Treatment for a deviated nasal septum with difficulty in nasal breathing

Deviated Nasal Septum and Impaired Nasal Breathing: An Overview

Difficulty in nasal breathing is the most prevalent complaint among patients presenting with a curvature or deviation of the nasal septum, often coexisting with hypertrophic rhinitis (enlargement of the nasal turbinates). The combination of septal deformation and turbinate hypertrophy significantly impairs the primary respiratory function of the nose. This disruption in the normal passage of airflow through the nasal cavity can contribute to the development of various pathological conditions affecting the nose and paranasal sinuses.

Pathophysiology and Consequences

Deformation of the nasal dorsum (external nose) and septum disrupts the natural and rational architectonics of intranasal structures. This inevitably affects the complex regulatory mechanisms involved in cleaning, humidifying, and warming inhaled air, as well as the proper formation and direction of the airstream. The normal autonomic response of the abundant vascular network within the paranasal sinuses and nasal mucosa is disturbed, leading to impaired vascular wall tone. Consequently, puffiness or edema of the mucous membrane often appears, and the outflow openings (ostia) of the paranasal sinuses may become narrowed or completely covered. This compromises sinus aeration and creates conditions favorable for the development of vasomotor rhinitis, other forms of non-allergic rhinitis, and eventually, inflammatory processes within the paranasal sinuses (sinusitis). All these factors negatively impact the functional state of the upper respiratory tract and the entire respiratory system.

Specifically, a curvature of the nasal septum alters the direction and speed of airflow. This can lead to impaired neuroreflex regulation of the nasal cycle (the alternating congestion and decongestion of the turbinates) and contribute to the development of vasomotor rhinitis, which is often accompanied by persistent hypertrophy of the inferior turbinates. Characteristically, the turbinate on the side opposite to the septal curvature is often more affected (compensatory hypertrophy) as it attempts to fill the relatively wider nasal passage. Over time, this reactive cavernous tissue engorgement can be replaced by fibrous connective tissue, transforming vasomotor rhinitis into a more fixed hypertrophic rhinitis. In such cases, even after surgical correction of the deviated nasal septum, nasal breathing may not improve sufficiently unless the hypertrophied inferior turbinates are also addressed.

Deformation of the bones of the nasal dorsum and the nasal septum, commonly resulting in a deviated or curved nasal septum, is frequently a consequence of domestic accidents, sports-related injuries, or road traffic incidents.

The Role of Surgical Intervention

Given these anatomical and physiological disruptions, the only effective method to eliminate the anatomical and morphological changes in the nasal cavity that develop with septal deformation and associated hypertrophic rhinitis is surgical intervention. The goal of such surgery is to restore normal nasal anatomy, improve airflow, and thereby alleviate symptoms and prevent secondary pathologies.

Evolution of Surgical Techniques for Deviated Septum and Turbinate Hypertrophy

The surgical tactics for correcting a deviated nasal septum vary widely depending on the type and severity of the deformation. Historically, submucosal resection (SMR) of the septum was a common procedure.

Traditional vs. Modern Sparing Approaches

Many ENT surgeons traditionally performed the Killian submucosal resection of the nasal septum, where a functional result (improved airway) was often achieved by removing a significant portion of the supporting cartilaginous and bony part of the septum. However, this extensive removal could sometimes lead to complications like septal perforation, saddle nose deformity, or a weakened septum.

Current best practice emphasizes functional, cartilage-sparing options for septal surgery, such as septoplasty and septocorrection technologies. These techniques aim to straighten the septum by repositioning, reshaping, or removing only the deviated portions while preserving as much of the structural integrity of the osteochondral framework as possible. This approach minimizes complications and better maintains the physiological support of the nose.

Addressing Compensatory Turbinate Hypertrophy

As mentioned, when a deviated septum is present, it is often necessary to concurrently correct hypertrophied inferior turbinates to achieve optimal nasal breathing. Numerous techniques exist for turbinate reduction. However, older, more aggressive methods like radical conchotomy (complete or near-complete removal of the turbinate) or extensive galvanocautery (surface cauterization) are now considered unacceptable by many specialists. These aggressive techniques can result in the loss of a large area of functional mucous membrane, thereby impairing the vital excretory, transport (mucociliary clearance), and absorptive functions of the nose, potentially leading to complications like atrophic rhinitis or "empty nose syndrome."

Therefore, for the correction of hypertrophied inferior turbinates, sparing methods are currently preferred. These include:

• Submucosal Vasotomy: Involves destroying or reducing the submucosal cavernous plexus (the erectile vascular tissue responsible for swelling) while preserving the overlying mucosa. This can be done by incising and reducing the vascular tissue from the side of the bone.
• Lateroconchopexy (Turbinate Lateralization/Outfracture): The bony base of the inferior turbinate is fractured and displaced laterally to widen the nasal passage. Submucosal vasotomy can be supplemented with lateroconchopexy if necessary.
• Submucosal Diathermocoagulation or Radiofrequency Ablation: Uses heat generated by electrical current or radio waves to coagulate and shrink the submucosal cavernous plexuses.
• Cavernosotomy: Creating openings into the cavernous tissue.
• Submucosal Cryodestruction: Using extreme cold to destroy the submucosal erectile tissue.
• Powered Instrumentation (Microdebrider-Assisted Turbinoplasty): Allows for precise submucosal tissue removal.
• Laser Surgery: Can be used for turbinate reduction, though a specific technique (e.g., submucosal vs. surface ablation) and laser type will influence outcomes.

The combined pathology of the inferior turbinates and the nasal septum, which impairs the basic functions of the nose, necessitates corrective surgery on both structures, ideally in a single stage, using maximally sparing techniques. Despite the many proposed methods, there is no single universal technique for septoplasty and turbinoplasty that fits all cases. Each variant of septal and turbinate deformity requires an individualized surgical approach. The search for new techniques and the refinement of existing ones continue, with otorhinolaryngologists actively revisiting and advancing solutions to this common problem.

Studies, including one involving 18 patients aged 9 to 15 years, have demonstrated the efficacy of combined ultrasound septocorrection and ultrasound intraconchal turbinoplasty for treating deformities of the nasal septum and dorsum associated with nasal breathing obstruction.