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Septoplasty Without Packings Or Splints

Posted Jun 12 2011 11:23am

One of the most uncomfortable things you can do to another person is to place nasal packs in their nose after nasal surgery.  What’s even worse is when you have to take it out. I know what it feels like, as I had nasal packs after I broke my nose when I was six. I still remember waking up after surgery, with my nose completely stuffed up, and my sleep was terrible.

Unfortunately, ENT surgeons still routinely use nasal packing after nasal surgery, especially during septoplasty. The reason why packing is used is due to a combination of of the nature of the surgery and tradition: The mucous membrane layer on both sides of the midline cartilaginous septum is peeled off, and the deviated portion of the cartilage or bone is removed. Next, the mucous membrane layers are placed back together in the midline. Packs (either long gauge strips or an expandable absorbent sponge are placed on either side of the septum, to compress the mucous membrane layers together. Since cartilage doesn’t have  blood vessels for nutrition, it has to receive its’ nutrient supply from diffusion and osmosis from the inner walls of the mucous membrane layers. If you have a blood clot that separates the two mucous membrane layers, nutrient flow to the remaining cartilage will be shut off, and the cartilage will die off, leading to a drooping of your nasal tip.

So if you don’t use nasal packs, what else can you do? Some surgeons place two plastic or silastic sheets in the nose next to the septum, and then tie the two splints together in the front through the nasal septum. You still have to put something in your nose to press the silastic sheets together. Some use rolled up Telfa pads (the nonstick surface that you see on Band Aids), and others place packing around the splints. Most surgeons take out the splints or packing after 2-3 days, but some leave it in up to 7 days.

Many years ago, I came across a paper showing that if you plug healthy college students’ noses and put them through a sleep study, you’ll see apneas. Another study showed that in patients without sleep apnea who undergo nasal packing for nasal or sinus surgery, the AHI increased from 11 to 37, and for patients with sleep apnea, 14 to 39. It’s interesting to note that patients without sleep apnea who need to undergo nasal surgery have mild underlying obstructive sleep apnea. This is in line with a study I performed many years ago showing that up to 80% of people who undergo nasal or sinus surgery and have recurrent or persistent symptoms have significant obstructive sleep apnea.

As I began to realize how important nasal breathing is to the quality of your sleep, I came to the conclusion that nasal packing was sure to cause apneas. If your septum is deviated, by definition, you’re going to be at a much higher risk of having jaw structures that predispose to obstructive sleep apnea. Total nasal congestion can only make things worse. This is also why even if you’re “normal”, having a stuffy nose from a cold or allergies makes you toss and turn more at night—it’s because you stop breathing more often. These obstructions don’t even have to be apneas or hypopneas—they can be short periods of obstruction that still wake you up multiple times per hour.

You’re probably wondering by now how I get away with not using any nasal packs or splints. It’s very simple: After removing the deviated cartilage or bone, I use a little 1/2 inch needle with a dissolvable chromic suture (stitch) and perform a quilting suture, back and forth from one side of the nose to the other, in a zig-zag manner, until all the areas of separated mucous membranes are closed together. In most cases, I do a very conservative shrinking procedures on the nasal turbinates, so there’s little to no risk of scar tissue connecting the raw surfaces of the septum and the turbinates. Some people also need their flimsy nostrils stiffened as well.

When you wake up from anesthesia, you’re breathing really well. But after a few days, it’s expected to get stuffy again, since all the blood, mucous and secretions will block your nose. You’ll go home a few hours after surgery. Two to three days later, I’ll see patients in the office for a 2 minute “cleaning”, after which you can breathe much better again.  Most people can go back to work after 2-3 days, and about 2/3 of patients don’t even take any prescription pain medications.

Contrary to conventional perceptions of the misery of undergoing a septoplasty procedure, there are now ways of minimizing pain and discomfort. Surgery is never a walk in the park, but well worth the ability to breathe clearly through your nose again.

 

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