Septoplasty & Turbinate Surgery

Nasal obstruction
Nasal obstruction can be caused by a number of problems.  Things like allergies can cause nasal obstruction.  Another very common cause of nasal obstruction is narrow nasal passages.  Often, narrow nasal passages are the result of problems with the nasal septum and turbinates.

The nasal septum and the turbinates are normal structures inside the nose.  The nasal septum is the structure that divides your nasal passages into the right and left sides.  A deviated septum refers to a septum that is crooked.

The turbinates are near the septum, but there is usually space between the septum and turbinates to allow air to pass through the nose.  The turbinates can contribute to nasal obstruction if they are too large.  There are several different types of turbinates in the nose.  The ones that most commonly affect airflow are called the inferior turbinates.


Nasal septum
The septum is made of cartilage and bone.   The cartilage and bone of the septum are lined by a thin membrane called mucosa.  This layer acts like a layer of skin for the inside of the nose.  This layer covers and protects the cartilage and bone.  It also helps to keep the inside of the nose moist.

When the septum is deviated, one or both sides of the nose can become blocked.  In these instances, surgery can help to correct the deviation and improve airflow.

 
Diagnosis
The diagnosis of a deviated septum can be made by your doctor.  Your doctor will perform a thorough evaluation of your symptoms and will examine your nose.  You may undergo a procedure in the office called a nasal endoscopy to diagnose the cause of your nasal obstruction.  A deviated septum can also be seen on a CT scan, but a scan is often not necessary to diagnose the cause of nasal obstruction.

After making the diagnosis, your doctor can discuss treatment options for you.  If you have troublesome symptoms, you may be a candidate for surgery to straighten your septum.

Surgery
Surgery to correct a deviated septum is called a septoplasty.  Septoplasty is most commonly performed to help relieve nasal obstruction.  Sometimes, septoplasty is a necessary part of other surgical procedures like sinus surgery or nasal tumor removal.
During a septoplasty, your surgeon will attempt to straighten the cartilage and bone that have led to the septum being deviated.  During the procedure, the lining (the mucosa) is first raised off the cartilage and bone.  The cartilage and bone can then be reshaped.  Sometimes, portions of the cartilage and bone need to be removed.  The lining is then laid back down.

Because the septal cartilage has 'memory'--it has an intrinsic tendency to assume its initial shape--the septal cartilage can sometimes bend after the surgery.
   
Septoplasty is a procedure that is done in the operating room under anesthesia.  The procedure is typically performed under general anesthesia, but your doctor can help you decide if local anesthesia is an option for you.  The procedure is typically performed on an outpatient basis.  This means that patients come in and go home the same day. 
You may have splints or packing inside your nose during the healing process.  In some instances, there may be nothing more than dissolving stitches inside your nose.  Your surgeon can let you know whether packing or splints will be placed in your nose and how long they will stay in place.

Post-operative care
You can expect to have pain, fatigue, nasal stuffiness, and mild nasal drainage after your surgery.  Pain is generally mild with this type of surgery and is typically well controlled with oral pain medications.  The stuffiness typically results from swelling after the procedure, and typically generally starts to improve after the first week.  You may have drainage of some mucus and blood from your nose after surgery.  This is a normal part of the healing process.

You may be asked to use saline sprays or irrigations after your surgery.  Please check with your surgeon about any post-operative care you will need to perform to allow your nose to heal properly.

 

Turbinates
The turbinates are structures on the side wall of the inside of the nose.  They project into the nasal passages as ridges of tissue.  The inferior turbinates can block nasal airflow when they are enlarged. 

 
The turbinates are made of bone and soft tissue.  Either the bone or the soft tissue can become enlarged.  In most patients, enlargement of the soft tissue part of the turbinate is the major problem when the turbinates become swollen.  When the turbinates are large, they are called hypertrophic turbinates.

Diagnosis
The diagnosis of enlarged inferior turbinates can be made by your doctor with a thorough evaluation of your symptoms and nasal examination.  Your doctor may perform a procedure in the office called a nasal endoscopy to diagnose the cause of your nasal obstruction. 
After making the diagnosis, your doctor can discuss treatment options for you.  If the turbinates are swollen, your doctor may recommend medications for you.  For many patients, medications can help reduce the size of the turbinates and can help improve their nasal obstruction.  If you have troublesome symptoms even after using medications, you may be a candidate for surgery to shrink the size of your turbinates.

Surgery
There are many ways to shrink the size of the turbinates.  Surgery is typically called turbinate reduction or turbinate resection.  Surgery can be performed either in the office or in the operating room.  In many instances, turbinate surgery is performed in conjunction with septoplasty.
It is important that the turbinate not be removed completely because its removal can result in a very dry and crusty nose.  In the absence of a turbinate, the air that is breathed may not be to adequately humidified and warmed.  Occasionally, turbinate tissue will re-grow after turbinate surgery and the procedure may need to be repeated.  This is preferable to the situation of totally removing the turbinate.

You may hear of many different terms being used when it comes to surgery for the turbinates.  Examples of these terms are cauterization, coblation, radiofrequency reduction, microdebrider resection, and partial resection.  These all refer to different methods of reducing the size of the turbinates.

Some methods rely on shrinking the turbinates without removing any of the turbinate bone or tissue.  These methods include cauterization, coblation, and radiofrequency reduction.  In each of these methods, a portion of the turbinate is heated up with a special device.  Over time, scar tissue forms in the heated portion of turbinate, causing the turbinate to shrink in size.

In some instances, a portion of the turbinate is removed.  It is important that enough of the turbinate be left intact so that the turbinate can warm and humidify the air that is flowing through the nose.  If a portion of the turbinate is removed, a procedure called a submucosal resection is typically performed.  This means that the lining of the turbinate is left intact, but the “stuffing” from the inside of the turbinate is removed.  As the turbinate heals, it will be much smaller than before surgery.  Sometimes, this resection can be performed with a device called a microdebrider.  This device allows the surgeon to remove the “stuffing” through a small opening in the turbinate.  In some instances, more of the turbinate is removed.

In some instances, packing may be placed in your nose during the healing process.

Post-operative care
You can expect to have pain, fatigue, nasal stuffiness, and mild nasal drainage after your surgery.  Pain is generally mild with this type of surgery and is typically well controlled with pain medications by mouth.  The stuffiness typically results from swelling after the procedure, and typically starts to improve after the first week.  You may have drainage of some mucus and blood from your nose after surgery.  This is a normal part of the healing process.

You may be asked to use saline sprays or irrigations after your surgery.  Please check with your surgeon about any post-operative care you will need to perform to allow your nose to heal properly. 

Endoscopic Sinus Surgery

Endoscopic sinus surgery is an operation performed using a nasal endoscope, a small lighted metal telescope placed into the nostril, which allows the surgeon to visualize the nose and sinuses.  It is a minimally invasive surgical technique for managing sinus conditions.  Compared to other sinus surgery techniques, endoscopic surgery has higher success rates, requires minimal nasal packing and is associated with less pain and shorter recovery times.


What are the indications for sinus surgery?
The most common indication for endoscopic sinus surgery is “chronic rhinosinusitis”.  Chronic rhinosinusitis is a term applied to various nasal processes which involve inflammation of the nose and sinuses that do not adequately improve with medical management.


What therapies should be attempted prior to sinus surgery?
Prior to undergoing endoscopic sinus surgery, patients should talk with their physicians to make sure that all reasonable medical options have been exhausted.

This list of medications that have been recommended for the treatment of sinusitis is quite long.  They include both prescription and hundreds of over the counter treatments located at your local pharmacy.   For acute sinusitis (an infection that typically occurs after a cold and lasts less than four weeks), antibiotics are the main treatment.  In addition, nasal saline irrigations or spray are another treatment with little risk and may be added to an antibiotic regimen. 

As an infection progresses beyond four weeks to become a more chronic illness, treatments may change.  Antibiotics that cover more types of bacteria may be utilized for longer than the typical 10-14 days.  Steroid sprays to decrease inflammation and oral steroids (i.e. prednisone) may also be used.  If sinus infections progress longer than four weeks, your physician may order a CT (cat) scan of your sinuses and obtain a culture of nasal mucus to help choose the appropriate antibiotic.

Allergy medications (antihistamines, nasal steroids, nasal antihistamine sprays, allergy shots) have a role in treating allergy, which is one of the major causes of nasal swelling.  If someone does not have allergies, these treatments are of little benefit (with the possible exception of nasal steroids).


What are the benefits of endoscopic sinus surgery?
If medical options have been unsuccessful in managing your symptoms, endoscopic sinus surgery may have tangible benefits. The overall goal of sinus surgery is to improve the drainage pathway of the sinuses.  By opening the natural drainage pathway of the diseased sinus, the frequency, duration and severity of infections should be reduced.

Although there are patients who have mechanical obstruction due to their particular anatomy, many patients have an intrinsic problem with the lining (mucous membrane) of their nose and sinuses.  While the patients with mechanical obstruction, will receive the maximal benefit from surgery (i.e. fixing the plumbing problem), the benefit for patients with mucous membrane disease is also tangible because the larger opening created during surgery will allow better drainage and more medication and rinses to get into the sinuses and help treat the diseased lining.  

One of the most important benefits of surgery is the ability to deliver medications (e.g. sprays, rinses, nebulized drugs) to the lining of your sinuses after they have been opened.  Therefore, surgery is an adjunct to, not a replacement for, proper medical management.

It is important to note, however, that if you are one of the patients who have diseased mucous membranes or form nasal polyps, no amount of surgery can change this fact.  So although surgery plays a role in managing the disease, it may not cure sinus disease with polyps or other types of chronic inflammation. Therefore, It should be emphasized that surgery is not a cure for sinusitis but is one of the multiple steps in managing your disease.


How is endoscopic sinus surgery performed?
Endoscopic sinus surgery may be performed under local or general anesthesia. The procedure involves the use of a small telescope (nasal endoscope) that is inserted into the nasal cavity through the nostril to visualize your nose and sinuses. The goal of the surgery is to identify the narrow channels that connect the paranasal sinuses to the nasal cavity, enlarge these areas and improve the drainage from the sinuses into the nose.

Most people have four sinuses on each side of their face, for a total of eight sinuses.  These are the maxillary, ethmoid, sphenoid and frontal sinuses.  The maxillary sinuses are in your cheek, the ethmoids are between your eyes, the sphenoid sinuses are almost exactly in the center of your head, and the frontal sinuses are in your forehead.  It is possible that you may not have all of these sinuses due to developmental differences from person to person, or they may have already been opened by previous procedures.

Sinusitis may affect some or all of your sinuses.  Your symptoms, endoscopic exam, and CT scan will determine which sinuses need to be opened.  

Sometimes sinus surgery may require simultaneous repair of the nasal septum, which divides the two sides of the nose, or the turbinates, which filter and humidify air inside of the nose.  Additional information about surgery of the nasal septum and turbinates is provided in other sections of this website.


What is the recovery after endoscopic sinus surgery?
The use of nasal packing will depend on the extent of surgery and the preference of your surgeon. The recovery period will also vary depending on the extent of surgery but postoperative discomfort, congestion, and drainage should significantly improve after the first few postoperative days, with mild symptoms sometimes lingering several weeks after the surgery.


How are the results of endosocopic sinus surgery?
Endoscopic sinus surgery generally yields excellent results, and significant symptomatic improvement is achieved in the vast majority of patients.   


What is “Sinuplasty” (or Balloon Sinuplasty)?
"Sinuplasty" refers to a procedure, or specifically a surgical device that was developed by a specific device manufacturer.  This device is similar to balloon angioplasty, the technology that expands the vessels in someone’s heart.  These balloons are advanced into the opening of a patient’s sinuses and are expanded to open the narrowed channels.  Sinuplasty may also be used in conjunction with more traditional endoscopic sinus surgery techniques.

Like all medical advances, the information in the popular press may not reflect reality.  Although useful, this new technology is not for everyone, and in many cases is not a substitute for standard techniques.  However, in some people it is a technique that may decrease recovery time.  Only with a thorough examination, in conjunction with a CT scan, can this be determined by your surgeon.


What are the potential complications of sinus surgery?
Adverse events are rare but may include postoperative bleeding, orbital (visual or eye) complications, complications from the general anesthetic, cerebrospinal fluid leaks and intracranial complications such as meningitis. However, it is important to realize that chronic sinus infections are located directly beneath the skull base and adjacent to the eye and the failure to treat this problem without surgery may lead to dire consequences, such as involvement of the eye or brain.


What are the alternatives?
Continuing medical therapy alone and avoiding surgery is always an alternative.  Medical therapy is chiefly antibiotics and/or steroids along with other medications.  As with any surgery, you should feel more than comfortable seeking a second opinion from another surgeon.