Sourced from Classic Sleep Care- Totally CPAP by Dr. Steven Park: Part VIII (Surgical Options)
In the second half of Chapter 8, Dr. Park focuses on the surgical options for the three most common conditions causing nasal congestion that might not be relieved by the medical options we discussed in Section 1 of this post: deviated septums, swollen turbinates and flimsy nostrils.
Septal Deviation and Septoplasty
Dr. Park begins with a discussion on how the septum or midline structure that separates the nostrils into two openings has a cartilage portion in the front and a bony portion in the back. When the septum is crooked for whatever reason, you may be more susceptible to a stuffy nose, and a septoplasty (to straighten the septum) may improve the stuffiness. However, you might also possess a crook septum and not have a stuffy nose, so there is no requirement to undergo surgery on your nose in such circumstances.
Dr. Park describes a very interesting theory about the origin of deviated septums. The conventional wisdom is that the septum becomes crooked following trauma, usually during delivery at birth or getting punched or knocked in the nose later in life. However, in this newer theory, in a nutshell, anatomical development of the jaw and dental structures are shrinking in modern society due to dietary and other influences, which changes the nasal cavity in such a way that the normal septal development must occur in a smaller space than normal. As a result the septum “buckles” and becomes crooked.
In Dr. Parks’ own words with some paraphrasing, here is a more detailed description:
“….jaws are shrinking due to what and how we eat….Soft foods, bottle-feeding, thumb-sucking, pacifier use, prematurity and nasal congestion…are all factors in crooked teeth….Crooked teeth means your jaws are not big enough to hold all your teeth….in some cases, the roof of the mouth doesn’t drop down normally, leading to narrow dental arches, resulting in smaller oral cavity size and crowding inside the mouth….Inside your nasal cavity, if the floor of the nose (the topside under which is the roof of your mouth) does not drop down, the nasal septum cannot grow properly and buckles from the limited space….The nostrils in turn will be pressed closer to the midline, leading to greater risk of collapse when breathing in.”
Dr. Park next describes the basics of a septoplasty, but without a diagram or other graphic to follow along, it was a bit difficult to follow the narrative, and I would not want to attempt to retrace his steps as I possess no surgical background. A main theme of this section is that the surgery must be done well, otherwise various side effects may occur; and at our center, we have noted that many patients with deviated septum repairs still demonstrate persisting septal deviations years later. It is also not a rarity for the surgery to fail and then be repeated within the next year, so we resonate a great deal with Dr. Park’s main point that the surgery must be done very well to get things right.
Post-surgery, your expectation should be that some immediate improvement in nasal breathing can occur in as little as 2 to 5 days, but the total healing process may take weeks or months, during which there will be ups and downs due to crusting, swelling, bleeding, and the need to evacuate the debris in a very gentle manner as well as managing the regular mucus build-up. Final, healthy scar tissue that situates things in their proper place could take weeks to months before benefits are maximized. Pain-wise most patients do well with over the counter pain killers.
The main risks from the surgery are infections and bleeding, but these problems are not very common. Careful follow-up by the surgeon can usually rectify these issues and insure no further consequences. Despite the high success rates for septoplasty, nasal congestion may return in some patients. Dr. Park points out the three most likely problems causing the persistence of congestion in these circumstances: (1) the septal repair was not aggressive enough; (2) the turbinates are swollen and need attention; and (3) the problem of flimsy nostrils.
Turbinates and Turbinoplasty
The turbinates are “like wings on the sidewalls of the nasal cavity.” They function to regulate airflow, moisturize the air, and also warm the air you breathe in, all of which improve the comfort and sensations of breathing. However, when turbinates swell up, the sensation turns into congested, stuffy or blocked feelings. Inflammation, irritation, and infection can all induce swelling in the turbinates. Even more subtle changes in weather, including variations in temperature, barometric pressure, and humidity can influence the swelling in the turbinates.
In this section, Dr. Park explains how the turbinates are particularly susceptible to changes from the non-allergic or vasomotor rhinitis problem that we’ve discussed in several prior posts. And, he notes that acid reflux can also trigger the same problems, that is, engorgement of the turbinates ultimately leading to excessive mucus production. The result is a congested, stuffy or runny nose.
Last, turbinates are also part of the nasal cycle, the change in the insides of the nasal cavity that can sometimes be experienced as an easier or more difficult period of breathing. The turbinates can increase in size in alternation between left and right sides every few hours. You may or may not notice these changes, but if you suffer from a deviated septum on one side and the turbinate enlarges on that same side, you have a greater chance of feeling the restricted airflow during that interval.
In beginning the discussion of turbinate surgery, I was very pleased to see Dr. Park’s direct approach to the problem of “empty nose syndrome” where the inferior turbinates are completely eliminated from inside the nose. While this condition is much rarer than in previous times, I have met patients with this condition, and it can prove psychologically debilitating. Due to the sensory capacities built into the turbinates, the empty nose syndrome not only can lead to problems with nasal congestion, but in some cases, the individual feels unable to obtain a full breath on inhalation. I was very fortunate in the 1980s to talk about a patient with Dr. Eugene Kern, who first wrote and talked about this condition. A very good friend of mine had experienced the full removal of her turbinates and developed severe anxiety problems in the aftermath. She visited Dr. Kern to eventually obtain the correct diagnosis of empty nose syndrome. You can learn more on Dr. Kern’s video.
As Dr. Park notes, we now know that turbinates play a vital role in respiratory physiology and that a certain degree of nasal resistance is required in order for the individual to experience “proper breathing.” Therefore, surgery is now directed at preserving this external turbinate tissue by focusing on shrinking procedures as opposed to surgical resection.
Dr. Park then describes various shrinkage procedures starting with a few that can be completed in a doctor’s office and then moving onto several inpatient procedures that require inpatient care involving general anesthesia. Again, not being a surgeon I will leave these details for when you read Dr. Park’s book. Following the surgery, Dr. Park points out a fact I had never heard previously, which is that turbinate procedures are usually not painful and do not require pain meds.
Debris, crusting, and mucus all are a part of the healing process, which takes weeks or longer, and it is imperative to be very cautious in evacuating material too forcefully from the nose after the surgery. Using nasal rinses are a preferred approach to assisting in the clearing of junk from the nose. Again, like with nasal septum surgery, bleeding and infection are major but rare side-effects. And as before, turbinate surgery failure occurs when the procedure may have been too conservative, there is a persistent nasal septal deviation or you suffer from flimsy nostrils.
As we noted earlier, the problem is that your nasal anatomy is just too small to begin with or the walls of your nostrils may not been sufficiently strong enough to let a normal volume of air flow into the nasal cavity. For some, this problem is their natural anatomy, while for others past nasal surgery may have weakened how the nostrils are functioning when trying to inhale. In this section of the book, Dr. Park provides 3 steps to self-diagnose the problem:
- Look in the mirror and watch the openings in your nose when you take a deep breath in; if the sidewalls collapse, that’s the problem.
- Place a fingertip next to the nose on each side and gently pull up the skin towards the outer corner of the eye. If breathing in is noticeably easier, it also suggests this problem.
- You can perform a similar #2 experiment by using the handle end of Q-tips, placing one in each nostril and gently lifting up and sideways. Again, noticeably improved breathing suggests this problem of flimsy nostrils.
Prior to surgical interventions, Dr. Park reminds us that this collapsibility may also be aggravated by the previously described problem of nasal congestion due to allergic or non-allergic rhinitis. Therefore, it is imperative to address beforehand any aspects of the congestion that might respond to appropriate medical treatments.
The basic rhinoplasty procedure that Dr. Parks describes for flimsy nostrils involves the addition of a small piece of cartilage onto the current flimsy sidewall cartilage that is causing the problem. This surgery is called the open rhinoplasty approach. Another way is to work directly inside the nose to examine and realign the internal cartilage, which then produces a “mild nose-lift” effect. A third possibility involves nasal valve repair.
Overall, this chapter of the book was the most detailed for the obvious reason surgical interventions were discussed. My sense is that many sleep doctors and patients are unfamiliar with much of this detail, so I believe many people would benefit from this information. Though I am not surgically-minded, I share the same sense as Dr. Park regarding the value of nasal surgery to make PAP easier to use. In fact, Dr. Park closes the chapter with a story about a man who had been struggling with CPAP until he underwent septoplasty, turbinoplasty, and nasal valve repair. After the procedure, his CPAP pressures needed to be lowered, and his response to treatment was much better, including a better adjustment to the lower settings and less episodes of mouth breathing. As Dr. Park highlights, many patients currently struggling with CPAP often benefit from a nasal evaluation from a skilled ENT physician. And, I would add that all of this information is equally relevant to individuals who forego CPAP and use the OAT dental device instead.