It is important to understand the functions behind your breathing and sinuses. This section will teach you about the anatomy of your nose and shed light on why you may be experiencing breathing or sinus problems.

Articles

Deviated Septum
Sinusitis and Sinus Surgery
Rhinoplasty
Broken Nose (Nasal Fracture)
Signs and Symptoms
Nasal Polyposis (Nose Polyps)
Nasal Valve Collapse Treatment


 

Deviated Septum

by Garrett H. Bennett, M.D.

What is a nasal septum and what are the nasal turbinates?

The nasal septum is the wall in the middle of your nose composed of bone and cartilage that splits the inside of your nose into the left and right. The inferior and middle turbinates are mucosal covered bony structures on either side of the nasal septum. The nasal septum and turbinates warm, humidify and filter the air we breathe to protect the lungs from  contaminants such as dust, pollen and cat dander.

Straight Nasal Septum

What is a deviated nasal septum and what are enlarged turbinates?

A deviated septum is when the cartilage or bone that makes up the nasal septum is off to one side or even to both sides. Enlargement of the inferior turbinates (turbinate hypertrophy) is caused by physical trauma to the turbinates from inhaled irritants or from internal swelling from allergies. Conditions like these will restrict breathing, stimulate snoring,  and may lead to sleep apnea or sinus infections. Nasal swelling can be treated with over-the-counter or prescription nasal sprays and oral medication.

Deviated Nasal Septum

Was I born with a deviated septum?

There are many theories on why the nasal septum is deviated. Trauma from traveling in the birthing canal may cause micro-fractures in the nose that can become larger as we grow. Any nasal or septal fractures can cause deviation to the outside and the inside of the nose.  As the nose ages, the septal shape may change as cartilage matures and twists. We receive genetic traits from our families and a deviated septum or twisted nose may be a gift from your parents.

When do you need  surgery for a deviated septum?

Straightening the deviated nasal septum is called a septoplasty.  Shrinking the size of the inferior turbinates is called a turbinoplasty. These corrective procedures may be required when medication and other conservative treatments have not improved breathing. Functional nasal surgery provides improved breathing, decreased snoring, and better sinus function. These procedures are performed with no external incisions, going through the nostrils to straighten the septum and reduce turbinate size. The surgery takes about an hour at an ambulatory surgery center and can be done with local or general anesthesia. Patients can go home about an hour after surgery. There is generally a noticeable improvement in breathing within one week of the procedure. Breathing can continue to improve over the next couple of years.

Is packing the nose needed after surgery?

Nasal packing involves placing long strips of vaseline gauze in each side of the nose after surgery.  Doctor Bennett finds that placement of nasal packing is very rarely required for his patients. Surgical techniques have greatly advanced in the last 15 years. Today, doctors have a better understanding of how the nose heals . Packing placement and the subsequent removal can cause trauma to the nasal septum, sinuses and turbinates and may cause scarring. Packing does not prevent a nose-bleed and may block the topical decongestants or nasal irrigation from working.

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Sinusitis and Sinus Surgery

by Garrett H. Bennett, M.D.

What are  sinuses?

The sinuses are hollow spaces in the skull that are lined with mucosal tissue. This specialized tissue moves mucus and impurities from the sinuses into the nose and throat. Tiny passages known as osteomeatal complexes, connect the sinuses with the inside of the nose. The sinuses are shown below:

What is acute sinusitis?

Allergies, a deviated septum, or common cold can prevent the sinuses from draining normally. When this happens, a sinus infection (sinusitis) can occur. Because the draining spaces inside the nose are millimeters or less in size, even minimal swelling can cause sinusitis. A head cold that lasts more than a few days may be an acute sinus infection. Multiple episodes are termed “recurrent acute sinusitis”.

What is chronic sinusitis?

If the sinus infection lasts greater than three months, you have a chronic sinus infection. The bacteria will be more complex than during acute sinusitis and antibiotics are used mainly for worsening episodes of the sinus infection.

 



What are sinusitis signs and symptoms?

 

Thickened nasal discharge- Infected mucus becomes increasingly thick, green or yellow in color, and may have a bad odor. The discharge can drain from the nose or be coughed up.

Headaches or sinus facial pain- Pressure from obstruction of the small sinus passageways can cause severe facial pain, headaches, toothaches, or worsened nasal congestion.

Repeated sinus infections- Swollen and blocked tissue inside the sinuses can narrow the channels that lead from the sinuses, therefore causing repeated infections. The bacteria inside the nose may become resistant to antibiotics and not completely go away between infections.

Fatigue- Spending energy to fight an infection will waste the body’s reserves and can interfere with sleep and mental energy.

 

How is sinusitis treated?

Successful treatment of an acute sinus infection is often possible using antibiotics directed toward the most likely causes of infection.  The management of chronic sinusitis is more directed towards decreasing sinus inflammation. Failure of antibiotics may require further testing, including a sinus CAT scan. Other conservative treatment includes combinations of anti-allergy medication, decongestants, nasal sprays, and saline rinses. Environmental controls, such as removing your carpet, having the cat sleep in another room, or using an air purifier, can also decrease symptoms. If left untreated, a sinus infection can bring about severe complications. Do not hesitate to speak with a sinus specialist if you are suffering from breathing problems.

 

When do you need sinus surgery?

Recurrent acute or chronic infections can negatively affect your quality of life. After medical treatment has failed, sinus surgery can dramatically improve nasal function and your sense of well-being. Functional endoscopic sinus surgery (FESS) removes blockages, allowing the  sinuses to ventilate and drain through its natural opening.

 

How is the recovery from sinus surgery?

With Dr. Bennett’s advanced surgical techniques, packing placement in the nasal cavities and the associated discomfort is rarely needed. This improves the overall experience and contributes to a more rapid recovery. Patients typically return to normal activity in 7-10 days.

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Rhinoplasty

by Garrett H. Bennett, M.D.

What is a rhinoplasty?

Rhinoplasty Before and After

The nose is one of the most defining characteristics of the face. Whether you would like to improve the appearance of your nose or you are having difficulty breathing, a rhinoplasty may be a suitable option. A rhinoplasty, or nasal reshaping, is a surgical procedure designed to create harmony between the nose and other facial features by reshaping the size,  width, or profile of the nose and it may also be used to improve breathing. A cosmetic rhinoplasty is never covered by insurance. However, a rhinoplasty to repair a broken or fractured nose,  to correct a severely deviated septum, or nose surgery to fix nasal obstruction from collapsing of the nostrils may be covered by insurance.

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Broken Nose (Nasal Fracture)

by Garrett H. Bennett, MD

What is a nasal fracture?

The nasal bones are a pair of bones that extend about a third of the way from the forehead to the tip of the nose. Because they are very thin and in the center of the face, they are highly susceptible to injury. Nasal fractures account for 40 percent of all bone fractures.  Trauma to the nose can change the shape and functionality of the bone and cartilage that make up the nose.

Frontal Nasal Bones

How do I know if I have a broken nose?

Breaking the nose is usually very painful. The nose will swell, and breathing can become difficult. The outside of the nose may be depressed, twisted, or C-shaped. The nasal bones may be mobile, and you may be able to feel or hear them moving. The eyes may be black and blue and the nose will frequently bleed profusely.

Do I need to see a doctor?

Yes. It is important to see a doctor as soon as possible after the injury occurs. The doctor will look for signs of a septal hematoma, or blood collected against the cartilage of the middle nose that can cause infection and destruction of the cartilage. It is best to see an Ear, Nose and Throat doctor, as they will be able to diagnose and treat the problem at the same time. Diagnosis is usually made by physical examination and an X-ray is rarely necessary.

Deviated Septum and Septal Hematoma

How long do I have to fix my nose?

The broken bones will be mobile for up to two weeks and can sometimes be moved back into a natural position during that time. This can be done in the office or in an ambulatory surgery center. If the injury remains untreated for more than two weeks, the patient must wait at least two months – allowing the bones to completely heal – before seeking reparative treatment. The patient must then undergo a more extensive treatment to repair the nose.

Broken Frontal Nasal Bones

What are the complications of a broken nose?

The main complications of a broken nose include permanent difficulty breathing and physical deformity of the nose. A fractured or deviated septum may be the cause of this breathing difficulty. The shape of the nose tip may change if the tip of the septum is bent. A hole in the septum (septal perforation) can cause the nose to collapse (saddle nose deformity). The cerebrospinal fluid (CSF) that cushions the brain may leak. The patient may lose their sense of smell. Infections of the nose or sinuses may occur. Other bones of the face may also be fractured, so you should check carefully for any addition head or neck injuries. Seek emergency medical attention if you suspect you may have a septal hematoma, CSF leakage, or an uncontrollable nosebleed (epistaxis).

What can I do at home?

Applying ice across the nose and keeping your head elevated will reduce swelling. Consistent pressure to the nose for 10-15 minutes without letting go will control most nosebleeds. Afrin drops inside the nose may also help the bleeding stop. Tylenol (acetaminophen) is the only over the counter pain medication that should be used. Other pain medicines like Motrin/Advil (ibuprofen), aspirin, and Aleve (naproxen) can promote or worsen bleeding.

Will insurance pay to fix my broken nose?

Insurance will almost always cover the cost of broken nose and deviated septum repair, as these are considered functional issues. Insurance will never cover cosmetic surgery, although your nose may look better after it is repaired with functional surgery. We will check your benefits for you and let you know what they are.

Repair of a Broken Nose and Deviated Septum

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Nasal Polyposis (Nose polyps)

by Garrett H. Bennett, MD

What causes nasal polyps?

Nasal polyposis (Nose polyps) occurs when tissue within the nose swells and grows outward, creating mucus-filled sacs. No conclusive cause for nasal polyposis has been established, but they are thought to be caused by allergy or sinus irritation, and can be associated with asthma in adults and cystic fibrosis in children. More recently, an allergy to fungal spores in the air has been identified as a major risk factor for nasal polyps.

Lateral View of Nasal Polyps

What are the symptoms of nasal polyps?

-Nose is always blocked (nasal congestion)
-Constant runny nose or postnasal drip
-Decreased or loss of sense of smell (anosmia)
-Headache or forehead and cheek pain
-A bad head cold that does not go away

How are nasal polyps diagnosed?

A doctor can often detect polyps simply by looking in the front of the nose with a headlight. For a more complete examination, the doctor can use a narrow lighted tube with a magnifying lens (nasal endoscope) to look deeper inside the nasal cavity. A CAT scan of the sinuses will show areas that cannot be seen by looking into the nose and can show the extent to which the polyps have spread in the sinuses.

CT Scan of Frontal Sinus Polyps

The doctor can use skin or blood allergy testing to determine if allergies are causing some of the inflammation.

What are the potential complications of nasal polyposis?

Patients may have recurrent sinus infections from obstructive nasal polyps. Large polyps can eventually compress the eyes or push on the brain. Nasal obstruction can cause sleep apnea, a condition that stops your breathing during sleep and can cause serious heart and lung damage.

What medical treatments are available?
Nasal or oral steroids can reduce inflammation and may shrink nasal polyps. Oral or nasal antihistamines can decrease symptoms of allergies. Sinus infections should be treated aggressively with antibiotics. For fungal sinusitis, an antifungal medication may be effective.

If your nasal polyps prove resistant to medications, then they can be removed in an ambulatory sinus surgery procedure (polypectomy). If you are experiencing sinus inflammation, endoscopic sinus surgery can ventilate and provide drainage to the sinuses. You will generally go home about an hour after surgery. You may feel congested following surgery, but your breathing may also be better immediately.

Photograph of a Nasal Polyp

Can I prevent nasal polyps from coming back?

The patient must maintain constant vigilance after nasal polyp removal. Unfortunately, nasal polyps will return in approximately 2 out of every 3 people who experience them. Saline rinses may decrease irritation in some patients, although others may feel that they cause more irritation. Air purification is always a good idea, as the air inside the home can have 5 to 10 times as many impurities as outside air. Avoiding dust, pollution, and irritating chemicals can decrease nasal swelling. Humidifiers can keep the inside lining of the nose moist in the winter or in dry environments. Medical treatment of allergies and asthma will also decrease inflammation inside the nose. Hand washing and covering your nose when you sneeze are some of the best ways to prevent the spread of viral and bacterial infections that may aggravate the polyposis.

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Nasal Valve Collapse and Treatment

by Garrett H. Bennett, MD

Introduction

Collapse of the nasal valves – internal and external – is a commonly overlooked cause of breathing obstruction. Common causes include previous trauma to the nose or cosmetic rhinoplasty. Lifting the soft tissue of the cheek on the affected side of the nose or using BreatheRite nasal strips may relieve some symptoms, but surgery is the best option for permanent treatment of nasal valve collapse. Many ENT surgeons are not comfortable with these surgical techniques. It may be necessary to find a surgeon with Facial Plastic Surgery Board certification, as he/she will have the additional training required to perform this corrective surgery.

Internal Valve Collapse

 

Before and after: Correction of bilateral internal valve collapse due to a previous cosmetic rhinoplasty. Note the ‘inverted-V’ shape of the nasal bones on the left (actual patient).

 

The intersection of the nasal septum and upper lateral cartilage forms an angle that is usually eight to 15 degrees. Less than this can cause collapse of the internal valve, where much of the sensation of breathing comes from. Internal collapse may also cause narrowing of the middle third of the nose. Visually, the nose may have an ‘inverted-V’ where cartilage has pulled away from the nasal bones. This can be corrected by placing of strips of cartilage at the area of collapse to splint out the valve, or reattaching the cartilage to the nasal septum.

External Valve Collapse

 

Before and after: correction of right external valve collapse (actual patient).

 

If the side of the nose collapses inward during inspiration (breathing in), you may have a collapsed external valved. The sidewalls of the nose may look pinched where the cartilage is weak or has collapsed inward. This can also make the nose tip appear larger when it in fact has a normal size. Placing a cartilage graft into the weakest area of the nose can prevent collapse in that area. A deviated nasal septum or enlarged inferior turbinates may further contribute to external valve collapse.

Causes of Valve Collapse

Aging weakens the nasal sidewalls and causes the tip of the nose to sag. These changes can obstruct airflow inside the nose. Weak cartilage or cartilage turned inward can also predispose patients to nasal valve obstruction. The primary cause of nasal valve obstruction requiring surgery is previous nasal surgery. Taking down a large bump or decreasing a large tip can weaken support in the rest of the nose. Dividing the cartilage from the septum can cause scarring in the internal valve area that is very difficult to correct. Cosmetically, the nose may look great, but your breathing is still problematic. This can be avoided by choosing a surgeon trained to avoid and correct this deformity.

Cottle Maneuver: If your breathing improves when holding the cheek outward (as pictured above), you may have a collapsed valve(s).

A “Cottle maneuver” is an invaluable tool for diagnosing nasal valve collapse. The nose’s internal and external valves are elevated outward and the improvement in breathing is scored on a 10 point scale. The doctor should perform an intranasal exam should be performed before and after the nose is decongested. He/she can also perform a nasal endoscopic exam to evaluate structures deeper within the nose. In addition to valve collapse, a complete intranasal exam should look for indications of a deviated nasal septum, inferior turbinate swelling, sinus infection, or adenoid enlargement. A Sinus CT scan may be required for some patients.

Is this considered cosmetic surgery?

No. The ability to breathe through the nose is recognized by insurance companies as important to health and has its own insurance code. The nose shape may be more pleasing aesthetically as a result of correction of the nasal valves. Insurance will cover the functional cost of the surgery.

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