Dr. Miller: So you have a deviated septum. Does that need to be fixed and what symptoms does a deviated symptom cause? We're going to talk about that next on Scope Radio.
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Dr. Miller: Hi, I'm here with Dr. Jeremiah Alt. He is an ear, nose and throat physician. He's also a professor here at the University of Utah and a member of the department of surgery. Jeremiah, what's the story of the deviated septum? What is a deviated septum and, if you have one, do you always need to have it fixed?
Dr. Alt: We commonly have patients who come in with complaints of just simple nasal obstruction. Commonly, we have to go through the differential diagnosis of what that is.
Dr. Miller: You mean they can't breathe out of one side or both sides of their nostrils, is that right?
Dr. Alt: Yeah, correct. As a rhinologist, I commonly see patients with sinus disease and congestion and allergies. It also commonly comes up that they just have what's called septal deviation and the septum itself separates basically the right and left side of the nose.
Dr. Miller: So it's your nose bone?
Dr. Alt: Yeah. It's made up of both cartilage bone. The septal deviation can occur just from normal development as everything is not perfectly symmetric as we develop. So it can be deviated to one side or the other. It can also occur from trauma.
Dr. Miller: Getting boxed in the nose.
Dr. Alt: Getting boxed, vehicle accidents, getting bumped in the nose. So after the trauma, this is an acute event, someone would come and say, "I can't breathe out of the right side of the nose," after getting bumped or something that's been there their whole lives and they've just noticed that they're having increased trouble breathing, they can't sleep as well.
Dr. Miller: I'm curious, is deviated septum mostly due to trauma or are people born with it?
Dr. Miller: I think the majority is they're born with it or we have a known etiology of why it's deviated.
Dr. Miller: Okay. So the come to you and they complain that they have difficulty breathing out of one side of the nose or the other or maybe both. At what point do you say, "Well, look, maybe we can repair this surgically if you need to have it repaired"?
Dr. Alt: A lot goes into talking about the deviated septum. In many instances, it's found incidentally, which means we look in their nose and they have a deviated septum but they don't describe nasal obstruction.
Dr. Miller: And under those circumstances, you probably wouldn't recommend surgery?
Dr. Alt: Correct. In those situations, I don't even like to bring it up because then it's something that patients start to worry about. But if it's significantly deviated and we look at it and we assess the patient and it's significantly closing off one side of the airway, we can discuss different surgical options and how to correct that.
Dr. Miller: I have a question. How often do people come to you to looking for cosmetic reconstruction of that bone?
Dr. Alt: That bone itself is usually not cosmetic. It's functional. It doesn't correlate into how the nose looks.
Dr. Miller: So that's a whole different type of surgery.
Dr. Alt: Correct.
Dr. Miller: Not to be confused with the symptoms that a deviated septum would cause.
Dr. Alt: So that's really talking about what we usually term open septorhinoplasty is where were able to change the look of the outside of the nose or [Inaudible 00:03:12] and changed inside the nose for functional breathing, which sometimes we do in combination if the nose is broken or twisted on the outside, we also have to fix the outside in addition to the inside.
Dr. Miller: So how often do you find the patients with need to have surgical correction for a deviated septum?
Dr. Alt: It's actually quite common. It's one of the most common procedures we perform. Not only is it bothersome in the sense that they can't breathe but it substantially affects patients quality of life, which has been shown over and over again by improving the way we breathe through our nose substantially affects how we feel in our day-to-day activities. And this is most likely partially contributing to the way we sleep and the way we get good night's sleep. If we can't breathe through the nose, it forces us to breathe through the mouth and we may have more obstructive events and it can also potentially lead to what we call obstructive sleep apnea.
Dr. Miller: So how do you do the surgery?
Dr. Alt: So there are several options to do surgery and one that we're doing more and more that gets great results is doing endoscopic septoplasties. So it's using angled and straight, rigid endoscopes with that special high-definition camera. And we're able to make very specific and delicate incisions within the septum to take out those crooked parts and so there are no external incisions on the nose. It's all done on the inside of the nose and we feel that patients get great functional responses and, at the same time, have quicker healing.
Dr. Miller: Now, do you tell your patients that they are going under general anesthesia? Do you put them to sleep when you do these or is it a local sort of anesthetic you use?
Dr. Alt: Yeah. I would not recommend local and patients probably wouldn't like me very at the end of the procedure. So we really counsel the patients that these should be done under general anesthesia where they're totally asleep, they're not moving. We have the ability to take our time and do the job correctly.
Dr. Miller: What's the recovery like?
Dr. Alt: Really, the recovery's not too bad. We normally tell the patients they'll probably have to take pain medications for two to three days. Commonly, these type of procedures used to be packed with nasal packing. We no longer pack the nose. We moved into placing splints on the inside of the nose like flexible plastics splints, but even now we're even moving away from that. So many times, we can get away with doing the what we called endoscopic septoplasty without putting any packing in the nose and so this helps patients feels better and recover quicker too, as they're not obstructed with something in their nose we don't have to take out in a week. Usually, at a week, at that point, the patient feels great, usually back to light activity. At two weeks, you're completely healed.
Dr. Miller: Now, for a patient who is going to primary care physician, is a primary care physician usually able to tell if they have a deviated septum or do they usually refer them to make that diagnosis?
Dr. Alt: I think in general, you can determine what we call a caudal septal deviation. It's more towards the front of the nose because you can just look at it with the simple measure of using the nasal speculum looking at the front of the nose and you can tell if it's deviated. Interesting enough, those septums that are more deviated or caudally towards the front of the nose actually usually need a more significant type of surgery, which we'll discuss with the patient, but that usually actually leads to what we call an open septorhinoplasty.
Many times, the posterior septal deviations are easier to fix endoscopically and those are actually harder to diagnose because you need to see further into the nose. So seeing someone like an ENT or rhinology person like myself, we're able to use scopes to look at the septum more posteriorly in the nose to diagnose it.
Dr. Miller: So in conclusion, what three things might you told the patient that would lead them to your doorstep to where you would make a diagnosis of a deviated septum?
Dr. Alt: I think the first thing is if they're having trouble breathing through their nose. Typically, it's unilateral, but it can be both sides, bilateral. The next thing is if this is causing significant changes in how they feel and how they function during the day, if the obstruction's bad enough where they feel like they need some improvement. And third, which we didn't mention, but I think should be mentioned here conclusion, is that many times, medical management can improve nasal obstruction even with septal deviation. So commonly of pretrial of medical management needs to be done before you start discussing . . .
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updated: January 23, 2019
originally published: November 11, 2015
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