Nasal Airway Surgery

Nasal Airway Surgery

Contents


Introduction to Nasal Airway Surgery


Those of us without problems breathing through our nose take it for granted. Those with nasal congestion and obstruction know they can have a debilitating effect. It can ruin our sleep, impair physical performance, and diminish our overall health. For this reason, procedures to correct these conditions are typically covered by health insurance.

There is a wide variety of conditions that affect nasal breathing including deviated nasal septum, hypertrophic turbinates, internal and external nasal valve collapse, and nasal septal perforations. We specialize in correcting these issues to help patients breathe better. A more functional airway can lead to reduced sinus symptoms, better use of CPAP devices for sleep apnea, and even reduced snoring. During your consultation, Dr. Patel will let you know what custom combination of procedures will help maximize your nasal health.

Approaches & Techniques


Nasal Valve Repair

The nasal valve is the compressible portion of the nose below the bone. It is critical for breathing through the nose. Normally, the muscles and cartilage of the nose resist collapse. However, a structural weakness or crooked nose may predispose to nostril collapse. In addition, this area is affected by other internal structures such as the nasal septum and inferior turbinates. A nasal valve repair is performed by using grafts from your open septum to widen the valve area and improve airflow. 

Septoplasty 
(for Deviated Nasal Septum)

The nasal septum is the partition between the left and right nasal passages. It is composed of cartilage in the front of the nose and bone in the back. The septum is important for the function and appearance of the nose because it directs airflow and supports the lower nose. A deviated nasal septum may block a portion of the airway and cause the nose or nostrils to appear crooked. You may be born with this problem or it may develop from an injury to the nose. We often see patients who report childhood injuries that initially did not cause a problem, but became more apparent over time. This is a structural problem so nasal sprays and decongestants will only help to a limited degree. 

During surgery, we remove the affected cartilage, flatten it, and replace it in the septum. Sometimes we have to re-position an entire segment of the septum to the midline. For deviations present in the nasal valve area, we often use cartilage grafts to splint the septum and enlarge the valve area (see Nasal Valve Repair).

Turbinate Reduction

The turbinates are “mounds” of tissue in the nasal cavity that shrink and swell periodically to humidify, warm, and direct airflow. If we did not have turbinates, airflow would be dry, cool, and turbulent in a large nasal cavity. Allergies or infection can trigger persistent and excess swelling of the turbinates, thereby obstructing the airway. Steroid sprays, antihistamines, and decongestants are very helpful, but may not be enough over time. 

Because the turbinates play such an important role in normal nasal health, yet can be a problem in certain situations, the best treatment is a conservative reduction. This may involve merely fracturing and pushing the turbinate out of the way or partially removing turbinate bone and tissue.

Septal Perforation Repair

A through-and-through hole in the nasal septum may seem like it would help breathing, however, it actually makes it worse by creating turbulent airflow. Those who suffer from this problem may also experience a whistling nose when breathing, frequent crusting and nasal drainage, or severe bleeding from the nose. For some, it may even be painful or a saddle nose deformity may develop. Septal perforations have a variety of possible causes including intranasal drug/medication use, chronic picking, autoimmune disease, and previous surgery or trauma.

Repairing a nasal septal perforation is an extremely complicated operation requiring transferring of internal nasal tissues and free tissue grafts. To learn more about this, see the section below on Septal Perforation Repair Technique.

Saddle Nose Repair

A saddle nose deformity is a collapse of the nasal bridge and upturn of the nasal tip. For the unfortunate patients who suffer from this condition, it is socially and functionally debilitating. The deformity is usually due to a very large perforation that has weakened the support structures of the nose and may have resulted from trauma, previous surgery, infection, or autoimmune disease.

We must harvest and carve a rib cartilage graft to replace the nasal bridge. It is preferable to use your own rib cartilage, but Dr. Patel may also use donor rib cartilage for this purpose. A nasal valve repair may also be performed and the nasal tip is often re-positioned it to a more natural position.

Planning Your Procedure


The Consultation

During the consultation, we will also review your medical history and the history of your current airway problems. We will examine your nose, both externally and internally. We will test the airflow from both nasal passages and check for dynamic valve collapse.

Duration of Surgery

Nasal airway procedures usually take 1 to 3 hours, depending upon the number of procedures required. A septal perforation repair can be a much more complicated procedure requiring many more hours, if other types of grafts (e.g. temporal fascia, rib) are required. This is usually an outpatient procedure.

Anesthesia Options

To ensure that your lower airway is protected during the procedure, our standard protocol is general anesthesia at a surgery center. 

Incisions

The external incision for an open rhinoplasty is located on the columella (between the nostrils on the underside of the nose). The remainder of the incisions are located inside the nose. There are several ways techniques we use to make the incision heal well. First, the incision is shaped like a “W” instead of a straight line, as the human eye sees straight lines better than curved or jagged ones. Second, it is placed far back on the base of the nose, which allows better camouflage. Third, unlike most, we take the time to place deep, dissolvable sutures that keep the closure strong for many months. In the vast majority of patients, the incision heals well and will not be seen by the casual observer. The rare visible scar is easily correctable in the office.

Recovery

Typical at-home recovery time is 1 week. Immediately after surgery, most patients will have light packing in the nose that is removed the following day. A protective splint is placed on the nose upon which glasses may be worn. A mustache dressing is taped over the upper lip to passively collect any nasal drainage and is usually required for 24-48 hours. In most cases, there are stitches located between the nostrils. The splint and all visible stitches are removed after 5-7 days.

Pain

The first night after surgery, you will feel a dull ache around your nose that we will instruct you how to treat and minimize. Everyday thereafter, any discomfort will reduce significantly. Most patients are bothered by postoperative nasal congestion more so than pain. This congestion takes a few weeks to clear up but we will instruct you how to reduce it.

Swelling & Bruising

Swelling is a normal part of surgery that mostly manifests inside the nose. Bruising is rare except in rare cases of nasal valve repair. About 90% of the swelling subsides by 6 weeks after surgery. Drainage also reduces significantly over this period.

Nasal Packing

We use a very light packing the first night after surgery for most patients. It is of great benefit because it reduces the risk of any serious nose bleeds and helps keep swelling down inside the nose. The packs are not painful and are easily removed the day after surgery.

Nasal Congestion

Your nose will be congested after surgery. The swelling on the outside is also present on the inside. Also, the nose produces more drainage for a short time after surgery. These are all temporary. You may improve your breathing during this time with oral decongestants and non-medicated saline sprays.

Special Topics


The Internal vs External Nasal Valve

The nasal valve is usually separated into two parts: The internal nasal valve is located just below the bony bridge of the nose and can be pinched between your fingers. Notice when you do this how much it restricts your ability to breathe through your nose. The external nasal valve is located at the nostril opening. In some, this opening is slit-like and closes even with normal breaths. A droopy nasal tip may also contribute to external nasal valve collapse. 

The internal and external valve areas are continuations of one another and so it is not uncommon for a patient to have simultaneous collapse of both valves. For the internal nasal valve, cartilage grafts are used to spread apart the septum from the nasal sidewall. In effect, this “opens up” the valve to greater air flow. Also, sandwiching the septum between grafts has a splinting effect to help straighten the septum. Other techniques used in this area include placing permanent sutures to suspend the valve and resist collapse. For the external nasal valve, cartilage grafts are used to support the tip cartilages and nostrils to prevent collapse. The cartilage may be obtained from the nasal septum or from the bowl of the ear. When the patient has a droopy tip, elevating the tip also may open the nostrils. 

Septal Perforation Repair Technique

Generally, small- and medium-sized nasal septal perforations are best closed with an approach that replaces the perforation with adjacent intact septal mucosa. Often, free tissue grafts from the scalp are also used to support the repair and help prevent re-perforation. Closure with other techniques generally replaces the perforation with tissue that is quite unlike nasal mucosa, and this can lead to a chronic dry sensation in the nose after surgery. Large and subtotal perforations are often not repairable by the methods described above. In these cases, an alternative method may be required or some patients may elect to use an implant called a septal button. These soft, medical-grade silicone implants are cylinder-shaped and come in multiple sizes to fit the perforation.
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