Surgical Management ofNasal Airway Obstruction

John F. Teichgraeber, MDa, Ronald P. Gruber, MDb, Neil Tanna, MD, MBAc,*

KEYWORDS

� Nasal obstruction � Nasal breathing � Septal deviation � Nasal valve narrowing� Turbinate hypertrophy

KEY POINTS

� The management and diagnosis of nasal airway obstruction requires an understanding of the formand function of the nose.

� Nasal airway obstruction can be structural, physiologic, or a combination of both.

� Anatomic causes of airway obstruction include septal deviation, internal nasal valve narrowing,external nasal valve collapse, and inferior turbinate hypertrophy.

� Thus, the management of nasal air obstruction must be selective and carefully considered.

� The goal of surgery is to address the deformity and not just enlarge the nasal cavity.

INTRODUCTION

The management and diagnosis of nasal airwayobstruction requires an understanding of theform and function of the nose. Nasal airwayobstruction can be structural, physiologic, or acombination of both. Thus, the management ofnasal airway obstruction must be selective andoften involves medical management. The goal ofsurgery is to address the deformity and not justenlarge the nasal cavity. This article reviews airwayobstruction and its treatment.

ANATOMY

The nasal airway is both a dynamic and rigid struc-ture. It begins at the external nasal valve, which iscomposed of the caudal edge of the lower lateralcartilages, caudal septum, nostril sill, and thesoft tissue alae. The septum and the bone wallsprovide the rigid structure of the nose. The septumis made up of quadrilateral cartilage, nasal spine,frontal spine, perpendicular plate of the ethmoid,

Disclosures: The authors have no financial disclosures.a Division of Plastic & Reconstructive Surgery, Universitynin Street #1400, Houston, TX 77030, USA; b Division ofStanford, California, USA; c Division of Plastic & ReconstrMarcus Avenue, Suite 102, Lake Success, NY 11042, USA* Corresponding author.E-mail address: ntanna@gmail.com

Clin Plastic Surg 43 (2016) 41–46http://dx.doi.org/10.1016/j.cps.2015.09.0060094-1298/16/$ – see front matter � 2016 Elsevier Inc. All

vomer, and maxillary crest. The narrowest portionof the nose is the internal nasal valve (10�–15�),which is formed by the septum, the inferior turbi-nate, and the upper lateral cartilage. Short nasalbones, a narrow midnasal fold, and malpositionof the alar cartilages all predispose patients to in-ternal valve incompetence.

The lateral wall of the nose contains 3 to 4 turbi-nates (inferior, middle, superior, supreme) and thecorresponding meatuses that drain the paranasalsinuses. The nasolacrimal duct drains throughthe inferior meatus, whereas the maxillary, frontal,and anterior ethmoid sinuses articulate with themiddle meatus. The posterior ethmoid sinus opensinto the superior meatus. The nasal cavity ends atthe choanae as the airflow passes into thenasopharynx.

FUNCTION

The nose is not only a conduit for inspired air butalso an air conditioner that cleans, humidifies,

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and warms the inspired air. It is also involved inolfaction and speech. Inspired air passes throughthe nose at 200 kph (125 mph) in a parabolic curvemoving vertically through the roof of the nasal ves-tibule and then through the internal nasal valve.The nose is the site of nearly half of the total respi-ratory resistance; a third of the resistance occursat the external valve and two-thirds occur at the in-ternal valve. The gatekeeper of nasal airflow is theinternal valve, which aids in respiration by limitingthe flow of air so that it does not exceed the nose’sability to process it. On deep inspiration the nostrilenlarges and the internal valve narrows, whereason expiration the nostril narrows and the internalvalve enlarges. Complete closure of the internalvalve is prevented by the action of the alae, whichflare outward and upward exerting a checkrein ac-tion on the connective-tissue aponeurosis of theupper lateral cartilages.

CAUSES

Nasal obstruction can be physiologic and/or struc-tural. The differential diagnosis of physiologicnasal obstruction includes infections, allergies,medications, vasomotor rhinitis, endocrine disor-ders, and chemical irritants.The common cold is the most frequent cause of

physiologic nasal obstruction. It is usually self-limiting and treated with antihistamines and de-congestants. Allergic rhinitis can be seasonal orperennial. Seasonal symptoms can be managedwith antihistamines, decongestants, and topicaland/or systemic steroids. Perennial allergic rhinitisrequires a work-up, which includes nasal cytology,blood tests for immunoglobulin E levels, and skintest.Rhinitis medicamentosa is most frequently seen

in patients who use long-term nasal sprays ordrops. However, it can also result from oral medi-cations such as reserpine, propanol, and chlor-promazine. Its treatment requires stopping theoffending medication and providing airway sup-port with decongestants and systemic and/ortopical steroids.Pregnancy is a common endocrine cause of

nasal obstruction. However, rhinitis of pregnancyusually resolves with the end of pregnancy. Interimtreatment depends on the stage of the patient’spregnancy and the approach that the patient’sobstetrician has toward therapy during pregnancy.Persistent irritants can cause chronic allergic

rhinitis, and pollution is the most common environ-mental cause. Other causes are primarily occupa-tional, which include dust, fumes, and chemicals.The treatment is preventative and avoidance ofthe irritants.

DIAGNOSIS

The diagnosis of nasal obstruction begins with acomplete history, including several key elements,including (1) duration and frequency of the symp-toms, (2) whether they are unilateral or bilateral, (3)whether they are perennial or seasonal, (4) historyof trauma, (5) history of surgery, (6) presence ofallergic symptoms, and (7) medication usage. Ex-amination of the patient’s nasal cavities requiresgood illumination and adequate decongestion.The patient is initially observed at rest without aspeculum. The external nasal valve is first exam-ined and noted for alar collapse. The internal valveis also evaluated without a speculum, checking formucosal scarring and the relationship of the upperlateral cartilage to the septum. The Cottle test isused to evaluate nasal valve disorder. While thepatient breaths quietly, the cheek is retractedlaterally in order to open up the nasal valve. Ifthe patient’s breathing is improved, the Cottletest is positive, indicating that the nasal valve isa factor in the patient’s respiratory symptoms.However, if the valve is scarred, the maneuvermay not alter the symptoms, and the test resultsare designated as false-negative. In this case, aQ-tip may be used to retract the nasal valve later-ally. Although the Cottle test is specific for nasalvalve collapse, false-positive tests are seen in pa-tients with flaccid valves. Gruber and colleaguesalso described the use of a Breathe Right striptest to evaluate the internal and external valvesseparately.The nasal structures are then examined with a

nasal speculum. The nasal septum is evaluatedfor deviation, whereas the turbinates are evaluatedfor hypertrophy (Fig. 1). The caudal end of theseptum is examined and deviations of the quadri-lateral cartilage and bony septum are noted(Fig. 2). The nasal mucosa is examined for scarringor thinning. In addition, both inferior and middleturbinates are evaluated.

TREATMENT

Correction of the nasal airway obstruction isdirected toward the anatomic source of obstruc-tion. For septal deviation, a septoplasty can beconsidered. The goal of the septoplasty is the cor-rect septal deviation while at the same time pre-serving as much of the septum anatomy aspossible.The septum can be approached endonasally

through a hemitransfixion or Killian incision. Alter-natively, an open approach can be used. In com-plex nasal airway cases, the septum is besttreated with an open rhinoplasty. The open

Fig. 1. Septal deviation and left turbinatehypertrophy.

Fig. 3. A spreader graft being placed to correct inter-nal nasal valve dysfunction.

Surgical Management of Nasal Airway Obstruction 43

approach allows the surgeon to simultaneouslyapproach the caudal and dorsal septum. The up-per lateral is separated from the septum after asubmucosal tunnel is developed on both sides ofthe nose. The quadrilateral cartilage is usually ap-proached dorsally through a mucoperichondrialflap that is connected to a mucoperiosteal flap.The quadrilateral cartilage is separated from theperpendicular plate of the ethmoid, the vomer,and the maxillary crest. Bilateral mucoperiostealflaps are developed, isolating the boney septum.The obstructing bone is fractured with double-action scissors and repositioned. Cuts in theboney septum are usually high on the perpendic-ular plate of the ethmoid and along the floor ofthe nose. The septal cut on the ethmoid is to pre-vent fracturing of the cribriform plate.

Once the boney septum is repositioned, thequadrilateral cartilage is approached. The quadri-lateral cartilage is usually left attached to the ante-rolateral mucoperichondrium unless the caudal

Fig. 2. Caudal septal deflection obstructing the leftnasal cavity.

septum needs repositioning. In this case, thecaudal septum is freed from the ipsilateral and/orcontralateral mucoperichondrium as far asneeded. Vertical septal angulation is treated withvertical resection and horizontal angulation withhorizontal resection. The thickened cartilage isshaved and, if the deformity persists, it may benecessary to weaken the deformed segment withcross-hatching or conservative morcellation. Thearea of deflection along the caudal and dorsal bor-ders of quadrilateral cartilages is managed with in-cisions within 2 mm of the affected border.Although this helps straighten the quadrilateralcartilage it may also weaken it. In order to preventloss of nasal support, grafts (3 mm� 10–20mm) ofseptal cartilage or ethmoidal bone are sutured tothe concave side of the caudal and/or dorsalseptal borders, which helps reinforce andstraighten the septum as well as fixing it in themidline. The authors have also used absorbableplates made of polylactic and polyglycolic acid(Synthes) (3 mm � 20 mm) to reinforce or

Fig. 4. A suspension suture can also be used to correctinternal nasal valve narrowing.

Fig. 5. A mattress suture is placed to improve the in-ternal nasal valve.

Teichgraeber et al44

straighten the deviated septum. The plates are su-tured through preexisting holes to the quadrilateralcartilages with through-and-through polydioxa-none sutures. Following the septoplasty, a septal

Fig. 6. Rim grafts can be used to treat external nasal valv

suture of 4-0 plain on a Keith needle is used tocoapt the mucosal flaps.After the septum is corrected, the upper lateral

cartilages and internal valve are approached. Thelower lateral cartilages have already been sepa-rated submucosally from the septum. Abnormal-ities of the medial portion of the upper lateralsmay require conservation resection. If the internalvalve has collapsed, a spreader flap and/orspreader grafts are used to laterally displace thecartilages, in order to open up the internal valve.The spreader grafts maybe be harvested fromthe septum, ear, and/or rib in order of preference.The grafts (2–4 mm � 20–30 mm) are sutured2 mm below the septal border with polydioxanonesutures (Fig. 3). Subsequently, the upper lateralsare sutured back to the septum with the same su-ture. A composite graft from the ear is used in pa-tients with internal nasal collapse from mucosalscarring. An alternative method to correct internalnasal valve narrowing is to use a permanentmattress suspension suture (Figs. 4 and 5).The external valve is usually obstructed because

of a malposition of the lower lateral cartilage, inad-equate underlying support, and/or mucosal scar-ring. Reconstruction of the external valve andnasal tip begins with a columellar strut, which isharvested from the septum, ear, or rib. It is sutured

e collapse.

Fig. 7. Rim grafts can be considered when concavityof the rim exists.

Surgical Management of Nasal Airway Obstruction 45

between the medial crura with a polydioxanonesuture. Once the central limb of the tripod is stabi-lized, attention is directed to its lateral limbs. Inpatients with adequate lower lateral cartilage,

Fig. 8. Preoperative (left) and postoperative (right) resultspreoperative external nasal valve narrowing.

repositioning of the lower lateral cartilage to theupper lateral cartilages and septum often stabi-lizes the lower lateral cartilages and opens up thevalve. If the lateral crura are over-resected orweak, they are reinforced with lateral crura span-ning grafts from the septum or ear. These graftsare placed lateral to the dome running one-halfto one-third the length of the lateral crura (1.0–1.5 cm) and sandwiched between the lower lateralcartilages and the nasal lining. They are suturedwith polydioxanone sutures. Rim grafts have alsobeen advocated for supporting the external nasalvalve (Figs. 6–8).

If its external valve needs further opening orsupport, a lateral crural spanning graft is used.The graft is usually harvested from the septum orthe ear (2 mm � 16–18 mm) and helps expandthe intercrural space. The position of the nasalvalve and lateral crural spanning grafts areadjusted by stabilizing the structures with two27-gauge needles and redraping the retractedskin. When both vestibular skin and cartilage areneeded, a composite graft from the ear is used.

The inferior turbinate often plays a major role innasal obstruction. The anterior third of the turbi-nate forms the internal valve, the narrowest portionof the nasal airway. A multitude of destructive andnondestructive turbinotomy techniques have been

with rim graft placement. The arrow shows the area of

Fig. 9. Intranasal view before (A) and after (B) septoplasty and turbinate reduction.

Teichgraeber et al46

described to treat the enlarged turbinates. Treat-ment approaches include turbinectomy, submu-cous resection (Fig. 9), turbinate outfracture(Fig. 10), radiofrequency ablation, submucousdiathermy, laser cautery, cryosurgical reduction,and septoturbinotomy.Septoturbinotomy is a noninvasive procedure

used to correct turbinate hypertrophy and septaldeviation. It can expand the nasal vault with inser-tion of a large and long speculum that outfracturesthe turbinates and also centralizes the bonyseptum when the handles are compressed. Alter-natively, a large clamp can be passed into thenasal cavity and expanded (in reverse nutcracker

Fig. 10. Turbinate outfracture is performed by lateral-izing the turbinate.

fashion) to achieve a similar result. Mechanicaldilation (expansion) of the nasal vault with thespeculum or large clamp improves the airwaydiameter of the nasal vault and may preclude theneed for further work on the turbinates. The nasalvault is not necessarily expanded to the maximaldiameter that could be achieved with resectionprocedures, but it may be to achieve satisfactoryair flow.An enlarged middle turbinate can also cause

nasal obstruction and necessitate endoscopicsurgery. In some patients, nasal obstruction re-sults from the loss of boney support. In these pa-tients medial and lateral osteotomies withbilateral spreader grafts are used to lateralizethe upper lateral cartilages and nasal bones. Insome cases, a cantilever costochondral graft isrequired.

SUMMARY

The management of nasal obstruction requires aclear understanding of nasal anatomy and func-tion. Nasal obstruction can be physiologic,anatomic, or a combination of both. The operativetreatment is aided by the open approach, which al-lows clear visualization of the nasal structures, andenables surgeons to precisely address the under-lying anatomic deformities. Even though theseptum is the key to treating nasal obstruction,attention must also be given to the internal andexternal nasal valves and the turbinates.