Functional Nasal Surgery

Nasal obstruction is characterized by a decreased ability to breathe through one or both sides of the nose and can have a significant impact on daily life. Some of the ways this can interfere in lifestyle include:

• Poor sleep
• Waking up with a dry mouth
• Exercise intolerance due to mouth breathing
• Inability to breathe when lips are closed

Determining the exact cause of the obstruction is paramount to successfully treating the obstruction. Nasal obstruction can be caused by a single factor or a combination of many factors. The most common causes of nasal obstruction are:

• Allergic rhinitis – allergies causing nasal lining swelling
• Septal deviation – a crooked septum blocking the nasal passageway
• Nasal valve collapse – weak nasal sidewalls that slightly collapse with breathing

Each of these factors must be carefully evaluated to see how they contribute to your symptoms. Depending on the cause of the nasal obstruction, these issues may be treated with medications, nonsurgical interventions such as nasal cones, or with surgical correction.

What to Expect During Your Appointment

At your first appointment you will meet with the surgeon who will carefully review your personal and medical history along with a thorough examination of your nose; both inside and out. Be prepared to discuss any difficulties breathing through your nose as well as any previous nasal surgeries. The examination may include nasal endoscopy to carefully inspect the structures inside the nose. This involves placing a small endoscope into the nose to see more detail than is visible looking directly through the nostrils, a topical numbing spray will be used prior to the exam.

Your surgeon will explain the details of the surgery, operative risks, expected recovery time, post-operative medications and restrictions along with follow up visit schedule. You should expect the opportunity to ask all questions you may have about the surgery and understand what to expect throughout the process.

Surgical Treatment Options

Surgical treatment options will vary depending on the identified cause of your nasal obstruction. Your surgeon will tailor treatment to match your individual needs. Sometimes additional cartilage is necessary in order to provide a stable nasal structure, this may be obtained using cartilage removed from the far back portion of the septum, the ear, the rib, or cadaveric cartilage.

Septoplasty

One of the possible causes of nasal obstruction may be a crooked (deviated) septum. The septum is the part of the nose that divides the nostrils. Septoplasty surgery involves straightening and occasionally removing crooked areas of the septum. Depending on where the septum is deviated, surgery may be performed in different ways. If the septum is crooked toward the back of the septum, then often times, a traditional “endonasal/closed” septoplasty is performed. This approach uses an incision inside the nose and does not change the appearance of the nose. If the septum is crooked at the front, or the entire septum is so crooked that it causes the outside of the nose to appear crooked, then an “external/open” approach is utilized. This approach is used for rhinoplasty surgeries as well and involves a small incision along the front of the nose called the columella. Although this incision is on the outside of the nose, it typically heals so well, that it is imperceptible. When this approach is taken, the entire septum is treated, and the external nose also will appear straighter after surgery.

Before & after septorhinoplasty: frontal view.

Before & after septorhinoplasty: side view.

Nasal Valve Repair

The nasal valves are known as the most narrow points within the nasal passageway. When these valves are narrow or weak, it can cause significant nasal obstruction, also known as nasal valve collapse. The two most narrow areas in the nose are at the external valve and the internal valve. When the external valves are narrowed, this sometimes can appear as deep creases along the upper nostrils. When the internal valves are narrowed, this sometimes can appear as a pinched nose at the middle region of the nose. The nasal valves may be narrowed at rest, or may narrow only with inspiration.

Signs of nasal valve collapse include:

• The nostrils collapsing inward with deep breathing
• Pulling the cheek outward improves breathing
• Improved breathing by wearing Breathe Right® strips

There are several surgical techniques utilized to address nasal valve issues. These techniques involve placing a cartilage graft and sutures to help support the structure of the nasal valve. Like a septoplasty, the incisions may need to be placed inside the nostrils or a small incision may need to be placed across the columella. The surgical approach to repairing nasal valves depends on the severity and location of the obstruction. Nasal valve surgery can be performed at the same time as the septoplasty and turbinate reduction, if all procedures are needed.

Nasal valve collapse: before & after surgery.

Alar retraction: before & after surgery.

Turbinate Reduction

Enlarged turbinates may reduce the airflow through the nose. There are three turbinates on each side of the nose, these function to humidify and heat the air we breathe. However, when the turbinates get too big they can obstruct the airflow, causing issues with breathing. There are several surgical options to decrease their size. Turbinate surgery is most often done as a supplemental surgery.

What to Expect

The Day of Surgery

Functional nasal surgery is done in the operating room under general anesthesia. Expect to arrive to the hospital or surgery center one to two hours before your scheduled surgery time and remember not to eat or drink anything after midnight before surgery to minimize risks related to anesthesia. You will meet the Anesthesiologist and operating room team at this time. Your surgeon will also see you before the surgery begins to review the plan and make sure all of your questions are answered.

The surgery itself will last several hours. After surgery the skin of your nose will be covered with some surgical tape and often a plastic cast. Dissolvable sutures will be present inside the nose and if needed there may be some sutures on the strip of skin between your nostrils. Sometimes flexible splints are secured inside your nose. You may have some occasional oozing of blood from the nostrils as well as some swelling and discomfort of the nose. There may also be some bruising under the eyes.

In the recovery room you will be closely monitored to ensure your pain is well controlled and all of your vitals are stable. At this point you will be cleared for discharge home. You will need a friend or relative to drive you home after surgery and stay with you for the first one to two days after surgery.

During Your Recovery

After surgery you will be discharged home with prescriptions for pain medication and possibly antibiotics or anti-nausea medication. You will also have written wound care instructions which include spraying the inside of your nose with a saline spray several times per day and applying antibiotic ointment to the incision lines. It is common to have some intermittent drops of blood from the nostrils for the first several days that can be dabbed away with a tissue. Expect your nose to feel congested after surgery, especially if splints are placed inside the nose.

You will have pain following surgery, but with the medication the pain should be tolerable. This rapidly improves through the first week. You may also have some swelling or bruising under the eyes. Elevating your head during sleep and applying light weight ice packs to the cheeks can help speed up the resolution of the swelling and bruising. You should be up and around the house after surgery but avoid any strenuous activity, bending at the waist, or heavy lifting to minimize swelling, bleeding, and discomfort. Walking and light activity is encouraged and may help speed up your recovery.

Your first post-operative visit will be scheduled for five to seven days after surgery. At that time you will meet with the surgeon to review your recovery. The external nasal splint will be removed at that time along with any sutures on the skin or splints inside your nose. Your nose will be carefully examined to assure that you are healing well. At this visit your surgeon will discuss the next steps in your recovery including any limitations on activity or work and additional follow up visits. Most people return to work one to two weeks after surgery. While recovery proceeds quickly in the following weeks, keep in mind that it will take a full year for all the swelling to resolve

Combined Functional & Cosmetic Rhinoplasty

Many of the cosmetic rhinoplasty procedures that address desired cosmetic changes to the nose use the same surgical approach that is used for functional nasal surgery, and it is common to combine surgery to improve breathing as well as the shape of the nose. When structural issues are present that require surgery to improve breathing, these procedures are typically covered by most insurance companies. Surgery to change the shape of the nose that does not affect breathing is not covered by insurance and carries a separate cost, but can easily be completed while you are having surgery to improve breathing.

Combined Functional Nasal & Sinus Surgery

Some people suffer from a combination of issues with nasal breathing and chronic sinus problems. We work with our partners who are specialists trained in sinus surgery to address your health needs.