Correction to This Article
An Aug. 8 Health article reported incorrectly that rhinoplasty is performed on the external surfaces of the nose. Rhinoplasty often involves internal, as well as external, procedures.

Writer's Blockage

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By Jeffrey G. Ghassemi
Washington Post Staff Writer
Tuesday, August 8, 2006

It was an idea of ostensible brilliance, born of utter desperation. It involved tweezers.

Using only a vague knowledge of nasal anatomy, I squeezed the tweezers closed and guided them up my left nostril to the recesses of my nose. I counted to three, released the instrument and winced as the prongs sprang open.

I had hoped that this propping trick would provide some momentary ventilation. It brought pain and humiliation instead.

I was deviated. My nose was, at least.

Like many a nasal septum -- the rubbery center divider of the nose -- mine was off line. My septum veered so far left that my nose was effectively plugged.

It wasn't always that way. I've had episodes of trauma to my nose -- an errant elbow during soccer season, a line drive during Little League -- that may have shifted my septal posture over time. But the older I grew, the harder it was to breathe, except through my mouth. Attempts to take in air through my nose produced a sound like a kazoo.

This was not so good for daily life. I tired easily during sports. I could sleep only in certain positions. I suffered frequent nosebleeds. I was distracted in class. And, let's face it, sounding like Steve Erkel didn't exactly help in the confidence arena.

When conventional remedies such as decongestants, allergy sprays and nasal breathing strips failed, I devised more creative fixes: a straw as a nasal stent, physical manipulation of my septum, and, yes, the tweezers. Those all flopped, too.

There was no way around it, I concluded. I would need surgery. And I while I had no idea then, I would face the knife not once but twice.

The Other Nose Job

Made mainly of cartilage, a tough yet flexible connective tissue, the septum is rarely completely straight. More than 80 percent of people have a bend in the dividing wall between the nostrils, according to the American Academy of Otolaryngology-Head and Neck Surgery. Of these, nearly a quarter have a septum so crooked that it blocks the nasal passage and produces such symptoms as recurrent sinus infections, snoring and a diminished sense of smell and taste.

"For a lot of people, nasal obstruction can be life-altering," said Seth Oringher, assistant clinical professor of otolaryngology at the Georgetown University School of Medicine. "When you can't sleep in the same room as your partner or enjoy activities outdoors, it takes a toll on your quality of life."

Googling "septal deviation" opens up a world of bizarre tales of septal suffering. Some bloggers find solace in the deviations of celebrity septums, including Barbara Streisand's, Meryl Streep's and Bob Dylan's. Others tell of septums gone awry from excessive nose picking or chronic cocaine snorting. (Both untrue, says Oringher.)

While injuries cause most deviated septums, Oringher speculates that pressure on the nose during childbirth may also account for some cases. Whatever the cause, people spend an estimated $5 billion annually on self-treatments such as intranasal steroids, decongestants and Breathe Right strips, and millions more on surgical remedies.

One of the first descriptions of surgery on the septum came from Philippe-Frédéric Blandin, a 19th-century French surgeon who believed that septal deformities could be corrected with a swift punch to the offending organ. Fortunately, the procedure has advanced since then.

Septoplasty, the modern-day outpatient procedure to correct a deviated septum, is one of the most common ENT (ear, nose, throat) procedures, with more than 1 million performed in the United States each year, according to Alpin Patel, assistant professor of otolaryngology at Emory University School of Medicine in Atlanta. Risks include excessive bleeding, infection, scarring, tearing of the septal cartilage and loss of smell, but these are rare, he said.

Unlike the ever-popular rhinoplasty, or "nose job" -- the external reshaping of the nose -- a septoplasty is performed internally, through the nostrils. Severely skewed portions of the septum may be removed entirely, or reshaped and repositioned.

In many cases, the procedure is done in conjunction with a turbinectomy, a trimming of the turbinate bones that warm and humidify air coming into the nasal passage. The operation, which takes about an hour, runs about $4,000 and is covered by most insurers.

Recovery generally takes two days to a week. Patients often need a few weeks longer, until internal swelling subsides, to experience full relief.

After surgery, "my patients are so relieved -- they think I'm the greatest thing ever," said Oringher. "They take their first clear breath and can't believe what they were missing. I think it goes to show the great effect that nasal congestion can have on a patient's quality of life."

Hard-nosed

I passed on the first head and neck surgeon I saw, a private practice doctor whom I found too dismissive of my concerns. I went with a university-affiliated physician. Noting the hump on my nose -- a trait that had nothing to do with my breathing problem -- he offered to throw in some cosmetic work, as if surgery were a burger and he was offering fries with it. I declined the cosmetics and scheduled the septoplasty.

I had my surgery in the morning and was groggily back home by late afternoon. I felt no great pain -- just the pressure of nasal packing jammed up my nose. The packing came out a week later, and I waited. But the aha moment that I had feverishly anticipated never came. My septum was still off balance and I still couldn't breathe through my nose.

In about 5 to 10 percent of cases, Patel explains, the surgery does not produce relief. I was among them.

I was determined to give surgery another chance, hoping the problem was the particular surgeon, not the science. I scheduled consultations with three more specialists. I began to feel like Goldilocks in a house of ENT surgeons: One was too cold. Another was too inexperienced. Then I saw Roger Crumley at the University of California, Irvine Medical Center. Before pushing for any procedure, he helped me understand my condition and what to expect from treatment.

He agreed to do a second septoplasty and informed me of its risks, slightly elevated since the septum had already been compromised. While he didn't guarantee me a home run, he did promise some relief.

Two days after surgery, I had my brother help me remove the nasal packing, as instructed. He did so gingerly. My mother supervised with concern. If I still can't breathe after this, I thought, just cut the thing off.

And then I went for the $4,000 breath -- no, wait, make that $8,000.

I felt an unfamiliar sensation: air! It rushed up through my nose to the back of my throat and then down to my lungs, just as nature had intended. Sweet nasal liberty! I rejoiced with my family, who could finally breathe easier themselves.

Six specialists and two surgeries after I confronted my problem, my septum is right where it should be. As for the tweezers, they've served their purpose. But maybe I'll just keep them around if I ever have to fend off a unibrow. ยท

Comments:ghassemij@washpost.com.



Photo Illustration by Julia Ewan - The Washington Post
© 2006 The Washington Post Company

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