Deviated septum 

The septum is the nose's principal supporting structure, providing support to the dorsum, columella, and nasal tip. It also divides the nasal cavity, resulting in two unique nasal airways that allow for warming, humification, and turbulent air movement. A septum deviation can lower the cross-sectional area of the nasal valve, resulting in airway obstruction.

This can cause nasal obstruction and, in rare cases, aggravate the symptoms of obstructive sleep apnea. Epistaxis, headaches, and face discomfort can be caused by bony spurs caused by a deviated nasal septum.

 

What's deviated septum?

A deviation of the cartilaginous or bony sections of the septum into the right or left nasal channel, resulting in a reduction in cross-sectional area, obstructing airflow, and generating a sense of nasal obstruction Patients may have signs of blockage during exertion or when exercising in particular. Trauma is the most typical cause of the abnormality. Patients must be symptomatic with nasal obstruction in order for functional surgery to be performed.

When a person has a deviated septum, one side of the nose is broader than the other. This changes the arrangement of airflow in the nose and might occasionally obstruct the constricted side. Sinus apertures can become clogged in some circumstances, resulting in a sinus infection (sinusitis) that lasts a long period or continues reoccurring. Because of the changed airflow pattern within the nose, the skin of the nasal septum can become dry and cracked, resulting in recurrent nosebleeds.

 

Septal anatomy

The septum is made up of three primary parts: membranous, cartilaginous, and bony. The membranous septum is formed of fibrous tissue and is located between the lower lateral alar cartilages. The quadrangular cartilage, as the name implies, is quadrangular in form and is located posterior to this membranous part. It connects to the bony septum posteriorly, the maxillary crest inferiorly, the upper and lower lateral cartilages anteriorly, and the maxillary crest inferiorly.

The bone septum is composed of the vomer, which is inferior-posterior to the cartilage, and the perpendicular plate of the ethmoid (PPE), which is superior-posterior. The ethmoid bone connects to the skull base and sphenoid bone. The nasal bone is located on the dorsal side of the nose, superior to the perpendicular plate.

The septum is surgically fixed at two points: the intersection with the anterior nasal spine of the maxilla and the 'keystone location.' The keystone area is located at the junction of the nasal bones, quadrangular cartilage, upper lateral cartilages, and PPE; it is an important location for stability and structure and must be taken into account during surgical handling during septoplasty.

These cartilaginous and bony components are surrounded by mucoperichondrium and mucoperiosteum, which offer innervation and a plentiful vascular supply. This allows the mucosa to expand and contract, allowing air to be heated and humidified via the nasal cavity. The surface mucosa is mostly composed of pseudostratified respiratory epithelial cells. The olfactory epithelium is placed more superiorly towards the nose's olfactory area.

 

Blood Supply

The nasal septum is supplied with blood by a network of arteries coming from the internal and external carotid arteries. The internal carotid artery gives birth to the anterior and posterior ethmoidal arteries, which supply the upper portion of the septum (through the ophthalmic artery).

The external carotid artery gives birth to the facial and maxillary arteries, with the terminal branches giving the remaining circulatory supply. The facial artery branches to produce the superior labial artery, which supplies the anterior portion. 

The maxillary artery splits into the larger palatine and sphenopalatine arteries, which supply the inferior and posterior septums. They connect anteriorly to create Keisselbach's plexus, also known as Little's region and the most common location of epistaxis.

 

Deviated septum causes

Impact trauma, such as a hit to the face, is the most common cause. It might also be a congenital disease induced by nasal constriction after labor. Genetic connective tissue illnesses such as Marfan syndrome, homocystinuria, and Ehlers–Danlos syndrome are linked to a deviated septum.

A detailed history is required to determine whether concurrent conditions, such as trauma, rhinosinusitis, allergies, vasculitis, illegal drug use, chronic use of decongestants, autoimmune illness, or cancer, may contribute to or cause blockage. In these circumstances, appropriate medical therapy (e.g., intranasal corticosteroids for chronic rhinosinusitis) should be provided as soon as possible.

 

Deviated septum symptoms

Only more severe examples of a deviated septum will cause breathing difficulties and necessitate treatment. Infections of the sinuses and sleep apnea, snoring, recurrent sneezing, face discomfort, nosebleeds, mouth breathing, trouble breathing, and mild to a severe loss of smell are all symptoms of a deviated septum.

The nasal septum is a bone and cartilage structure in the nose that divides the nasal cavity into two nostrils. The cartilage is known as quadrangular cartilage, and the septum is made up of bones such as the maxillary crest, vomer, and the perpendicular plate of the ethmoid. Normally, the septum is located in the center of the nasal airways, resulting in symmetrical nasal passages.

A deviated septum is a condition in which the top of the cartilaginous ridge bends to the left or right, obstructing the afflicted nasal channel. The issue might lead to inadequate sinus outflow. People may also complain about breathing difficulties, headaches, bloody noses, or sleeping abnormalities such as snoring or sleep apnea.

Nasal septa frequently vary from the precise centerline; the septum is only deemed deviated if the displacement is significant or causes complications. Many people who have a deviation are unaware of it until they experience pain. A deviated septum on its own might lie undiagnosed for years, necessitating no treatment.

 

Diagnosis

The most prevalent cause of nasal obstruction is nasal septum deviation. A history of nasal trauma, such as birth trauma or microfractures, is frequently present. A medical practitioner, such as an otorhinolaryngologist, often determines the diagnosis after obtaining a comprehensive history and completing a physical examination on the patient. Imaging of the nose is also occasionally utilized to help in diagnosis.

Following a review of your symptoms, the doctor will ask you whether you have ever broken or badly damaged your nose, as well as if you have ever had nasal surgery. Your nose and the location of your nasal septum will be examined by your doctor. Your doctor will evaluate the inside surface of each nostril with a powerful light and a nasal speculum (a device that gently spreads open your nostril).

To acquire a better view of the whole septum, temporarily shrink the nasal lining tissues using Afrin or Neo-Synephrine nasal spray. A fiberoptic scope may be put into the nose to examine the posterior septum directly. In most circumstances, no extra testing is required.

If your deviated septum is causing frequent nosebleeds, sinus infections, or other serious issues, your primary care physician will recommend you to an otolaryngologist (ear, nose, and throat specialist) or plastic surgeon for repair.

 

Treatment for a Deviated Septum

Before contemplating a surgical technique to address nasal septum deviation, medical therapy with nasal sprays such as decongestants, antihistamines, or nasal corticosteroid sprays is usually explored first. The medication alleviates symptoms momentarily but does not address the underlying cause. Nasal strips can also provide non-medical relief.

Septoplasty, a small surgical treatment, can alleviate discomfort caused by septal abnormalities. The operation takes around an hour and leaves no aesthetic changes or outward scars. Nasal congestion, discomfort, discharge, or edema may develop in the days following surgery.

The surgery might take anything from 2 days to 4 weeks to properly recover. Septal bones do not regenerate. If symptoms reappearance occurs, it is not due to deviations. The recurrence of symptoms might be attributed to nasal mucosal metaplasia.

Laser septo-chondroplasty is now the mildest and successful therapy for septal cartilage segment distortion, while ultrasonic septoplasty is helpful for septal cartilage and bone deformation.

 

How to fix deviated septum without surgery?

The only true management for a deviated septum is surgery if it is successful. However, if you are unsure about undergoing surgery or are not physically prepared for surgery, there are alternatives to deviated septum surgery.

 

Surgery for a deviated septum

Septoplasty

Nasal septoplasty is one of the most popular ENT and plastic surgery operations. The most common reason for surgery is septal deviation, which causes significant and symptomatic nasal airway obstruction.

Recurrent epistaxis, obstructive sleep apnea, sinusitis, and face discomfort and/or headaches caused by septal spurs are all reasons for septoplasty. Septoplasty may also be required in combination with endoscopic sinus, skull, or orbital surgery to provide for improved surgical access to critical tissues.

Patient satisfaction, quality of life outcomes, and symptom improvement are widely used to assess postoperative results. It is difficult to assess symptom improvement since it is frequently subjective, and objective data may not always correspond with patient impression.

 

Preoperative

  • History

A detailed history of the type and degree of the nasal symptoms should be collected. Other sinonasal or systemic pathologies, such as allergies, should be investigated. Nasal obstructive symptoms can be graded using scoring methods such as the NOSE Scale.

A thorough pharmacological history should be collected, with a special emphasis on intranasal decongestants and corticosteroids, as well as any recreational drug usage. If the patient smokes, they should be counseled to quit or reduce their tobacco consumption. It's important to know if the patient has had past nose or sinus surgery, problems with previous anesthetics, or bleeding problems.


  • Examination

In the outpatient clinic, patients should be carefully examined. A thorough head and neck examination should be performed, followed by an anterior rhinoscopy with a nasal speculum. Flexible nasendoscopy can be used to detect sinonasal illness or masses in the posterior nasal space. When examining the nasal septum, the surgeon should check for evidence of inflammation in the mucosa as well as the size and type of the turbinates, notably the inferior turbinate.

A turbinoplasty may be necessary if access is restricted owing to too large turbinates. The septum should be palpated to assess the size, position, and type of the deviation, noting if it seems cartilaginous or bony and whether there is any septal perforation, dislocation, or bony spurs.

External inspection should be performed, noting any further deformity and degree of caudal tip support. Finally, Cottle's procedure should be used to evaluate internal valve stenosis. A comprehensive assessment will aid in determining if surgery is necessary, the amount of difficulty, and which strategy and method would be most suited for this patient.


Preparation

  • The patient is positioned with the head ring and his head angled slightly towards the surgeon, wearing conventional drapes. 
  • Trimming of prominent nasal hairs
  • Some surgeons prefer to use xylometazoline or Moffatt's solution to decongest the nose.
  • Local anesthetic insertion in the submucoperichondrial plane with 1 percent lidocaine and adrenaline (1:100,000) until the mucosa is fully blanched. This aids in hydro-dissection of the planes, as well as analgesia and hemostasis.

 

Contraindications of septoplasty

There are various reasons why surgery should not be performed. To begin, there are concomitant disorders, such as rhinosinusitis or vasculitis, for which suitable medical therapy has not been tested. This would provide the misleading impression that the procedure would alleviate symptoms when, in reality, it might have no impact or possibly aggravate the condition.

The current recreational drug use, particularly intranasal cocaine, is extremely dangerous. Cocaine's vasoconstriction and mucosal damage might result in problems such as poor cartilage repair, delayed healing, septal perforation, and dorsal collapse. Before operating, it is standard practice to verify that patients have been abstinent for at least 6 to 12 months, and a toxicological test may be required. Similar measures should be used with individuals who exhibit symptoms of medicamentosa rhinitis. Vasoconstrictive decongestant nasal sprays should be avoided for a large amount of time before and after surgery.

 

Complications of septoplasty  

A variety of issues may arise as a result of septoplasty procedures; they must be properly documented and disclosed to the patient during informed consent. Excessive bleeding is the most prevalent; some seeping is to be expected, but more severe bleeding can be treated using nasal packing and, in rare cases, cautery. Septal hematomas can form when there is bleeding underneath the mucoperichondrium.

To avoid a septal perforation, this will need to be drained in the operating room. Perforations can also occur as a result of bilateral mucosal perforations intra-operatively, resulting in decreased vascular supply; if a perforation induces dorsal collapse, a saddle nose deformity may develop, necessitating revision surgery.

Infection, clogged nose, and slow healing can all occur in certain people. This is treatable with antibiotics, and the great majority of people will recover completely within a few weeks. Hyposmia has been reported in some people, however, it generally cures itself within 6 months. Intranasal adhesions can occur, however, using Silastic splints reduces the risk. Finally, individuals may feel numbness in their upper teeth or lips; this is generally temporary and recovers after a few months.

 

Recovery after septoplasty

Your doctor may prescribe medicine to help you recuperate after septoplasty. Taking it can lower your risk of post-operative infection or help you manage pain or discomfort. It is critical that you take all of the drugs that your doctor has prescribed for you.

You also don't want to irritate your nose while it's mending. By three to six months following surgery, the septum is largely stable. Some alterations might occur up to a year later. Avoid bumping your septum as much as possible to avoid this.

After the procedure, you can aid healing by following these tips:

  • Don’t blow your nose.
  • Elevate your head when you’re sleeping.
  • Avoid strenuous exercise, including cardio.
  • Wear clothes that fasten in the front instead of pulling over your head.

 

Prevention

By avoiding nasal injuries, you can assist to prevent a deviated septum. Wear seat belts and shoulder harnesses anytime you ride in a car, and wear well-fitting headgear during contact sports like football or karate to protect your face.

 

Deviated septum surgery cost

Deviated septum surgery without insurance coverage often costs between $4,000 and $6,000 if rhinoplasty is not also performed. With insurance, the patient's copays and deductibles determine the real cost; hence, it might be entirely free or a modest cost of $500 to $2500.

 

Conclusion 

The septal deformity is classified into two types, which can occur separately or together: anterior cartilage deformity of the quadrilateral septal cartilage, caused by direct trauma or pressure at any age, and combined septal deformity involving all septal components, caused by compression across the maxilla from pressures during pregnancy or parturition.