Making people breathe better through their nose is an issue near and dear to Dr. Grant Gillman’s heart. He presented “Nasal Obstruction: The Deviated Septum – Everything You’d Want to Know,” in the Eye & Ear Foundation’s September 7th webinar.
Dr. Gillman, MD, FRCS, is an Associate Professor and the Director of Facial Plastic and Reconstructive Surgery in the Department of Otolaryngology. Born and bred in Canada, he did his residency there and had two fellowships in the U.S., one in Pittsburgh. He has been a UPMC surgeon since 1998. Though he is an ENT, his primary interest/expertise is in nasal surgery – nasal airway obstruction (functional surgery), deviated septum, crooked nose, previously operated, cosmetic rhinoplasty, sinus etc.
Nasal Obstruction – Why Talk About It?
Nasal obstruction is one of the most common complaints presented to a general ENT, allergist, rhinologist (sinus specialist), or facial plastic surgeon. After a tonsillectomy, adenoidectomy, and putting tubes in ears, septoplasty is the third most commonly performed surgical procedure among ENT surgeons.
The ability to breathe through the nose has shown to possibly improve quality of life in the following:
- Snoring/sleep disordered breathing/CPAP tolerance
- Risk for recurrent sinusitis
- Allergy control
- Hyposmia (decreased sense of smell)
- Eustachian tube dysfunction
- Facial pain
There are several possible causes for nasal obstruction. It can be inflammatory, from allergies or connective tissue disorders. It can be due to an infection like sinusitis. A nasal mass might be present, whether malignant or benign (polyps, adenoids, a benign tumor). There might also be structural problems, as in how the nose is built.
Nasal Structure and Nasal Obstruction
The external part of the nose is comprised of nasal bones and cartilage. The internal nose, or nasal cavity, consists of the nasal septum and turbinates.
External Nasal Anatomy
The nasal bones make up the upper third of the nose. Upper lateral cartilage is the middle third of the nose, and lower lateral cartilage is the lower third of the nose.
Cartilage is a little more flexible and pliable, so noses feel softer in the area. This is what provides support to the lower two-thirds of the nose.
“To look at it differently,” Dr. Gillman said, “if you think of the nose as a tent, you need space on the inside of the tent, but you also need a framework or walls to that tent that are well supported and not collapsing or together those two can compromise the amount of space on the inside. The cartilage is what supports the external nose and makes up that framework.”
Internal Nasal Anatomy
The nasal septum divides the two sides of the nose. Turbinates are normal structures that sit on either side of the septum. They are more variable in terms of their size, and are more likely to fluctuate in size, both normally and even more so with upper respiratory infections or in those with allergies.
The septum actually runs from the tip of the nose to the back of the throat and is about 3.5-4 inches long. “It is not just what we see on the outside and is much longer than most of us imagine,” Dr. Gillman said. It is made up of bone — typically in the back and low down — and cartilage, which is in the front. The relative amounts of bone and cartilage can differ from one person to the next. There can be shifts or deviations of the septum in the bone or cartilage or both.
In many people, as the septum shifts to one side, the turbinates on the more open side over time increase in size because there is room for them to get bigger or expand. So, for many people, surgery on the inside of the nose involves addressing the septum and turbinates at the same time.
Deviated Septum FAQs
What does it mean? The partition that separates the two sides of the nose on the inside is shifted to one side or another. As a result, the breathing on one side of the nose feels more restricted/blocked than the opposite side.
What causes it? The most common causes are either developmental or nasal trauma/injury.
Could I have one and not know it? Absolutely. For many people with a milder shift of the septum, it might not bother them in any way. There isn’t necessarily a linear relationship between the extent of shift and how well we do or do not breathe through the nose. Some people just seem to tolerate it well and some people not so well.
Is it common? Very. Nasal obstruction is one of the commonest presenting concerns to ENT surgeons. Approximately two out of three people have a deviated septum to some degree. Not everyone is symptomatic.
Can it affect both sides of my nose? Yes. The septum can shift in either direction and sometimes both. Other things that should be considered when both sides of the nose are affected – turbinate enlargement, allergies, polyps, medications, etc.
Is it serious? No, not in any way.
Do I have to have an operation? No. It is not a life-threatening problem. But a balanced/equal nasal airway can have significant quality of life implications.
What are the advantages of breathing through the nose (vs mouth breathing)? Contrary to popular perception, more oxygen is not an advantage. Both the nose and mouth lead to the throat, which carries the oxygen to the lungs. The lungs do not care where the oxygen comes from. Nasal function is an advantage, however, as breathing through the nose filters the air we breathe (dust, allergens, pollen, foreign particles), warms the air we breathe (brings it to body temperature), and humidifies the air we breathe.
Breathing through the nose might benefit related conditions such as:
- Sleep quality/snoring (general wellbeing, daytime energy)
- Allergy control (allows medication to be better delivered)
- Recurrent sinusitis
- Olfaction (sense of smell)
How is DNS Diagnosed?
A physical exam is done that includes an anterior rhinoscopy, which is using a speculum to look inside the nose. This is complemented by a nasal endoscopy, in which the doctor numbs the nose and passes a thin telescope through to get a better view. X-rays and scans are typically not necessary. Sometimes they are done as a complement to the exam when looking for other things that might be relevant.
How is DNS Treated?
Nonsurgical options to treat DNS include nasal sprays – nasal steroid sprays, naturopathic sprays, optimize allergy control – but NOT over-the-counter nasal decongestant sprays. These contain such things as oxymetazoline or pseudoephedrine that are not safe for daily use. External or internal nasal dilators are also used.
Surgical treatments are a septoplasty with or without turbinate reductions or a functional (non-cosmetic) septorhinoplasty with or without turbinate reductions for more complex/extreme septal deviations or those involving external (framework) issues as well.
“There is no one-size-fits-all operation,” Dr. Gillman said. “It needs to be individualized or tapered.”
Objective of Nasal Septal Surgery
The objective is to establish a normal anatomic nasal airway and to minimize complications like a suboptimal outcome/dissatisfaction or need for revision surgery.
What Does the Surgery Entail?
- Outpatient surgery, approx. 60 minutes
- General anesthesia
- No external incisions
- Deviated portions of the septal bone or cartilage are removed or repositioned
- No bruising, no (or minimal) swelling
- Splints inside the nose for 5-7 days (hollow rubber tubes), comes out in the office
- Activity – light (no strenuous activity)
- Outpatient surgery, approx. 2-3 hours
- General anesthesia
- Small external incision between the nostrils – probably 5-7 mm in length total, fades away, becomes virtually imperceptible in most circumstances over time
- Deviated portions of the septal bone or cartilage are removed, repositioned, or reconstructed
- Mild bruising/swelling – usually gone by the time people come back to get their splints taken out
- Splints inside and on the nose for 5-7 days
- Activity – light (no strenuous activity)
Do you have to break my nose? No. If there is a big shift in the bones on the outside of the nose that would in some way contribute or have some added value to the airway, then maybe. But in a routine one, no. In a function septalrhinoplasty, sometimes, but only again if the shift in the bones is so severe that it is carrying the septum and everything off to one side.
Many of the following surgical risks are pretty uncommon; all are small and infrequent:
- Diminished/loss of sense of smell
- Septal perforation
- Excessive bleeding
- Change in external shape
- Shift/drift of the healing septum (need for further surgery or revision), 3-5%
“In general, when properly done, there is a HIGH satisfaction rate, and LOW complication rate,” Dr. Gillman said.