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Dr. Miller: So you have a deviated septum. Does that need to be fixed and what symptoms does a deviated symptom cause? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi, I'm here with Dr. Jeremiah Alt. He is an ear, nose and throat physician. He's also a professor here at the University of Utah and a member of the department of surgery. Jeremiah, what's the story of the deviated septum? What is a deviated septum and, if you have one, do you always need to have it fixed?

Dr. Alt: We commonly have patients who come in with complaints of just simple nasal obstruction. Commonly, we have to go through the differential diagnosis of what that is.

Dr. Miller: You mean they can't breathe out of one side or both sides of their nostrils, is that right?

Dr. Alt: Yeah, correct. As a rhinologist, I commonly see patients with sinus disease and congestion and allergies. It also commonly comes up that they just have what's called septal deviation and the septum itself separates basically the right and left side of the nose.

Dr. Miller: So it's your nose bone?

Dr. Alt: Yeah. It's made up of both cartilage bone. The septal deviation can occur just from normal development as everything is not perfectly symmetric as we develop. So it can be deviated to one side or the other. It can also occur from trauma.

Dr. Miller: Getting boxed in the nose.

Dr. Alt: Getting boxed, vehicle accidents, getting bumped in the nose. So after the trauma, this is an acute event, someone would come and say, "I can't breathe out of the right side of the nose," after getting bumped or something that's been there their whole lives and they've just noticed that they're having increased trouble breathing, they can't sleep as well.

Dr. Miller: I'm curious, is deviated septum mostly due to trauma or are people born with it?

Dr. Miller: I think the majority is they're born with it or we have a known etiology of why it's deviated.

Dr. Miller: Okay. So the come to you and they complain that they have difficulty breathing out of one side of the nose or the other or maybe both. At what point do you say, "Well, look, maybe we can repair this surgically if you need to have it repaired"?

Dr. Alt: A lot goes into talking about the deviated septum. In many instances, it's found incidentally, which means we look in their nose and they have a deviated septum but they don't describe nasal obstruction.

Dr. Miller: And under those circumstances, you probably wouldn't recommend surgery?

Dr. Alt: Correct. In those situations, I don't even like to bring it up because then it's something that patients start to worry about. But if it's significantly deviated and we look at it and we assess the patient and it's significantly closing off one side of the airway, we can discuss different surgical options and how to correct that.

Dr. Miller: I have a question. How often do people come to you to looking for cosmetic reconstruction of that bone?

Dr. Alt: That bone itself is usually not cosmetic. It's functional. It doesn't correlate into how the nose looks.

Dr. Miller: So that's a whole different type of surgery.

Dr. Alt: Correct.

Dr. Miller: Not to be confused with the symptoms that a deviated septum would cause.

Dr. Alt: So that's really talking about what we usually term open septorhinoplasty is where were able to change the look of the outside of the nose or [Inaudible 00:03:12] and changed inside the nose for functional breathing, which sometimes we do in combination if the nose is broken or twisted on the outside, we also have to fix the outside in addition to the inside.

Dr. Miller: So how often do you find the patients with need to have surgical correction for a deviated septum?

Dr. Alt: It's actually quite common. It's one of the most common procedures we perform. Not only is it bothersome in the sense that they can't breathe but it substantially affects patients quality of life, which has been shown over and over again by improving the way we breathe through our nose substantially affects how we feel in our day-to-day activities. And this is most likely partially contributing to the way we sleep and the way we get good night's sleep. If we can't breathe through the nose, it forces us to breathe through the mouth and we may have more obstructive events and it can also potentially lead to what we call obstructive sleep apnea.

Dr. Miller: So how do you do the surgery?

Dr. Alt: So there are several options to do surgery and one that we're doing more and more that gets great results is doing endoscopic septoplasties. So it's using angled and straight, rigid endoscopes with that special high-definition camera. And we're able to make very specific and delicate incisions within the septum to take out those crooked parts and so there are no external incisions on the nose. It's all done on the inside of the nose and we feel that patients get great functional responses and, at the same time, have quicker healing.

Dr. Miller: Now, do you tell your patients that they are going under general anesthesia? Do you put them to sleep when you do these or is it a local sort of anesthetic you use?

Dr. Alt: Yeah. I would not recommend local and patients probably wouldn't like me very at the end of the procedure. So we really counsel the patients that these should be done under general anesthesia where they're totally asleep, they're not moving. We have the ability to take our time and do the job correctly.

Dr. Miller: What's the recovery like?

Dr. Alt: Really, the recovery's not too bad. We normally tell the patients they'll probably have to take pain medications for two to three days. Commonly, these type of procedures used to be packed with nasal packing. We no longer pack the nose. We moved into placing splints on the inside of the nose like flexible plastics splints, but even now we're even moving away from that. So many times, we can get away with doing the what we called endoscopic septoplasty without putting any packing in the nose and so this helps patients feels better and recover quicker too, as they're not obstructed with something in their nose we don't have to take out in a week. Usually, at a week, at that point, the patient feels great, usually back to light activity. At two weeks, you're completely healed.

Dr. Miller: Now, for a patient who is going to primary care physician, is a primary care physician usually able to tell if they have a deviated septum or do they usually refer them to make that diagnosis?

Dr. Alt: I think in general, you can determine what we call a caudal septal deviation. It's more towards the front of the nose because you can just look at it with the simple measure of using the nasal speculum looking at the front of the nose and you can tell if it's deviated. Interesting enough, those septums that are more deviated or caudally towards the front of the nose actually usually need a more significant type of surgery, which we'll discuss with the patient, but that usually actually leads to what we call an open septorhinoplasty.

Many times, the posterior septal deviations are easier to fix endoscopically and those are actually harder to diagnose because you need to see further into the nose. So seeing someone like an ENT or rhinology person like myself, we're able to use scopes to look at the septum more posteriorly in the nose to diagnose it.

Dr. Miller: So in conclusion, what three things might you told the patient that would lead them to your doorstep to where you would make a diagnosis of a deviated septum?

Dr. Alt: I think the first thing is if they're having trouble breathing through their nose. Typically, it's unilateral, but it can be both sides, bilateral. The next thing is if this is causing significant changes in how they feel and how they function during the day, if the obstruction's bad enough where they feel like they need some improvement. And third, which we didn't mention, but I think should be mentioned here conclusion, is that many times, medical management can improve nasal obstruction even with septal deviation. So commonly of pretrial of medical management needs to be done before you start discussing . . .

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updated: January 23, 2019
originally published: November 11, 2015

Dr. Miller: When does short-term sinusitis become long-term or chronic sinusitis? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Dr. Miller: Hi, I'm here with Dr. Jeremiah Alt. He is an ENT surgeon, Ear, Nose and Throat Physician. He is in the Department of Surgery here at the University of Utah. Jeremiah, all of us, or most of us, I would think, have had acute or sudden onset sinusitis and most of that is due to viruses that last a few days to a week or so and then goes away. When does that become chronic sinusitis? What is chronic sinusitis?

Dr. Alt: Something we commonly see in my practice as a rhinologist, we commonly describe acute sinusitis is either viral or bacterial. And these are really short-term. These consider viral up to seven days and if they're lasting over seven days, then you can start considering this to be potentially a bacterial rhinosinusitis. And, commonly, that's when your provider is going to prescribe an antibiotic. It's normal to have two to three episodes of these either viral or bacterial rhinosinusitis a year in general amongst the population. The concern becomes when these occur more than four times a year. When they occur more than four times a year, we start to come into a category of sinusitis that needs a little bit more specialty care and this is called recurrent acute rhinosinusitis.

Dr. Miller: Now, this is different than what people would experience during an allergy season. It's not just runny nose or itchy nose and sneezing. I mean, you've got pain, discomfort and post-nasal drip and basically during sinus inflammation you don't feel very good.

Dr. Alt: Yeah, that's correct. We commonly really describe this with four big symptoms that I like to talk about and one is nasal obstruction or congestion. Another is a loss of the smell. Third is facial pain and pressure that the patient has during these episodes.

Dr. Miller: Is there any particular place that they'll have the pain?

Dr. Alt: That's some of the studies that we're doing that we quite don't particularly understand, which is a misconception that pain in pressure behind the eyes or underneath eyes correlates well to a sinus infection. That's just not true per se, although . . .

Dr. Miller: I suspect that's also true with headaches. I know there's been this association and I'm not sure that's clear association.

Dr. Alt: Correct. And so commonly we need to do further imaging or testing and to determine if their facial pain and pressure are really due to a sinus infection. And the difference really between acute and chronic then is really about the time course. So acute, we're talking about seven to 10 days. And chronic is really what we describe the something that occurs over 12 weeks. So this is a long, drawn-out infection that they continue to have congestion/obstruction, loss of the smell, facial pain and pressure. And it's not cleared by medical management, which what I mean by that is antibiotics or oral steroids or rinses for the nose or decongestants. And they continue to have a substantially reduced quality of life during this time.

Dr. Miller: How do you deal with if they've had several courses of antibiotics or course of steroids and they're still plugged up, so to speak? What the next step there?

Dr. Alt: Well, part of the issue is, what is the etiology of chronic sinusitis. And the etiology of chronic sinusitis isn't completely known. Many different things can be contributing. This probably has to due to an array of different competing factors, such as allergy or environmental exposure of the poor air quality, could be due to a non-immune issue. So what I'm getting at is the underlying cause of chronic rhinosinusitis is not the bacteria itself or the infection, it's really a disease of inflammation that we're just beginning to understand.

Dr. Miller: When they make it to your doorstep, you end up treating them again medically to see if that works? I know sometimes the duration of the antibiotic course is not necessarily long enough. Sometimes it might help to do both antibiotics and steroids to reduce the inflammation as you speak about. But it sounds like maybe you . . . do you give them another chance of medical therapy before you start talking about surgical correction?

Dr. Alt: Yeah. We normally like to discuss what we consider maximum medical management for patients with this disease. And that really entails four big things that most of the rhinologists across the United States agree with. Recent surveys in 2007 and 2013 looking at all the rhinologists across the United States, they really kind of agree on four big things. And those four big things are was the patient treated with an oral antibiotic. Yes or no? If no, they need to be on it. The next is basically topical corticosteroids. These are drugs you probably heard in the news with Nasonex or . . .

Dr. Miller: Are now over the counter, as I recall.

Dr. Alt: That's correct. Now they're over the counter. So this is a second thing that patients really need to be on. The third is actually some type of high-volume irrigation in their nose. So they're irrigating their nose out with some type a sailing solution. And the fourth would be oral steroids, particularly in those patients where we diagnose as chronic sinusitis with nasal polyps.

Dr. Miller: What about the use of topical sympathomimetics like Afrin that you could buy over the counter? I think some people find initially that that works pretty well. Is there a problem with long-term use of that?

Dr. Alt: Yeah. So short-term use, I think these can be very beneficial to the patient with improving the nasal obstruction and congestion that they feel. And it may also open up the sinuses some to help deliver medication. However, we commonly discourage long-term use of these because they can be somewhat addictive to your nose where your nose can become more inflamed and release more mucus, causing overall longer term deficits with that medication.

Dr. Miller: So let's say that you take with position through the four steps that you've outlined and they don't respond to therapy. What would be the next step?

Dr. Alt: So the next step is an honest discussion of how this is really affecting their overall quality of life. Because the next step we commonly think of is surgery. And surgery isn't a cure for chronic sinusitis, but it does help improve the medical treatment of chronic sinusitis. So I like to really discuss that this is overall an elective procedure. If their chronic sinus disease is affecting them enough, which we know it is just as severe or more severe than those on kidney dialysis or diabetes or hip replacement, so we know it really affects a patient's quality of life. So surgery gives them the opportunity to basically, what I like to term, hit the reset button to help open up the sinuses to help us deliver better medical care.

Dr. Miller: What percentage of patients with chronic sinusitis does end up with surgery as a potential treatment?

Dr. Alt: I think it depends on the surgeon and who you're talking with. I would say here at the University of Utah, we normally deal with more complex cases. Patients many times have already had one or two surgeries and they've been treated with multiple rounds of different types of medical therapies. So in my practice, I would say the majority end up needing some type of surgical management to get to hold off the problem. In the community, it just depends. You can have great response with a thoughtful program and medical treatment for your chronic sinusitis. It doesn't always need to have surgery.

Dr. Miller: So in conclusion, what would you tell a patient who is seeing one of the primary care physician, in terms of when might it be time for them to head on over and seek your expertise?

Dr. Alt: Yeah, as we talked about in the beginning, I think it is . . . really need to consider how many times a year you're getting sinus infections. Is it four or more? How long do you have the sinus problem in general? Is it seven to 10 days or do they really stretch out between one month, three months? And definitely if the disease is stretching onto that two or three months, you probably need to see a specialist.

Dr. Miller: I'd like to put a final plug in and I'll see if you agree with me that if you have acute sinusitis, sudden onset sinusitis that lasts only a week, you shouldn't necessarily be asking for antibiotics.

Dr. Alt: Yeah, that's a great point, the common misperception of that. I think we overprescribe antibiotics and patients commonly feel they have a sinusitis. But with a good medical physical exam, many times it's viral and you can wait. Now, you have to be cautious and every patient's different. Many times, you can have complications from a viral sinusitis. So it's depending on the patient, but overall, in general, you're right.

Dr. Miller: Generally up to seven days.

Dr. Alt: Yep. If it clears in seven days you do not need an antibiotic.

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