Why Can’t I Breathe After Septoplasty?

What you’ll learn

• Why patients may still experience difficulty breathing through their nose after a previous septoplasty or nasal surgery
• The reasons for persistent nasal obstruction, including issues with the nasal valve, turbinates, and other areas of the nose.
• Other factors, such as allergies, irritants, and lung problems, can also contribute to nasal obstruction and should be considered in the evaluation and treatment process.

Listen to the audio version below.

Audio Transcript:

Dr. Smith

Hello, welcome back to the We Nose Noses podcast. Dr. Smith here with Dr. Reddy and Dr. Undavia. And today we’re gonna discuss a common topic that we see frequently in the office, which is I’ve had a previous septoplasty or nasal surgery. However, I still feel like I just can’t breathe freely or clearly through my nose. And so we’ll go over some of the common kind of pitfalls or mistakes that sometimes may happen after nasal surgery, as well as maybe some other options and some things that might be out there for patients who still just feel like they can’t breathe completely freely through their nose after a previous nasal surgery.

Dr. Reddy, can you tell me kind of what these patients may present like and kind of your experience with these patients coming in to see you?

Dr. Reddy:

Sure, so oftentimes we’ll get these second opinion type consults where a patient might come in to see us and they’re basically frustrated that they’ve been to an outside surgeon and oftentimes have gotten some type of a nose procedure, usually a septoplasty. And maybe they were breathing better for a little bit after the procedure, or maybe they were never really breathing better after the procedure. And they’re a bit frustrated because they went through this whole surgery with this whole recovery and they still have their symptoms of nasal obstruction.

Dr. Smith:

Perfect. So Dr. Undavia, some, to kind of explain what a septoplasty is in layman’s terms for patients, cause sometimes people just think nasal surgery and they have not really sure what they had done in their nose, but what are some common things that maybe they would have done in layman’s terms in their nose to help with their breathing?

Dr. Undavia:

Yeah, most patients come in and they say, I had my sinuses fixed when really they had a septoplasty. A septum is the dividing wall of the nose and it starts here and it goes all the way back to your ear and it is a long structure. And when you have a septoplasty, if it was crooked like that, you make it straight like that. That is the most common thing people have had done.

Sometimes they have their turbinates addressed and there’s many different ways to address a turbinate, but they’ve had their turbinates addressed in one of those ways. And then sometimes they’ve had actual sinus surgery where they’ve had their sinuses opened.

Dr. Smith:

Right. Okay. Perfect. And so, you know, nasal breathing through the nose, there’s a lot of areas where there can be restriction. And so when we talk to patients in the office, you know, most commonly we talk to them about their septoplasty or the hard fixed structures that may be causing some nasal obstruction that are kind of right in the forefront of our vision and view that might be more obvious. And the septum is one of them. The turbinates are another one. Dr. Reddy, do you want to describe kind of one of the one area in the nasal cavity or what the nasal valve is and how that can affect the nasal breathing?

Dr. Reddy:

Sure. So the nasal valve, is comprised of two different areas. There’s the external nasal valve, which is basically your nostril, and then you have the internal nasal valve, which is comprised of these different structures. There’s this cartilage called the upper lateral cartilage, your septum, and where your turbinate is, your inferior turbinate. And that area is oftentimes frequently narrowed. And in my experience, this both external and internal nasal valve collapses grossly kind of misdiagnosed or under diagnosed in the general public. Even oftentimes by doctors, including ear, nose and throat doctors, it’s very oftentimes not seen or not addressed in the first surgery that they have. And so a lot of patients that have persistent issues with breathing, almost all of them have some type of dysfunction with those two areas.

Dr. Smith:

Yeah, perfect. So the nasal valve, sometimes those you know, we like to think that if you fix the septum and you fix the turbinate, you may not need to do anything for that lateral nasal wall cartilage, but sometimes you do. And so that’s sometimes tricky to figure out upfront whether that nasal cartilage needs to be addressed at the same time. And some patients may have thin skin. And so you’re afraid of doing anything that might cosmetically change the outward appearance of the nose as well. And sometimes nasal valve procedures can affect the position of the cartilage and the appearance of the nose. Now typically it does not, but occasionally those things can change the outward appearance of the nose as well. Now there are other procedures for the nasal valve as well. Dr. Undavia, since you do a lot of cosmetics and facial plastics, do you want to go over kind of what a functional rhinoplasty is and some of the things that we may traditionally do for a nasal valve?

Dr. Undavia:

I was just thinking, so yeah, do you want to go over what we see in these patients first before we go through that? Like, I can do that really quick.

Dr. Smith:

We’ll go over that and then I’ll talk about other things that we might miss that might, or a patient might not be doing ahead of time that we want to do before doing a procedure, but this is more anatomy type thing.

Dr. Undavia:

Got it. Okay. So yeah, when we talk about the nasal valve and what we might do for a functional rhinoplasty, we’re really talking about either supporting, well, we are talking about supporting the soft structures of the nose. So non -bony structures. So either the soft tissue part of the nostril right here or the cartilaginous part of the nose up here. So when you talk about fixing what Dr. Reddy called the external nasal valve, we talk about putting either an allar batten graft or a lateral strut graft, which are just rigid pieces of cartilage here to make sure that the nostril doesn’t come down here.

Or you can do something called a spreader graft, which is a rigid piece of cartilage here, which takes, the internal nasal valve should be about 15 degrees. So if it’s narrowed, you just want to put a graft in there and it brings it out to about 15 degrees.

Dr. Smith:

Okay. So yeah, so there are anatomical things that can be addressed that may be a problem. So we look for those or examples of those on exam. One thing when we start talking to a patient taking their history, you want to make sure that we figure out allergies because a lot of patients may have acquired nasal obstruction. So they may have a great septoplasty and turbinate reduction, but they’re not using nasal steroids or antihistamines or saline rinses or maybe getting exposures to a lot of irritants from chemicals and paint and other things that work that may cause inflammation in the nose. So, you know, they’re not always just straight anatomical or anatomy problems.

Sometimes they are swellings within the nasal cavity due to allergies, irritants, and other things that can trigger swelling in the nasal cavity. There are reactive tissues within the nose, like those turbinate tissues. And so one area that doesn’t often get addressed in an original procedure are some of the turbinate and turbinate -like tissues. So we often reduce some of the size of the turbinates by reducing the bone.

But there are other areas in the nose and maybe Dr. Reddy can talk about these areas that more recently in the last five, 10 years, we’ve started kind of being able to address due to more minimally invasive techniques and procedures.

Dr. Reddy:

Yeah, sure. So the procedure you’re alluding to is called Viveir, which is a radio frequency ablation device that we do right in the office that basically shrinks tissues and makes cartilage a little bit more resilient to collapsing. And the areas that they can treat is the internal nasal valve, which Dr. Undavia alluded to, but also these other less understood areas in the nose called the septal swell bodies or the vestibular swell bodies. Now these areas in the nose have similar function to maybe what the inferior turbinates and the middle turbinates have in the nose. They provide some amount of airway resistance. They help with humidification and filtration and warming of the air. But if they’re too swollen, they can cause a lot of issues with nasal obstruction. And so traditional surgery, it’s difficult to address those issues. But with a radio frequency ablation wand like Viveir, you can actually shrink those tissues at the same time as you address the nasal valve.

Dr. Smith:

Great, so yeah, of course, going back to what we were just talking about with the procedures, we wanna make sure that everybody’s exhausted just with any other surgical option. We wanna make sure they exhaust all medical options first, and so that’s including rinses and nasal steroids and antihistamines. And so when a patient comes in and they’ve either been consistent with doing that, they’ve had allergy testing, they’ve done everything that they can possibly think of, and we kind of assess to make sure that that was done appropriately, either with a prior ENT or an allergist and/or ourselves, then we start thinking about surgical options. And we’ve kind of addressed some of those and talked about those as well. But when do you discuss with a patient about, okay, I think we’ve tried everything else. Now I think one of these options might be the way to go.

Dr. Undavia:

Yeah, I think if you’ve given nasal sprays at least six weeks, if you’ve given sinus rinses at least six weeks and you just don’t feel better after your first surgery, we have to do something because at six weeks you should have a pretty good result with whatever you’re trying medically. Sometimes we have, especially with the nasal valve, we have patients try like a breathe right strip just to see if that works. A breathe right strip is not a surgical thing, but it’s something you buy over the counter. And again, it just helps to have some of the soft tissues flare out gives you a little bit more of a nostril opening and you can see if that resolves the problem. And if that does, we’re not telling you to wear a Breathe Right Strip forever, but it helps us decide what to do next, which is support whichever structure the Breathe Right Strip is helping. But yeah, after about six weeks, if it’s not helpful, we talk about surgery.

Dr. Smith:

Yeah. Another thing that we sometimes will ask patients to try, which I tell patients I hate this medication, but often I’ll ask if they’ve tried it, a nasal decongestant. So just like the breathe right strips, you can get an idea if the nasal valve might be an issue. A nasal decongestant like Afrin will shrink all turbinate and turbinate like tissue. And so the swell bodies, vestibular bodies, and the turbinates will shrink up quite a bit, those responsive tissues. And so if they use Afrin, they notice a significant improvement with their nasal breathing that can allude to give you some ideas as to what procedure they may be better having. Of course, we can do that in the office by the way. We can check for you. We can decongest and take a look at as before and after decongestant to see does the nose significantly look better and does that correlate to your symptomatic improvement of nasal obstruction and nasal restriction. And then at that point we can kind of figure out what the next step is.

So I tell patients like the one pitfall I’ve seen with patients coming in for second opinions is that often, you look in there and you look and you go, the septum’s still maybe a little bit crooked one way or the other way. And the turbinates, maybe they’re a little bit too big in one little spot and maybe that’s the problem. And sometimes there are, like sometimes septums will redeviate, sometimes the surgery wasn’t good enough and it didn’t straighten it enough. And sometimes the turbinates were left too large. But the one thing I always tell patients is like, you wanna be leery about like repeat turbinate surgeries, right? You don’t wanna just keep cutting more and more turbinate out and missing the very obvious nasal valve. Because a lot of patients, yeah, you might look in there and go, yeah, the septum’s a little bit deviated, but in reality, it might be a nasal valve. And as Dr. Undavia said, there’s Breat Right strips and decongestants. They can help with that.

Dr. Undavia:

I wanted to just talk quickly about patients are obviously very frustrated after their first septoplasty. And a lot of times they want to say like something was done wrong afterwards. So first, there’s about 10 or 15 different ways to do a turbinate, which tells you one thing. No one way is perfect. If there was one way to do it, then the perfect way to do it, we’d only have one way. So there’s a lot of factors that go into how you do a turbinate reduction. And so each one has its benefits and its negatives. But the other thing that patients, especially in my practice, come in the office and they tell me my nose still has a deviated septum. And you know, sometimes there’s a deviated septum in the back a little bit. But what I really wanted to talk about was the front part of the septum where there’s one centimeter of septum along the top and in the front that you cannot take out. And you can make adjustments to them. But if that part is still crooked, that’s a difficult thing to fix because if you can’t take that out, if you did, your nose would collapse.

So a lot of times patients still do have a deviated septum afterwards, but it’s appropriate. It’s appropriate.

Dr. Smith:

Yeah. And as I was saying, like not all small deviations in the septum is making a big obstruction in the nose. So I think that’s one common pitfall is a look at that septum and go, I could make that a little bit better. Let’s keep going back there and trying to get it. So, you know, finding an ENT that understands the anatomy well, all the options out there.

We’ve talked about this, Dr. Reddy, a lot about making sure someone knows all of the options and not just some of the options. And there’s minimally invasive procedures like these newer radiofrequency or these newer implant type procedures that can be done for the lateral nasal valve are an important part of our armamentarium to make sure that we have all of the options at our disposal so that patients really can get the best result.

How about anything beyond the nose that might have been missed or not treated and may be causing, you know, quote unquote nasal obstruction or patients that say they can’t breathe freely after they’ve had a septoplasty or there are other areas in the nose or even outside of the nose that you may think of that might cause nasal obstruction and been overlooked? Like adenoids.

Dr. Undavia:

Yeah. So like some things in the back of the nose like the adenoids, which is essentially the tonsils, but a little bit higher.

If they’re still a little bit big, they’re technically the last valve before the air enters into the back of the mouth. So if they’re big, no matter how straight your septum is, you’re still going to have trouble breathing.

Dr. Smith:

And of course, like lungs and lung problems, like there are some patients that come in and tell me, I can’t breathe. I can’t breathe through my nose. And it really is wide open, but they may have some restrictive lung problems and so some people do need like a pulmonary or an allergy workup As well to make sure there’s no other issues.

Dr. Reddy:

Yeah, and the other make the other big area is habitual right? There’s a lot of people that can breathe through their nose well after surgery, but they may be so used to breathing through their mouth for so long that it takes some time for them to really retrain themselves to breathe through their nose. And so that’s when I, mouth taping can be really helpful and that’s taken off a lot. But you just have to make sure that if you’re mouth taping that there is no obstruction because it’s technically unsafe if you do it that way.

Dr. Smith:

And there are physical therapists that will also do like breathing retraining. So there are certain types of breathing retraining therapies that are out there as well. Seems kind of silly how could you not know how to breathe through your nose but if you’re constantly breathing through your mouth, yep, it’s habitual. So I think we’ve kind of talked about this at length. If there’s any questions or any things that you guys would like to discuss, feel free to contact us. Thanks for joining us on another episode of We Know’s Noses podcast.