Septoplasty (+/- Turbinate Reduction)

What you need to know about your operation …

Introduction

What does the nasal septum do?
The nasal septum is a vertical sheet of tissue that divides the nasal cavity into two halves. At the front of the nose it is made up of a central flat sheet of cartilage covered in a layer of the lining tissue of the nose on both sides. Further back in the nose the central sheet is made of a thin sheet of bone instead of cartilage. At the very back of the nose the nasal septum ends and there is single cavity leading down to the throat. As well as dividing the nasal cavity into two halves, the front piece of cartilage shapes and supports the tip of the lower half of the nose.

What are Turbinates?
Turbinates are structures on the side wall of the nose. There are 3 in each nostril (inferior, middle and superior turbinates). They are composed of a thin boney strut that sticks out into the airway and it is covered by mucus membrane on both sides. The mucus membrane has a rich blood supply. Their function is to moisten and warm the air that we breathe in through the nostrils before it reaches the lungs. The turbinates swell or shrink in response to nerve impulses. The Inferior turbinates are important in nasal blockage.

Why is a Septoplasty performed?
The usual reason for surgery on the septum (Septoplasty) is because the nasal septum is bent to one side of the nose causing blockage. The bend is often referred to as a “Spur”. The septum may just grow this way with age, or the bend may result from a nasal injury or broken nose. A Septoplasty involves removing this bent bit of the septum and thereby improving the airway and breathing.

Alternatively the operation will be recommended when some other surgery is being performed on the nose, e.g. in sinus surgery to allow access to the sinuses.
A septoplasty is rarely performed in children because of the risk to future growth of the nose.

Why is a Turbinectomy performed?
The inferior turbinate on the opposite side to a Septal deviation (spur) swells excessively and will therefore cause blockage of that side once the Septum is put back into the middle. Therefore it becomes necessary to reduce its size of the turbinates (Turbinectomy). They may also swell in response to allergies and infection/inflammation causing nasal blockage.
There are a number of techniques available to your surgeon to reduce the size of the turbinates. These include Submucosal diathermy; Outfracture; Partial or submucosal resection; or a combination of these techniques.

What does the operation involve?

Before the operation:
Arrange for a couple of weeks off work.
Check that you have a friend or relative who can take you home after the operation.
You must not drive for at least 24 hours after a general anaesthetic.
Make sure that you have a supply of simple painkillers at home.

The day of the operation:
Admission is almost always on the day of surgery. The nurses will complete some routine paperwork and tests. You will be asked to change into a gown ready for theatre. The anaesthetist will come to see you and discuss the anaesthetic side of things. A member of the ENT team will also see you before your operation.

The anaesthetic:
In children the operation is performed under general anaesthetic. In adults it may be possible to perform the operation under local anaesthetic.

The operation itself:
The operation is performed with you asleep under the anaesthetic, and takes 30-60 minutes in all. The operation is all done inside the nose, with no cuts on the outside. A cut is made just inside the nose and the bent areas of the nasal septum cartilage and bone are taken out. The lining of the nose is repositioned at the end and fixed in place with 1 or 2 dissolving stitches. Sometimes it is necessary to place a thin sheet of silastic (a splint) inside the nose on both sides at this stage. The splint prevents scarring or adhesions (bands of scar tissue) between the side wall of the nose and the nasal septum. It is usually kept in place with a silk stitch just inside the nose. Bleeding and bruising within the nasal septum where the surgery has been performed is possible after the operation, and so it is usual practice to put a dressing (pack) into both sides of the nose at the end of the operation. There is usually no swelling or bruising visible on the face afterwards.

After the operation:
After a short time in the recovery area you will be taken back to the ward. You will be encouraged to drink and then eat as soon as the anaesthetic has worn off. You will be given painkillers as needed.

Your discharge from hospital:

The pack will need to stay in your nose for a period of time – sometimes this will be overnight. Most people are discharged home by lunchtime the day after the operation. You will need to arrange for a responsible adult to pick you up to take you home and stay with you for 24 hours after discharge (following a general anaesthetic). Depending on how fit and active you are before your operation, you may need to arrange for someone to stay with you for a few days.

What should I do when I leave hospital?

Activity:
Following a general anaesthetic you may find that you need more rest than before for a day or two. This is normal. You should keep away from dry and smoky atmospheres and other people who may have coughs and colds. Please do not smoke.

Driving:
You should not drive for at least 24 hours following your operation, depending on your progress. You can then drive when you are able to perform an emergency stop safely.

Wound care:
If silastic sheets (splints) are used in the nose, arrangements will be made for you to return to the ward after a week or so for them to be removed.

At first the nose becomes blocked and runny, like having a head cold. Over the first week or so the nose dries up, but stays blocked over the next few weeks as the lining of the nose settles down.

You may be given instructions to use a saltwater spray for your nose and possibly some steroids.

Work:
You will need about 2 weeks off work after the operation, to allow your nose to settle down from the surgery.

Are there any risks involved in this operation?
Although modern surgery and anaesthetics are considered to be safe, all medical procedures carry some risks. The surgeon will discuss all these risks with you.

Risks associated with the operation are:

Bleeding during the operation: or in the first few hours after the operation may be a problem (but only once in several hundred cases on average), and usually settles if a fresh dressing (pack) is put into the nose.
Bleeding after discharge from hospital: may occur and is often associated with infection. The chance of this happening is about 1 in 100 after a Septoplasty but 2 in 100 after a Turbinate Resection. It often begins a few days after the operation. Fresh (bright red) blood from the nose after discharge from hospital is abnormal, and if it occurs you should go to the Emergency Department as soon as possible; some cases will need to be admitted to the ward. Rarely patients may need to go back to theatre and have a blood transfusion. The problem almost always settles down with antibiotics, a dressing in the nose and bed rest.
Septal Heamatoma: blood may collect between the two layers of the lining of the septum. This may cause blockage of both nostrils and may require drainage in theatre.
Infection (Septal abcess): is the other potential complication. If your nose becomes more rather than less sore and increasingly blocked, after the first few days, this may indicate that a septal heamatoma has become infected. This requires urgent drainage in theatre.
Septal Perforation (2-4%): may occur after a septal abcess or for no apparent reason. Most perforations do not cause symptoms but they may give rise to bleeding, crusting or whistling noises when breathing through the nose. They may also cause a feeling of blockage. Further surgery may be needed to correct the perforation but is not always successful.
In the long term, a slight change in shape of the outline of the nose is possible. This is most likely if a lot of cartilage or bone needs to be taken out at the operation or if there is infection afterwards. Over a one to two year period this would show as a slight droop of the tip of the nose or a lowering of the bridge of the nose in its middle part (saddling). In general E.N.T. surgeons are very careful to remove as little cartilage and bone as possible at the operation and the problem is an infrequent one (<1%). Corrective surgery may be necessary.
• There may be numbness of the central top teeth which will normally settle over a few months.
Sense of smell: rarely this may be reduced, lost or distorted following septal surgery.
A Cerebrospinal fluid (CSF) leak: this is very rare and results from surgical damage to the roof of the nose. This allows CSF that surrounds the brain to leak into the nose. This may result in meningitis so surgery is often needed to seal the leak.
Adhesions: bands of scar tissue between the septum and the side wall of the nose can occur. These may cause further nasal blockage. Further surgery may be needed to divide them.
Failure to relieve symptoms: one in ten patients may fail to get relief of their sense of blockage post operatively despite good airflow through the nose. This may be due to poor sensation from airflow receptors. This could be due to damage from flu virus or surgical removal of these receptors. Further surgery may not help. Rarely, symptoms may be worse after surgery. Snoring may not improve with this surgery as snoring is often due to a number of factors.
Recurrent nasal blockage: this can occur despite successful Septoplasty and turbinate reduction. This can be because of persistent swelling of the Turbinate, residual bowing of the septum or ongoing nasal problems eg. Allergy or infection. Further treatment, including surgery may be needed.
Chronic Dryness: removal of turbinate tissue may cause chronic dryness of the nasal cavity. This may cause crusting, a sensation of nasal blockage and rarely disturbances in the sense of smell.

Risks associated with a general anaesthetic are rare and include:

• Infection can occur, requiring antibiotics and further treatment.
• Bleeding can occur and may require return to theatre. Bleeding is more common if you are on blood thinning drugs.
• Chest infection. Small areas of the lung can collapse, increasing the risks of chest infections. This may need antibiotics and physiotherapy.
• Blood clots in the legs (DVT) can cause pain and swelling of the legs. Rarely pieces of the clot can break off and can travel to the lungs (pulmonary embolism). This is a particular problem in obese patients. Patients may wear tight stockings and are advised to keep moving their legs to help the circulation. Blood thinning injections are often given to prevent this.
• Heart attack or stroke could occur due to the strain on the heart.
• Increased risk in obese patients of wound infection, chest infection, heart and lung complications and thrombosis (DVT).
• Death as a result of a general anaesthetic/ this procedure is possible.

Are there any alternatives to this operation?
If the nasal blockage is just the result of the bent nasal septum, no drug treatment will help. If the blockage is partly because of swelling of the lining of the nose, e.g. allergy, there may be improvement with steroid nasal sprays, or some other form of medical treatment. This medical treatment would need to be long-term in order to maintain the improvement.

If you would like a second opinion about the proposed surgery please ask your G.P or Surgeon to arrange this.

Are there any risks of not having this operation?

If you decide not to have surgery your symptoms may persist or worsen.

Where can I find out more about the operation?

Royal Australian College of Surgeons
http://www.surgeons.org
Australasian Society of Otolaryngology and Head & Neck Surgery (ASOHNS)
http://www.asohns.org.au

Alternatively visit following websites:
ENT UK have a patient information leaflets:
https://entuk.org/docs/patient_info_leaflets
or just Google ‘ information leaflet’ and many ENT departments around the country have produced their own patient information leaflets.
If you have any questions about general anaesthetics, the Royal College of Anaesthetists website has a lot of information:
http://www.rcoa.ac.uk/patientinfo

Further information and advice
If you experience pain not relieved by painkillers or heavy bleeding after your operation please contact your GP or go to the Accident & Emergency Department.