Dr. Undavia: So most people think that this part is all that’s there and that’s the cartilage part that can move, that is actually bony. So the bony part of your septum connects, believe it or not, from the hard part of your palate, so from here all the way up to the bottom part of your brain. It’s a big wall like this. And so if you have a deviation in your septum, you can have it in the cartilage part, the bony part, or both.
Dr. Reddy: Hey guys, welcome to another episode of We Nose Noses. This podcast. I’m Dr. Reddy and I’m joined here by Dr. Undavia. So today’s topic is everything related to deviated septums and the way we treat it is generally with a septoplasty. So first, I’m going to have Dr. Undavia talk a little bit about what is a deviated septum.
Dr. Undavia: Good question. So deviated just means crooked. So you have a nose that you could see from here to here, but to be honest the nose is huge. It goes all the way back to the ear. And the nose has two openings there called your nostrils and they have a wall that should go straight all the way to the back. But a deviation means that it’s crooked like this. and it can cause nasal obstruction, which is just difficulty breathing, but it can also cause plenty of other problems that we’ll talk about in a second. You don’t have to have a crooked nose to have a deviated septum actually. You may never know that you have a deviated septum. So many people have deviated septums.
Dr. Reddy: Thank you. Can you go over the difference in terms of the deviated septum? There’s a bony part of the septum, and then there’s the cartilaginous part of the septum. Then there’s a part of the septum on the inside that you can’t see, and then a part of the septum that you can see on the outside. Can you talk a little bit about the nuances between all of that?
Dr. Undavia: Definitely. I think I could speak for Dr. Reddy and myself. We both love this surgery. It’s probably one of our favorite things to do and so we can just jump into any part of the topic at any point. But it is worthwhile to talk about the anatomy. So the nose that you see on the outside has three distinct separation. So there’s the upper third, the middle third, and the lower third. The upper third is nasal bones and then the lower third and the middle third are cartilage. And the septum, that wall that divides the nose into left and right, comes all the way up to the top and gives you the height that you have right here. So most people think that this part is all that’s there and that’s the cartilage part that can move, that is actually bony. So the bony part of your septum connects, believe it or not, from the hard part of your palate, so from here all the way up to the bottom part of your brain. It’s a big wall like this. And so if you have a deviation in your septum, you can have it in the cartilage part, the bony part, or both.
Dr. Reddy: And just for anatomic purposes, the cartilaginous part, the front part of the septum, is referred to oftentimes as a quadrangular cartilage. And then the bony part generally is going to be the maxillary crest, which is on the bottom, and posteriorly or way in the back is going to be referred to as the vomer part of the cartilage. So now that we know what a deviated septum is. The question is, if you have a deviated septum, what does it actually cause? Do you want to touch a little bit about that?
Dr. Undavia: Yes. There’s a few symptoms that you may have. The first might be very obvious. You have a crooked nose. You have a crooked nose likely means that you have also a crooked or deviated septum. The second and third symptoms, or the other symptoms are more about what you feel, not about what you see. You could have difficulty breathing on one side or both sides, even though the deviation is only on one side. You could have nosebleeds. have a runny nose only on one side. You could have pressure on one side. You could have sinus infections. Believe it or not, you can actually have ear symptoms only on one side popping or congestion on one ear compared to the other. There are many symptoms that a deviated septum can give you, but there are also a whole host of patients that have deviated septums that we see that we don’t fix. So just because you have a deviated septum doesn’t mean you need to fix it. I was going to ask Dr. Reddy, who you see in the office complain about when you eventually book them for a deviated septum surgery.
Dr. Reddy: Yeah, so like Dr. Undavia was saying, a lot of people actually have deviated symptoms. The majority of people with deviated symptoms actually have no symptoms at all. The deviation doesn’t usually cause symptoms. But the most common complaint that I get is trouble breathing through your nose. And the trouble breathing through your nose is usually worse when you’re doing some type of strenuous activity, you know, like working out. sports or something like that. And the other common time where people complain of trouble breathing through their nose is when they’re laying flat and when they’re trying to sleep. And that’s because if you already have a narrowing of your nose and then you’re laying flat and your nose is now getting more congested with blood flow because of gravity and your nose is at the same level of your heart, that’s when you can have the signs and symptoms of a deviated symptom can become more apparent. So those are some of the main symptoms that we see.
Dr. Undavia: Do you remember the name of the formula that you learned in physics for airway resistance?
Dr. Reddy: Ah, geez. That’s what Bernoulli’s principle are you referring to?
Dr. Undavia: Well, I think it’s, I’m going to butcher the name. It’s like Pussois-lar, something like that. But in any case, it’s airway resistance is inversely proportional to radius to the fourth power. So a really tiny change in radius, so patients with a deviated septum that’s only a millimeter off on one side or the other can have a very significant impact in breathing. Anyway, sorry, I wanted to catch you off guard.
Dr. Reddy: Yeah. Well, you caught me off guard. Let me go over a couple. A lot of people ask me why do I have a deviated septum. What would you do? Can you go over a couple of causes of deviations?
Dr. Undavia: There are two basic categories that people fall into. The first category is pretty obvious. There was some trauma. And the trauma can be… A long time ago, it can be just recent. A big thing that we see is like a basketball injury, like an elbow to the nose and it kind of slides the septum over. You know, some sports injury. That’s a big part of what happens. Sometimes people fall and they hit their nose and it can make the cartilage part or the bony part crooked. But things can happen when you’re really young. Let’s just say you’re learning how to walk when you were one and you fell on your nose and then your nose is just slightly crooked. But as your nose grew, your deviation grew. And so you can have these traumatic events at any point in your life. And they can give you this deviation. I’ve even read some things where a traumatic delivery when you were being born can cause a slight deviation. It’s really tough to know. It’s nobody’s fault. It just happened. But that’s one part. The second part is just, that was your genetic code. At some point, you were, whether it’s the top part or the bottom part, just tilted to one side, and then the rest kind of followed like that, and it’s been deviated ever since. Those are the two main things.
Dr. Reddy: Yeah. And generally, once you have a deviated septum, it is unlikely to get better on its own, right? So as time goes on, your nose starts actually changing shape a little bit and gravity starts to work on it. And it’s kind of like a leaning building over time. That leaning building is slowly probably either going to stay the same or it’s slowly going to get worse. And that generally is what happens with deviated septums. Do you want to go over a little bit of… about the surgery itself and how we fix this? Is there any alternatives to surgery? What are the options if somebody wants their deviated septum fixed?
Dr. Undavia: So yeah, the first thing we always do, and we have another podcast on this about nasal sprays and stuff, but the first thing we always like to do is talk about medical versus surgical. So medical treatments, I’ll just keep it short, are nasal sprays, sinus rinses, allergy pills. Sometimes you need to do antibiotics. If you still feel any of the symptoms that we talked about earlier in the episode, then it’s usually time to have your nose fixed. When we talk about deviated septum surgery, we’re talking about doing something on the inside of the nose, and we’re talking about taking the crooked parts out of your nose. There’s a couple ways to do it, but both involve doing things on the inside of your nose. One, and it’s more surgeon preference, it’s using an endoscope or using a speculum. And in both cases, the incision for having your septum fixed is on the inside where you can’t see it. It would be on the inside right there, most surgeons are right handed and therefore the incision is going to be in the left nostril. But that’s not always the case because sometimes the deviation in a certain place might make you make the incision on the right side of the nose. But typically when you do a deviated septum surgery, and this is a part that I wanted to talk about eventually but let’s just talk about it now. most of the cartilage and bone in the nose, but you must keep approximately one centimeter of the septum up top and one centimeter here. It’s called an L-strap and the reason you have to keep that is because that part of the septum gives your structure the nose. If you take that out, your nose collapses. You get something called a saddle nose deformity or even worse. So you do have to keep those areas. have all that removed because your septum is actually like a sandwich. There’s two layers of lining or mucosa on the sides, and then there’s a bone and cartilage in the middle. So what we’ll do is we separate those layers out. We take out the areas that we need to take out or that we can take out. And then we put those areas back together and use sutures to hold it in place. The sutures are absorbable. There’s a lot of new technology coming out about using. different types of material to hold those two areas together. But in general, something has to hold those two areas together. In most cases, I don’t think you or Dr. Smith use packing inside the nose, right? We don’t use packing. Occasionally, you have to use splits to hold it in place. But you take out the crooked parts. What I wanted to go over is this difficult situation where you take out the crooked parts of the nose and the one centimeter. front is still crooked. And it’s something I encounter a lot. It’s a tough situation. And you see that in the beginning before you even operate on those patients. And you just counsel them. You say, you know, you’re probably going to get a massive improvement on both sides, but you will have a better side on one side versus the other. And it depends on what side the deviation is on. And it’s important that patients just know that going that out. There’s things you can do to make it better, but ultimately there’s going to be a better side. That’s what I mainly wanted to talk about. Dr. Rady, you want to talk about what it’s like afterwards, after surgery?
Dr. Reddy: Sure, so after the surgery, you generally have a lot of congestion and obstruction in your nose for the first week until the swelling kind of comes down. If you have splints in your nose, it may feel like you can’t breathe very well through your nose while the splints are in place until they come out. And typically on the first post-op visit about a week later, most people are breathing better than when they came in. The first week after the procedure, you can potentially expect some numbness around your nose and maybe the upper part of your teeth and some bloody drainage coming out of the nose. It slowly gets better with time. So the recovery for something like this is not too bad. Out of most surgeries out there, most procedures, I would say it’s a relatively minor recovery for most people.
Dr. Undavia: How long do people take off of work?
Dr. Reddy: Most of my patients take about a week off from work, but it also depends on what you do. I have some people that work, you know, a lot of patients these days work from home and they even go back to work potentially the next day or within a couple days. On average, if you’re going into work, people generally take off a week. I did want to go over one actually additional thing that’s important, I think, with septoplasties that we haven’t touched base on, and that is the relationship with deviated septums. and obstructive sleep apnea and the role of correcting your septum and obstructive sleep apnea, especially with CPAP compliance. Did you want to just touch base on that real quick? So, obstructive sleep apnea is just when you have a cessation of breathing. along with a drop in your oxygenation levels while you’re asleep. And it’s a medical problem that can have long-term implications and generally is treated for most people with a CPAP device, which is continuous positive airway pressure. The problem with CPAP devices is that it is oftentimes not well tolerated and not very comfortable. And one of the main reasons for that for a lot of people, other than claustrophobia issues, blocked and the air can’t get through your nose which is constricted. And so what we find is that if we correct a person’s deviated septum in those people, while it may not cure the sleep apnea, it oftentimes makes using the CPAP device much more comfortable.
Dr. Undavia: Absolutely, absolutely. And the other thing that it will do, there’s actually a ton of studies showing that the quality of sleep and all the things that happen with improvement in quality of sleep get so much better when you have a nose that functions better. The quality of life scores are through the roof just because your quality of sleep is better. more energy during the day and that’s just a simple thing that can get better when you fix your septum.
Dr. Reddy: Remember, breathing through your nose is the way that you are meant to breathe. You are meant to eat food through your mouth, right? And breathe through your nose. Breathing through your nose is a physiologic way to breathe. When you breathe through your nose, your nose filters the air, it warms the air, and it humidifies the air, and there’s a chemical called nitric oxide that’s released that actually improves oxygenation. And this is why when you see… for example, marathon runners running, they’re coached generally to be breathing through their nose and not through their mouth. So breathing through your nose is important. NJENT can help with that. If you guys have any questions or if you want to get more information, you can always visit our website, njent.com, or you could give us a call for a consultation at 609-710-NOSE.