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Graphic of a noseFeature
It's a miracle!
For the first time in 50 years, Winnipeg
writer Gerald Flood is able to breathe
easy, following an operation to repair
his deviated septum
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By Gerald Flood
Mar/Apr 2019

A lifetime of chronic breathing difficulty ended for me last October with a fairly common operation to repair damaged septal cartilage and bone in my nose, and remove growths rooted in my sinuses. I went into an operating room at St. Boniface Hospital one afternoon and left the next morning having experienced, well, a miracle.

For the first time in 50 years I could breathe so effortlessly through my nose that it seemed I was inhaling compressed air.

It was a delight and a pleasure, and a revelation that breathing easy is the norm for most people who do it more than 25,000 times a day.

I also quickly learned that I was not alone in suffering needlessly.

Dr. Richard Gall, a Winnipeg otolaryngologist (ear, nose and throat surgeon), estimates that 50 per cent of his patients complain, as I did, that their breathing issues are not structural but result from "allergies" or "trouble breathing through my sinuses" or other vaguely defined conditions likely borrowed from endless television ads promoting relief from colds, flu viruses, and vague catch-alls like "stuffiness."

Given all the marketing focus on relieving symptoms with pills, it seemed to defy common sense that my problem really was inside my head, that my "broken nose" was the constant factor in a myriad of breathing issues.

In fact, for a great many people, nasal structural issues frequently are the source of breathing misery. They just don't know it, or believe it.

"I'll say to a patient, 'If you're telling me you're having sinus congestion, then explain what you mean.' And they say, 'Well, I'm having trouble getting air through this side,'" Gall says.

"Then I say, 'That's through your nose.' And they say, 'Well, yes.'

"To me, sinus congestion is pressure, fullness, discomfort, fever, facial pain, dental pain, which we see in people with [sinus] infections and things like that.

"There are so many different perceptions of what the source of the complaint is, that I [first] try to tease out who has trouble breathing through their nose and why that might be."

****

Photo of the CT scan and image of Gerald Flood's deviated septum, turbinates and polyp.
The CT scan and image above show the location of Gerald Flood's deviated septum, turbinates and polyp.

My breathing problems began when I was a boy. It was a sunny Sunday afternoon. My brother and I were playing at a friend's place when we realized we were late for supper. Late for supper was excusable most days, but not on Sundays when we had an entire afternoon to make sure we were on time and presentable.

So we raced home. My brother was on my heels when I tripped, and we both went down in a tangle, with his body driving my face into the turf. I heard a sound like a crunch inside my head that I never have forgotten.

I have no other memories of that moment. Did it hurt? Did it bleed? Were we scolded? No idea. Nor did I know that the sound that stayed in my memory also physically stayed in my nose as a mutilation of its internal structure.

The sound was the fracturing of my septum - the thin wall of cartilage and bone that stands at the centre of the nose and separates the right and left nasal passages.

My brother's weight and our combined inertia smashing down on the cartilage caused it to buckle and reshape itself as a zig-zag.

The zig was so extreme that it pretty much blocked my right air passage, while the zag, like an aftershock, was less intense and did not interfere with the left passage.

Such an injury is called a deviated septum. While people might think of it as being a broken nose, as I hinted above, it is not. To break your nose you have to break your nasal bones - that hard inverted Y structure where your skull meets your nose. A broken nose will bleed, and the eyes will blacken. A septum deviating seldom is so theatrical.

Studies have found that about 37 per cent of North Americans have a deviated septum. In some cases, it's believed to have happened under pressure in the birth canal. More typically, it results from a blow to the nose - a wayward elbow, perhaps, or a misjudged baseball catch.

Usually the deviations are minor and don't require a medical response. But in about 25 per cent of injuries (eight per cent of the population, about 100,000 Manitobans) the deviation is severe enough to cause breathing issues.

But blockage, per se, usually is not that big a deal.

Bigger is the fact that the nasal passages no longer work as they should. The smooth flow of air that occurs in normal passages - called laminar flow - can be so disrupted as to cause drying and irritation of the nasal lining, resulting in swelling and/or the production of mucus, either of which could disrupt breathing by further reducing airflow or by blocking airways.

When that happens, the person with the deviated septum might wrongly surmise that they are having an allergic reaction, or some other presumed condition.

More problematic than the deviation are the compounding effects on other nasal structures.

****

Just out of sight inside the nostrils are bones called turbinates. Most people have three pairs of turbinates, rising in steps or "folds" from the bottom to the top of the nasal passage. The largest pair, the inferior turbinates, are at the bottom. The smaller superior turbinates are at the top, and the middle turbinates are found, not surprisingly, in the middle.

Turbinates, in particular the large inferior turbinates, which are about five to seven centimetres long in adults, play a key role in respiration by cleaning, humidifying and warming air on its way to the lungs.

They are covered with a membrane called nasal mucosal. (In fact, the same tissue lines the entire nasal cavity, including the interiors of the eight sinus cavities.) Mucosal tissue is rich in blood vessels and contains cells that secrete mucus and others that grow tiny "hairs" called cilia. The mucus keeps nasal tissue moist while trapping particulate entering the nose.

Graphic of nose pathologies

We seldom notice that our nasal cavities daily produce about 1.5 litres of clear, liquid mucus and send it to our stomachs. But when the nasal lining is irritated, especially as a result of a virus or allergy, mucus production can skyrocket to more than three litres a day, causing noticeable effects like runny noses, congestion and nasal drip.

At such times, the tiny openings of sinuses can become blocked, so that clear mucous "stagnates" inside and turns green - a process not unlike a puddle of rainwater discolouring over time. Many people wrongly believe that expelled thick, green mucus is a sign of nasal infections. It is not. Infections produce pus, which is white.

The turbinates vastly increase the surface area of the nasal cavity. Because they are lined with tissue rich in blood vessels, air passing over them quickly warms to body temperature - quite a feat when it's -30 C outside.

Because they are close to the septum, anything that causes a turbinate to swell toward the septum could lead to blockage. This becomes almost certain if a deviated septum already is partially blocking the passage.

Swelling of turbinates - or all the nasal lining, for that matter - most commonly results when nasal tissue is irritated, a condition called rhinitis.

About 40 per cent of rhinitis is caused by allergies - usually airborne allergens like pollen or dust mites. The other 60 per cent, however, is a grab bag of probable causes ranging from viruses like colds and flu to irritants such as smoke, chemical odours, mould, spicy food, alcohol, changes in the weather, and even sexual arousal.

The diversity of causes again makes it easy for someone like me to link viral and allergy issues (swollen turbinates) to breathing difficulty, and ignore structural ones like a deviated septum.

In fact, turbinate swelling occurs normally even in the absence of irritants. Every two to eight hours, the blood vessels in the lining of one turbinate swell (congest) while vessels in the other shrink (decongest).

Photo of Dr. Richard Gall demonstrating how a probe is inserted into a patient's nose
Dr. Richard Gall inserts an endescope equipped with a microscopic video camera into the nose of Nick Tkaczyk, a fourth year resident at St. Boniface Hospital. An enlarged imaged of Tkaczyk's nasal passage is projected live on the screen (centre). A high-intensity lamp strapped to Dr. Gall's head is used to help see into ears, noses and throats. (Photo: Marianne Helm)

The reason is not well established. According to the Mayo Clinic website, it might be that the cycle ensures that one or the other passage always has at least a shot at having superior air flow.

The cycle sometimes manifests itself in what is known as "paradoxical nasal obstruction." If, for example, a patient's left air passage is blocked by their septum, it won't much matter if the left turbinate swells or shrinks; air will not pass through. The patient might logically come to believe that since the left passage always performs the same, it is not a source of blockage.

But swelling and shrinking of the turbinate on the right side will noticeably reduce air flow on the right side, leading the patient - paradoxically - to conclude that the right passage is problematic, not the left.

****

Turbinates also play a role in our "experience" of breathing. Nerves in their surface signal to the brain that air is passing over them. Surgically reducing the size of the inferior turbinates, sometimes necessary to open a nasal passage, will also reduce its surface area, weakening air-flow signals to the brain.

People whose signals have thus been weakened often experience a condition called "empty nose syndrome." Because their nose has stopped signalling the passage of air, they think they do not, or cannot, breathe through their noses.

Addiction to antihistamines or cocaine will cause severe damage to mucosa and lead to the same "empty nose" sensation.

People who use "vapour rub" believing it will open airways, meanwhile, should know that the menthol released by rubs does not open passages. What it actually does is stimulate the same air-flow receptors that cause "empty nose syndrome," but in reverse, creating the sensation of increased air flow where no increase actually takes place.

It's not wrong to use rubs - feeling better often is half the battle, Gall says.

Nor is it wrong to use decongestants. They actually do work by causing the blood vessels in the mucosa to shrink and so reduce swelling and mucus production.

But the efficacy of a decongestant falls the more it is used, leading to a vicious spiral in which the more a person uses one, the more it needs to be used.

Decongestant addiction, with its capacity to destroy nasal tissue and facilitate chronic nasal problems, is more common than one might think. Gall recalls a patient recently telling him that he had been spraying decongestant into his nose 10 times a day for 10 years.

Heavy users of decongestants often experience greater relief by stopping their use and allowing mucosa to regain a normal state.

A last word on potentially confusing issues. We have in our brains a "cough centre" that prevents us from coughing while we are sleeping. "We wouldn't be able to sleep otherwise," Gall says. Not knowing that such a centre exists, the average person might wrongly conclude that coughing after waking up is an allergic reaction to - who knows? - mouth wash, orange juice, caffeine?

****

I could go on about the role the nose plays in smelling, tasting, hearing and speaking, but for the purposes of understanding why surgery improved my breathing, I'll mention only one more condition - the growth of polyps in the nose.

Nasal polyps are soft, gelatinous growths usually located on the lining of the sinuses. They are painless, bloodless and, statistically speaking, non-cancerous. Gall, for example, will not rule out the possibility of malignant polyps, but at the same time, he has not in 20 years of practice come across one.

What causes nasal polyps is unknown, but there exists a clear correlation between the onset of polyp growth and chronic inflammation of the nasal membrane due to viruses, infections, allergies and the gamut of non-allergic rhinitis triggers.

Polyps can exist out of sight and out of mind in our noses for years and decades. They only come to our notice when they grow so large as to block openings to sinuses and so encourage infections, or when they grow so large as to hang into the nasal passage and restrict breathing.

Gall has a photograph of a polyp the size of a jalapeƱo pepper hanging from a man's nostril. Trust me, you don't want to see it.

****

In a nutshell, then: A deviated septum often is not, in and of itself, a big deal.

It becomes a big deal when its unnatural shape and positioning interferes with other natural functions of the rest of the nose.

A person with a deviated septum, for instance, might switch to mouth breathing when even mild physical activity increases demand for oxygen. A mild case of rhinitis that might otherwise go unnoticed becomes a struggle to breathe with a deviated septum. The worse the rhinitis, the worse the breathing issue.

The natural cycle of turbinate swelling becomes a cycle of breathing difficulty with a deviated septum, and the growth of polyps that might go unnoticed will have an outsized impact in a nasal cavity whose volume already has been reduced by a deviated septum.

****

The final straw for me came when I was experimenting with the use of a continuous positive airway pressure (CPAP) machine to see whether it could remedy the sleep apnea I was experiencing and put a cork in my snoring.

Sure enough, the machine worked like a charm for several weeks. But then, I started waking in the night, with attacks of sneezing, coughing, hacking, mucus overload and watery eyes. The attacks started small and slowly increased in duration to an hour and more.

I was sure that the CPAP machine somehow was involved. I wrongly concluded that it was exacerbating my familiar "allergy issues," instead of rightly concluding that the machine was forcing too much air up my one functioning nostril, causing extreme drying and irritation.

I complained to my family doctor, who referred me to Gall and to an allergist. I got in to see Gall first.

He asked if I had a deviated septum. I said something to the effect that "Yes, but that's a minor problem compared to the terrible allergic reactions I've been having all my life, but especially since I tried using a CPAP machine."

He listened calmly and asked again whether I had a deviated septum.

The third time he asked, I answered, "Yes. Why?"

Photo of Dr. Richard Gall
Dr. Richard Gall pioneered endoscopic sinus surgery, particularly polyp removal, in Manitoba. (Photo: Marianne Helm)

The rest, as they say, is history. Gall very quickly used a device called an endoscope to peer into my nose and determine that my septum was deviated so severely that I was likely drawing no air to speak of through my right nostril.

He said if I wanted I could consider having the septum surgically repaired, that it likely would involve only minor pain, my eyes would not blacken, and the whole thing would be done and finished in less than a day.

I don't think I said, "Yes, please," but I did manage words to that effect.

A subsequent CT scan confirmed the deviation in extraordinary detail. It also showed that I had polyps, including a large one in my left nostril that likely was problematic whenever my nose membrane was irritated and swelled.

On the day of the surgery I reported to St. Boniface Hospital, quickly was divested of my clothes, and before I knew it, I was unconscious on an operating table.

****

The first recorded nasal surgeries were performed in Egypt 5,500 years ago on criminals sentenced to have their nose (and septum) cut from their face as a gruesome form of punishment and disfigurement.

About 7,400 years later, in 1882, American physician Ephraim Fletcher Ingals became "the father of septal surgery" when he invented a surgical technique called the "window resection," which has remained standard procedure ever since.

The resection begins when a surgeon makes a horizontal cut the length of the septal lining. The incision creates two flaps that can be lifted away to expose the cartilage. The next step typically is to cut along the bottom of the cartilage to free it from its bone foundation. The surgeon next cuts the cartilage vertically at points of deviation, allowing them to be pushed, or to spring back, into alignment.

****

Technology has been improving the speed and success of nasal surgery. The longest standing challenge, no doubt, has been how best to shed light on nasal issues. Seeing a nose is easy, seeing into one, not so much.

Candles and reflected light were employed from the start. A century ago, a tube called an endoscope was developed that improved seeing, mostly into throats. With the discovery of fibre optics in the 1950s, however, the dark ages of nasal surgery came to an end.

Crucially, marrying fibre optics and endoscopes made it possible to not only illuminate interior cavities, but to send the image back to a surgeon's eye at the other end of the tube. The light emitted, in fact, is bright enough that patients report "seeing" it with the back of their eyes.

The invention and then miniaturization of video cameras took it a step further, making it possible to view high-definition images of nasal cavities in real time on monitors. Flexible endoscopes that can slither like snakes, allowing surgeons to see around corners, became commonplace, as did miniature surgical instruments that are inserted through endoscope tubes to perform surgical tasks in response to signals generated by surgeons manipulating remote-control consoles.

All of these developments were surfacing in the medical mainstream at about the same time as Gall was cutting his teeth in medical school and serving a five-year-residency with the University of Manitoba in the Department of Otolaryngology-Head and Neck Surgery.

****

Richard Gall grew up in Garden City, where he says the idea of becoming a doctor seemed a natural, even stereotypical, piece of the "immigrant experience" - he was born in Winnipeg, but his father, a Holocaust survivor, immigrated to Canada from Poland in 1949, while his mother, born in Afghanistan, immigrated to Canada from Israel in 1960.

Whatever the inspiration, he did not unconditionally embrace the idea of a career in medicine until his second year in a science program at University of Winnipeg. It was a "great relief," he says, to have had a goal.

A nascent interest in otolaryngology - ear, nose and throat medicine - was planted while Gall was in medical school. Chance relationships with resident students studying otolaryngology led him to the realization that it could be a fascinating field, filled with a myriad of specialty and sub-specialty opportunities.

One sub-specialty in particular piqued his curiosity - endoscopic sinus surgery. At the time it was an emerging field of non-invasive surgery that originated in Austria and was revolutionizing nasal surgery the world over. It had newly arrived in Canada as Gall was completing his five-year residency in the late 1990s in Winnipeg.

He decided to pursue a fellowship in nasal surgery at the University of Toronto, where the new techniques were being taught.

A year later, in 2000, he put up his shingle in Winnipeg and pioneered endoscopic sinus surgery, particularly polyp removal, in Manitoba.

In the early years, pent-up demand for his skills was so great that his waiting list was 18 months long. When I first met him 18 years later, it had shrunk to about three months, as other local specialists acquired the skills he had pioneered here.

****

Gall performed two separate procedures to remove obstacles interfering with normal breathing through my nose.

The first, to fix my deviated septum, was an old-school septoplasty, not much different than the resection invented by Ingals.

But old-school or not, it is Gall's "favourite" procedure, because, as routine as they might seem, each is unique.

Gall compares septoplasty to auto body work. Every car that comes into the body shop is smashed. But otherwise, every car is different - different makes, models, some rear-ended, some that rolled into ditches or skidded into trees. They all are damaged, and all uniquely so.

"You have to think what to do," he says. "The challenge is the repair."

It was a similar need for diversity that led to his decision to become a surgeon in the first place. Doing surgery gets him out of the office, puts him in different environments, with different colleagues and challenges, he says.

If the first procedure to fix my breathing was old-school, the second was brand spanking new-school.

My CT scan had identified a number of small polyps in my right nasal passage and a fairly large one in the left passage.

The standard procedure to remove polyps until recently was to encircle them with a wire loop that can be drawn tight so as to pinch off pieces. The technique, however, is limited in that the loops can only reach the portion of the polyp found in the nasal passage. The root, as it were, stays behind, inaccessible inside a sinus.

More recently, surgical tools called microdebriders have become the go-to technology. "They've revolutionized polyp surgery," Gall says.

A microdebrider essentially is a long, narrow tube with a powered, oscillating blade at the tip. Suction is created in the hollow centre of the tool. The suction simultaneously draw polyps into the blade to be chopped into bits and then sucks them away to a container for disposal.

The surgeon uses a scope to guide the tip and direct its progress back to the polyp's root.

Polyps invariably grow back. But the microdebrider's ability to reduce a polyp to its root increases the time required for it to grow back.

****

My surgeries lasted less than an hour. Soon after, I woke up, groggy and a bit disoriented. But I felt no pain, only discomfort from the tampon-like packing that filled my nose. Most patients go home after a septoplasty, but I was held overnight for observation because the surgery potentially could exacerbate my sleep apnea.

I watched the Jets win a home game in the TV room that evening and then slept soundly, except for a few occasions when the nurse jostled me to stop my snoring, confirming Gall's pronouncement that surgery would improve my breathing, but equally would not curb my snoring.

In the morning, a medical resident came to my bedside and removed the packing from my nose. It was at that moment that I experienced, well, a miracle.

Gerald Flood is a Winnipeg writer.

Nose numbers

Here is a summary of nasal surgeries, split out between nose/nasal cavity and sinus interventions.

Type of Intervention 2007/2008 2017/2018
Nose and Nasal Cavity Interventions 1,395 1,674
Nasal Sinus Interventions 433 534

The figures represent both elective and urgent nasal/sinus surgeries carried out by any provider (not just otolaryngologists) in a Manitoba hospital on any inpatient or day surgery patient during the fiscal year identified.