

1. Bleeding (intra‑operative and post operative)…small amount - COMMON. Profuse bleeding may require nasal packing, return to theatre, or blood transfusion – UNCOMMON.
2. Collection of blood (haematoma) within the septum. This may need drainage.- UNCOMMON.
3. Septal perforation. A communication through a hole in the septum from one side of the nose to the other. This may cause nasal crusting or interfere with breathing through the nose and could cause the front portion of the nose to bend inward.- RARE.
4. Infection (may result in thinning of the septal cartilage). - RARE.
5. Re‑dislocation of the septum, requiring revision surgery – UNCOMMON.
6. Failure to improve the nasal airway, requiring revision surgery. – UNCOMMON.
7. Scarring and adhesions may predispose to sinus infection and decreased smell – RARE.
8. Leak of Cerebrospinal Fluid (CSF) - The bone separating the brain from the sinuses is very thin in some places and a leak of fluid from around the brain (CSF) can occur. - VERY RARE.
9. There the usual risks with any general anaesthesia - VERY RARE.

Medications to Avoid Before and After Surgery

All medications that you are currently taking should be discussed with your surgeon prior to your operation.

There are two groups of drugs which are very important to avoid prior to your operation. These are Aspirin containing medications, and a family of drugs called 'Non Steroidal Anti Inflammatory Drugs' (NSAID's). Both of these drugs affect the ability of your blood to clot, and so may predispose to post operative bleeding and complications.

Please make sure to check this list carefully and avoid ALL these medications for two weeks prior to surgery, and for three weeks after surgery. If you have any questions regarding this or are taking any of these medications for specific conditions, please contact your general practitioner and notify this office.

Some herbal supplements (such as Garlic) may increase the risk of bleeding. Thus ALL herbal supplements should also be avoided for the above time periods specified.