Septoplasty and Turbinate Reduction

Summer greetings, Sandy!!  Hope all is going well.  I have an 18 year old patient who just underwent both septoplasty and turbinate reduction.  (ouch)….. It has been almost 4 weeks post and the parents/boy not noticing much change in ability to breathe through nose / practice spot posturing…. ENT told them it took time….do you have any experience with your patients re:  how long? (I’m guessing there is post surgical swelling that needs to go down??)  I am sure there are individual differences, but can you shed any experiential light on the subject?

I am to forward this to Dr. Mason. I have a feeling he might be able to give us input. Unfortunately I have not run across this and cannot speak about it intelligently enough to help you. I appreciate your coming to me with this question and I, too, look forward to finding an answer. Thanks again and let’s hope that Dr. Bob can shed some light on this for us both. Warmly, Sandy

San and J, Thanks for asking for my opinions and experience with this sort of problem. First of all, the aerodynamic (airflow) technology developed by Don Warren at UNC allowed Don and students (including me) the opportunity to assess many sites of airway interference and to develop perspectives about the impact of specific anatomical findings and interferences on breathing. The problem with ENT assessments of airway interference is that most of the time, the physician looks at the anatomy and then presumes about the functions involved. When one actually goes about measuring airflow through the system, and correlates physician findings with airflow data, surprises have followed. One major finding is that anatomy, and the “appearance” of a site of airway interference, does not always correlate with how air passes through and past such sites of interference; that is, anatomy does not predict the physiology involved very well, and breathing is a physiological event not directly impacted or predicted by a specific anatomical finding. When one rank-orders the sites of possible airway interference, the last thing on the list that is a problem is a deviated septum; that is, deviation of the septum does not usually pose a problem in breathing. As a result, thousands of unnecessary septal straightening operations have been done in the name of improving breathing. It is interesting that when the nostrils are spread with a speculum, the first things observed is the nasal septum and as well, the inferior turbinates. So what is seen has unfortunately resulted in a recommendation for surgery, while other sites more related to the airway interference, not easily observed directly, have been ignored or missed otherwise in evaluations. Because nasal breathing changes every 60-90 minutes between the nasal chambers, there is always a more free-breathing channel in the nasal cavity for adults that changes back and forth in a predictable manner. There is not a similar change in the better free-breathing channel in children, however. The point of all of this is that when I read the report about this patient, I immediately suspected that the operations involved may not have been needed since the evaluation may have inaccurately determined where the site of airway interference was for the patient. Knowing that a deviated septum is the last anatomical feature that is ever in need of surgical correction to enhance breathing, the next area of possible concern are the turbinates. A turbinectomy is usually done with a rongeur, a surgical gripping forceps instrument that “bites off” part of the inferior turbinate. It is not a clean procedure. Since turbinates are covered on both outward and inner surfaces with mucous membrane, with many hair cells, any removal of turbinates will create a considerable amount of swelling on outer and inner surfaces of what remains of the turbinates. The turbinates are more likely to result in much more swelling than by straightening the nasal septum. My guess is that it would take up to six months for the swelling to reduce significant enough to accurately evaluate any positive result in more free nasal breathing. By comparison, removal of tonsils and adenoids can interfere with velar elevation for up to six months, so those who become hypernasal after T&A are advised to wait for up to 6 months for the tissue swelling to resolve. For turbinates, there is no movements involved, as is the case with the velum following T&A, but the timing of the resolution of swelling is likely pretty much the same. So to respond specifically to the question of how long following surgery could breathing be adequately assessed, I would guess 6 months – possibly less – but certainly, swelling would remain after 4 weeks, as reported here. This situation demonstrates several things, in my view: 1) one cannot observe anatomy and presume about the functions involved; 2) It is easy to view the septum and turbinates, and thus, physicians are apt to stop there when they note some deviation of the septum or apparent enlargement of the inferior turbinates; 3) This situation shows the problem in the lack of airflow testing equipment not being available in most ENT offices; 4) Without knowledge of the findings of aerodynamic studies of the airway in a variety of patients, with specific attention to sites of constriction (and airflow instrumentation can identify the site of interferences), clinicians will continue to make false assumptions about what they “see”; and 5) The more accessible the anatomy is along the airway, the greater will links be made between what is easily seen as being the site of airway interference. Another interesting finding is that in many instances, the airway will be constricted at the anterior nasal valve (at the nostrils), known as the liminal valve (or the valve of Mink). During a nasal exam, the first thing done is to spread the nostrils to obtain a good look at the septum and turbinates. When in fact it is the liminal valve that is the source of constriction, the examiner completely misses the diagnosis. Subsequently, those ENTs who are cognizant of the contribution of the anterior nasal valve to airway interference will assess that valve before spreading it to observe the septum and turbinates. FYI – widening the nasal valve surgically is a simple ENT operation and now is often done instead of straightening the septum or breaking off part of the inferior turbinates. Also FYI – about 85% of a normal adult population has some deviation of the nasal septum, so that is another reason for ENTs to not put much stock in the observation of a deviated septum. Sadly, not much of what is said here can be shard with patient or family – but they need to be encouraged to be patient about the swelling involved, as it may take several months to adequately assess whether the operation achieved the success expected. Thanks for asking for my input. I hope that these observations help. Bob Post: Septoplasty and turbinate reduction