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Surgical Treatment of Nasal Obstruction in Rhinoplasty
S u r g i c a l Tre a t m e n t o f N a s a l Ob s t r u c t i o n i n Rhinoplasty Ankona Ghosh, MD, Oren Friedman, MD* KEYWORDS Nasal obstruction Septal deviation External valve Internal valve Turbinate Batten graft Spreader graft
KEY POINTS Nasal obstruction is an important consideration in both functional and aesthetic septorhinoplasty. For a successful surgical correction of nasal obstruction, diagnosing the precise anatomic point of collapse is fundamental. Recognition of the nature and location of nasal valve, septal, and turbinate disorders allows adequate correction and acceptable functional results.
Nasal obstruction is a common problem. Normal nasal breathing involves the interaction of static and dynamic forces, including the nasal septum, lateral nasal walls, and nasal mucosa. Although many patients who present for rhinoplasty evaluation have predominantly aesthetic concerns, many patients are also concerned for nasal airway obstruction. In addition, postoperative airway compromise can detract significantly from an otherwise good aesthetic surgical result. As such, preoperative analysis of the nasal airway is an imperative step in operative planning even if the patient does not necessarily raise concerns over this issue. Modern rhinoplasty techniques allow for success in both nasal aesthetics and function, improving the quality of life functionally and cosmetically as well as allowing for mutual satisfaction of patient and surgeon alike.1 It is therefore a paramount consideration in surgical planning. When evaluating patients with nasal obstruction, the most important variable of nasal airflow is the diameter of the nasal passage. The key to a
successful surgical correction of nasal obstruction is diagnosing the precise anatomic point of collapse.2 Causes of nasal obstruction with particular relevance for rhinoplasty surgeons are discussed later.
ANATOMIC CONSIDERATION Proper postoperative function of the inferior turbinates, septum, and nasal valves determines, to a large degree, the success of functional rhinoplasty. Although there are other anatomic aspects to consider, these structures largely contribute to the size and patency of the nasal airway. Constantian and Clardy3 performed nasal air flow measurements on patients with postrhinoplasty nasal obstruction and found septal deviation, internal nasal valve obstruction, and external nasal valve collapse to be the primary causes.
The Nasal Valves The nasal valve area has been the subject of numerous studies because of its functional
Disclosures: The authors have no financial disclosures. Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA * Corresponding author. 18th Floor, 800 Walnut Street, Philadelphia, PA 19004. E-mail address: [email protected] Clin Plastic Surg 43 (2016) 29–40 http://dx.doi.org/10.1016/j.cps.2015.09.007 0094-1298/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.
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INTRODUCTION
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Ghosh & Friedman importance. It was first described by Mink4 in 1903, and in 1970 Bridger5 further described this area as the flow-limiting segment of the nasal airway.4–6 The nasal valve area represents the area bound by the septum, the caudal aspect of the upper lateral cartilages and lower lateral cartilages, the lateral nasal wall, the nasal floor, and sometimes the head of the inferior turbinate. The valves, classified as external and internal, represent the narrowest portion of the nasal airway and account for half the total nasal airway resistance. Distinguishing between the internal valve and the external nasal valve helps to direct treatment among the different regions of the nasal sidewall.
The External Nasal Valve The external nasal valve is supported by the caudal aspect of the nasal side wall and is delineated by the nostril rim; it is referred to as the nasal inlet. It is defined medially by the medial crus of the lower lateral cartilage and inferiorly by the nasal spine and the soft tissues over the nasal floor.7 External nasal valve collapse is described as collapse of the alar margin of the nose on moderate to deep inspiration, caused by negative pressure during inspiration under the influence of Bernoulli forces.5 The collapse of the external nasal valve is most often seen in patients with narrow nostrils; an overprojected tip; and thin, weak sidewalls. It is often seen in patients with cephalically malpositioned lower lateral cartilage in whom the absence of cartilage support along the nostril rim leads to weakness of the sidewall. The external valve may also be narrow at rest, unrelated to dynamics of inspiration.
The Internal Nasal Valve The internal nasal valve angle is the angle created by the junction of the caudal border of the upper lateral cartilage and the nasal septum (Fig. 1). The valve angle measures 10 to 15 . However, the importance of this valve rests primarily with its area. The area of the internal nasal valve is the narrowest portion of the nasal airway and therefore it is the primary determinant of nasal air flow. Cole8 describes the 4 functional components of the internal nasal valve area as being the structural elements, which include the internal nasal valve angle and the bony pyriform aperture; and the mucovascular elements, which include the anterior head of the inferior turbinate and the erectile body of the septum. Internal nasal valve collapse is usually observed after previous reductive rhinoplasty or in patients with weakening of the supportive structures of the nose, such as the upper and lower lateral cartilages.
Fig. 1. Internal nasal valve area. (From Lam SM, Williams EF. Comprehensive facial rejuvenation. Philadelphia: LWW, 2003; with permission. Available at: http://www. lamfacialplastics.com/dallas-plastic-surgery-learningmodules/rhinoplasty-tutorial/.)
The Septum The septum is a midline nasal structure. Posteriorly, the bony nasal septum is formed by the perpendicular plate of the ethmoid bone and the vomer. Anteriorly, the quadrangular cartilage forms the cartilaginous septum, which articulates with the upper lateral cartilages. Septal deviation off the midline can result in structural blockage of nasal air flow during inspiration or it may cause turbulent airflow. This condition can be congenital or a result of previous nasal trauma. Specifically for nasal valve surgery, the important areas of the nasal septum are the caudal aspect at the nasal vestibule (which would narrow the external valve) and the internal nasal valve area (which relates to Cottle area 2). Cottle’s9 subdivision of the nasal cavities in 5 areas, based on morphologic and rhinomanometric observations, provided a practical scheme that is still useful to understand the relationship between obstruction and anatomic considerations, thus benefiting modern understanding of functional nasal surgery. In addition, deflection of the posterior septum can result in significant narrowing of the nasal airway and should not be overlooked when evaluating for causes of nasal obstruction. Nasal septal perforations may also contribute to the sensation of nasal airway obstruction.
The Turbinates The arteries of the nasal mucosa branch off to capillary vessels, which drain into the venous sinusoids of the erectile tissues of the mucosa. A major component of these erectile tissues contributes to the volume of the nasal mucosa; these are especially well developed at the interior part of the inferior turbinate and on the nasal septum. This expansile tissue can regulate nasal air flow because congestion of this entity can cause changes to the nasal cross-sectional area and resistance to airflow10; it is also a functional
Surgical Treatment of Nasal Obstruction component of the nasal valve as described by Cole.8 Inferior turbinate hypertrophy is a common contributor to nasal obstruction, but the inferior turbinates are also an essential functional component of the nose and should be approached cautiously.
PHYSICAL EXAMINATION As with any preoperative planning, the history and physical examination are key to identifying the causes of nasal airway obstruction. Although most rhinoplasty planning is based on study of the standard preoperative photographic images (frontal, base, lateral, oblique), an anterior rhinoscopy with headlight allows visualization of the nasal septum and the inferior turbinate as well as any disorders associated with these structures, especially after the decongestion of nasal mucosa. Nasopharyngoscopy is often useful to further assess the disorders of the posterior septum, middle turbinate, middle meatus, nasopharynx, and all regions that are in limited view with anterior rhinoscopy. It is also extremely important, when surgery is considered, to identify all intranasal disorders, to determine the amount of cartilage available for grafting and to rule out tumors, perforations, or nasopharyngeal lesions that could contribute to the patient’s symptoms. Approaching surgery with the greatest possible amount of information can help ensure the best outcome. An inspection of the base view of the nose yields important information. On base view, special attention should be given to triangularity and symmetry for sources of nasal obstruction as well as cosmesis. The nasal base should be configured as an isosceles triangle with a gently rounded apex at the nasal tip and subtle flaring of the alar sidewalls (Fig. 2). The caudal septum may be seen protruding into one of the nostrils (Fig. 3). The base view on normal breathing and deep inspiration can reveal collapse of the alar margin of the nose, which is diagnostic of external nasal valve collapse (Fig. 4). During physical examination, some patients report marked improvement in nasal obstruction when the nasal sidewall is distended with the wooden end of a cotton-tipped applicator or other device, or lateral retraction of the cheek. This maneuver, known as the Cottle maneuver, allows reliable identification of an internal nasal valve disorder and helps in identifying appropriate surgical candidates (Fig. 5). Objective obstruction measures include rhinomanometry and acoustic rhinometry. Rhinomanometry is the most commonly used objective test of the nasal airway. Although there are various
Fig. 2. Base view. (Courtesy of John Hilinski, MD, San Diego, CA.)
Fig. 3. Base view of septal deviation. (From Haack J, Papel ID. Caudal septal deviation. Otolaryngol Clin North Am 2009;42(3):427–36; with permission.)
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Fig. 4. Base view of external nasal valve collapse (A, normal breathing and B, inspiration). (From Becker D. Revision rhinoplasty. New York: Thieme; 2008; with permission.)
methods of rhinomanometry distinguished by the varying placement of the pressure sensor, anterior active rhinometry is the most commonly used in the clinical setting. The purpose of this testing is to measure airflow as a function of air pressure for each nasal cavity separately. To isolate one nasal cavity, the contralateral naris is occluded with a pressure-sensing plug, and the nasal airflow through the unoccluded cavity is quantified by a flow sensor embedded in a tight-fitting face
mask.11 Acoustic rhinometry, developed by Hilberg and colleagues12 in 1989, measures intranasal volume, the size and location of minimal cross-sectional area, and dimensional changes using sound reflections created by a sound generator and microphone coupled to a patient’s nose with a flexible silicon tube. Despite considerable interest and research, use of these objective tests is limited and rhinoplasty surgeons instead favor patient-reported subjective symptoms as well as the validated Nasal Obstruction Symptom Evaluation (NOSE) questionnaire as subjective assessments of patient breathing. Previously published research validates the practice of relying on patient subjective assessment of breathing along with the clinician’s physical examination in determining nasal obstruction and surgical candidacy.13,14 Once the history and physical examination have revealed the potential sources of nasal obstruction, operative planning can begin.
EXTERNAL NASAL VALVE Fig. 5. Cottle maneuver. (From Payam V, Behnam B. Contemporary rhinoplasty techniques. In: Motamedi MHK, editor. A textbook of advanced oral and maxillofacial surgery. vol. 2. Croatia: InTech; 2015. p. 750.)
Nasal obstruction from a narrowing or collapse of the external nasal valves can occur as a consequence of congenital malposition of the lower lateral cartilages, pyriform aperture stenosis, caudal septal deviation, facial paralysis, normal
Surgical Treatment of Nasal Obstruction aging, or complication following rhinoplasty. In most cases, the lateral crura of the lower lateral cartilages does not support the nasal ala effectively because of innate or acquired weakness, cephalic malposition, and/or protrusion of the distal part into the vestibule. Overresection of the lateral crura of the lower lateral cartilage is cited as the most common cause of external nasal valve collapse following rhinoplasty. To prevent collapse, the cross-sectional area of this segment needs to increase and the lateral component of the external nasal valve area needs to gain rigidity and strength. Various techniques to restore the external nasal valve strength and stability have been reported, most commonly cartilage grafts such as alar rim graft, alar batten graft, and shield-tip type grafts. An alar batten graft, which is a common surgical technique, is harvested from septal cartilage or ear cartilage and provides strength and structural support to the lateral crura. This graft can be achieved during rhinoplasty through a marginal incision (Fig. 6) or through a limited alar-facial stab approach (Fig. 7). In the marginal incision, an intranasal incision coursing along the caudal margin of the lower lateral cartilage is made. A sharp wide double hook is placed just inside the nostril margin retracting the skin. A pocket is then created with blunt scissors dissecting toward the alar-facial groove15 and the graft is placed in this pocket. The marginal incision is then closed with interrupted 5-0 chromic sutures. In the alar-facial stab method, described in 2010,16 a 2-mm stab incision is made in the alar-
Fig. 6. Marginal incision, alar rim. (From Deroee AF, Younes AA, Friedman O. External nasal valve collapse repair: the limited alar-facial stab approach. Laryngoscope 2011;121:475; with permission.)
Fig. 7. Facial stab, alar rim. (From Deroee AF, Younes AA, Friedman O. External nasal valve collapse repair: the limited alar-facial stab approach. Laryngoscope 2011;121:475; with permission.)
facial groove. Blunt dissection through the alar fibrofatty tissue is carried superiorly to create a pocket extending to the soft tissue triangle of the alar rim. Cartilage grafts are cut to appropriate dimensions (3–4 mm by 1.5 cm long) and inserted into the pocket using Brown-Adson forceps. The external stab incision is then closed with two 5-0 chromic sutures. Although suspension sutures are more commonly used for internal nasal valve repair, the lateral crus pull-up suture is described for isolated external nasal valve collapse. It has been described through an endonasal delivery approach to rotate the lateral crus of the lower lateral cartilage in a superolateral direction, held in place with a permanent spanning suture through the pyriform aperture. This technique is thought to supply strength and firmness to the lateral wall as a result of the continuous traction of the permanent spanning suture.17 Internal recurvature of the lateral crus to obstruct the nasal airway at the external nasal valve is commonly seen as a significant cause of nasal obstruction. Lateral crural strut grafts and lateral crural transposition techniques may be used to correct this problem. Structural shield tip–type grafts are often used to maintain stability of the restructured lateral nasal crura.18 In addition, cephalic malpositioning of the lower lateral cartilages often results in poorly supported alar sidewalls. Repositioning the lower lateral cartilages in a more caudal location helps improve nasal vestibule support.19
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Ghosh & Friedman These procedures strengthen the alar sidewall and provide both static and dynamic force to prevent external nasal valve collapse (Fig. 8).
INTERNAL NASAL VALVE When discussing internal nasal valve surgery, it is important to understand that maintaining structural integrity of the central pillar of the Anderson tripod (the combined medial crura, membranous septum, and caudal end of the septum) is imperative to a successful repair, such that any undertaking to perform internal nasal valve surgery should focus on strengthening the medial crura or expanding the nasal valve angle by repositioning the lateral cartilages, including the upper lateral cartilage and the alar cartilages (lateral crura). Kern20 described causes of nasal valve obstruction according to the affected functional component of the valve, including septal disorders, mucocutaneous disorders, and upper lateral cartilage disorders. Common septal disorders are discussed later. If the relationship between the upper lateral cartilage and the septum is appropriate and there is no mucocutaneous disorder, then the lateral aspect of the valve along the nasal sidewall is addressed.
In patients presenting after previous surgery, previous resection of the cephalic border of the lower lateral cartilages or dome division may lead to structural weakness at the transition of the upper lateral cartilage and lower lateral cartilage, as well as structural weakness at the domal angle between the intermediate crus and the lateral crus. In these cases, batten grafts are a valuable mechanism in correcting these deficiencies. These grafts, consisting of curved septal cartilage or auricular cartilage, can be applied into a precise pocket at the site of maximal lateral nasal wall collapse via a limited intercartilaginous endonasal incision or via the external rhinoplasty approach.21 The convex surface of the graft is oriented laterally to allow maximal lateralization of the collapsed portion of the lateral nasal wall and the graft may be fixated with mattress sutures to the upper lateral cartilage. One limitation of batten grafts is that they cannot correct valve obstruction associated with deformities of the middle vault and the valve angle. The middle vault is critical for nasal breathing. The insertions of the upper lateral cartilages into the septum typically form a rounded arch that shapes the nasal valve angle at its caudal margin (Fig. 9). Following dorsal reduction, in which the upper lateral cartilage has been resected and
Fig. 8. (A) Before and (B) after correction of external nasal valve collapse. (From Becker, D. Revision rhinoplasty. New York: Thieme; 2008; with permission.)
Surgical Treatment of Nasal Obstruction
Fig. 9. Middle nasal vault. (Courtesy of John Hilinski, MD, San Diego, CA.)
separated from the dorsal septum, the natural wide and convex relationship between the upper lateral cartilage and the septum may become concave and narrowed. Therefore during rhinoplasty, separation of the upper lateral cartilages from the septum is frequently followed by spreader graft placement (fashioned from septal or auricular cartilage), to reapproximate, stabilize, and widen the nasal valve angle (Fig. 10). Spreader grafts can be bilateral or unilateral to correct asymmetries.22 Another technique to reconstruct the middle vault is described by Alsarraf and Murakami23 and involves a dorsal onlay graft sutured to the edges of the upper lateral cartilages to widen the nasal valve (Fig. 11). A type of onlay graft that is gaining popularity is the butterfly graft, which is composed of
curved auricular cartilage. The butterfly graft can be placed through an endonasal or external approach, and is placed symmetrically over the nasal dorsum. If necessary, the dorsal septum can be shaved to accommodate the thickness of the graft to avoid a polly-beak deformity. The graft is then secured with a suture to the upper lateral cartilage on each side,24 which flares the upper lateral cartilages and widens the internal nasal valve angle (Fig. 12), thereby enlarging the nasal valve area. Autospreader grafts, or spreader flaps, are created by using the redundant dorsal portion of the upper lateral cartilage as the spreader graft. One advantage of this technique is that it obviates the harvesting of septal cartilage.25 Another method that allows excellent functional and cosmetic results is the placement of a longitudinal graft along the septum after the septum is slightly reduced in height. The upper lateral cartilages are then sutured along their entire length to the undersurface of this graft, resulting in a smooth dorsal contour and upward pull on the upper lateral cartilages. In addition, some surgeons advocate the use of suture techniques to repair nasal valve disorders. The flaring suture across the upper lateral cartilages may be useful when used in conjunction with other techniques of valve repair.26 Paniello27 described the suspension suture technique, in which external sutures attached to the maxillary periosteum are used to pull out the nasal sidewalls. However, this technique requires external incisions and drilling anchor locations. These techniques can be used as alternatives to definite anatomic repair for patients who are poor candidates for rhinoplasty. There are a
Fig. 10. Middle vault (A) with spreader grafts. (B) Separation of upper lateral cartilages (ULC). (C) Placement of spreader grafts between septum and ULC. (From Gassner HG. Structural grafts and suture techniques in functional and aesthetic rhinoplasty. GMS Curr Top Otorhinolaryngol Head Neck Surg 2010;9:Doc01.)
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Fig. 11. Middle vault (A) with dorsal only. (B) Separation of ULC. (C) Placement of spreader graft between septum and ULC. (D) Placement of dorsal onlay grafts. (From Gassner HG. Structural grafts and suture techniques in functional and aesthetic rhinoplasty. GMS Curr Top Otorhinolaryngol Head Neck Surg 2010;9:Doc01.)
variety of other techniques described for the repair of internal nasal valve collapse, and interested readers are encouraged to pursue additional sources.
DEVIATED SEPTUM Although the general techniques of septoplasty are discussed elsewhere, there are several critical
Surgical Treatment of Nasal Obstruction
Fig. 12. Middle vault with butterfly graft. (From http://noserevisionsurgeryandsurgeons.blogspot.com/2010/10/ mystery-of-different-types-of-nose.html; with permission.)
aspects to consider when performing septoplasty for nasal obstruction. For posterior septal deviations and septal spurs, standard septoplasty techniques are effective. However, it is important to understand the relationship of the dorsal septum to the upper lateral cartilages and to appreciate caudal septal deviation. In the former case, marked dorsal septal deformities may require separation of the upper lateral cartilages from the septum; this disarticulation may lead to both functional and aesthetic deformities when this area becomes weak and causes blunting of the internal nasal valve angle. Spreader grafts may be required at the time of the septoplasty to straighten the dorsal septal deviation, prevent internal nasal valve collapse, and/or correct preexisting valve defects that may be present. Furthermore, spreader grafts help the aesthetic deformity caused by dorsal septal deviation, which often causes crooked nose deformity. Caudal septal deviation should also be recognized early as a source of nasal obstruction, and one that can be challenging to correct. The goal of surgical treatment of caudal septal deformities is to reduce or eliminate the deviation while maintaining support of the nasal tip to prevent tip ptosis. Several maneuvers are at the surgeon’s disposal for treating caudal septal deviation. Traditional approaches include scoring the septal cartilage on the concave side, thereby relaxing the spring of the cartilage. Another traditional
approach is the swinging-door repositioning technique described by Gubisch28 and Peer,29 which involves excising a wedge of cartilage along the maxillary crest to release the caudal septal attachments and allow the septum to swing to the midline. The midline position may be secured with an absorbable suture attached to the periosteum adjacent to the opposite side of the nasal spine or attached to the midline maxillary crest. In severe cases, it may be necessary to perform a septal transplant. During this procedure, the surgeon may completely resect the anterior septum keeping a dorsal strut in place and subsequently reconstruct the caudal strut from a septal cartilage graft harvested during the septoplasty30 or, alternatively, rib cartilage or other grafting material. This neostrut is placed within the septal space and secured to the intact dorsal strut and maxillary spine, acting as both a strut graft for nasal tip stability and as a spreader graft within the middle nasal vault (Fig. 13). Additional strength may be created through the use of extended spreader grafts, which help secure the newly positioned caudal septal replacement. Another location of septal disorders less commonly seen is an elongated membranous septum resulting in tip ptosis and bilateral nasal valve obstruction. During the history and physical, the patient may indicate that pushing the nasal tip up relieves the obstruction. In addition to correcting any middle nasal vault disorders, recreation of
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Fig. 13. Anterior septal reconstruction (ASR). (From Surowitz J, Lee MK, Most SP. Anterior septal reconstruction for treatment of severe caudal septal deviation: clinical severity and outcomes. Otolaryngol Head Neck Surg 2015;153(1):27–33; with permission.)
the relationship between the columella and the caudal septum is important to correct such a deformity.
INFERIOR TURBINATE Although turbinate hypertrophy has not been well defined and is still poorly understood, recent literature suggests that there is some merit to addressing this entity. Before attributing nasal obstruction to turbinate hypertrophy, the integrity of the nasal valve should be verified, and the straightness of the septum should be ensured. Once this is complete, turbinate hypertrophy can be considered as a contribution to nasal obstruction. Turbinate hypertrophy should be refractory to antiinflammatory medical therapies before surgical intervention is considered. Because of the physiologic function of the turbinates, we also recommend that all other disorders be addressed in correcting nasal obstruction first. If the patient continues to have an obstructive airway, the surgeon may proceed with turbinate procedure.
Various techniques of turbinate reduction have been reported in the literature. Passali and colleagues31 showed that submucous resection with or without lateralization of the inferior turbinate via outfracture resulted in longer-lasting reduction of nasal airway resistance compared with turbinectomy, laser cautery, electrocautery, or cryotherapy. However, risk of atrophic rhinitis as a result of removal of this mucosa is substantial and should be considered in all patients who develop nasal congestion, crusting, and dryness secondary to turbinate surgery; this is known as empty nose syndrome. These symptoms occur when the humidifying function of the nasal mucosa decompensates after removal of important nasal mucosa.32 Lateral outfracture and selective submucous resection of bone seem to be the only surgical maneuvers that allow reduction of the impact of the turbinates on nasal resistance without destruction of their physiologic function. Because the excision of turbinate tissue has been associated with major morbidity such as empty nose syndrome, the resection of healthy functionally important turbinate tissue should be approached in extreme cases only.33 In almost all cases,
Surgical Treatment of Nasal Obstruction correction of septal and nasal valve disorders provides patients with extremely satisfying nasal airways and turbinate reduction is rarely required.
OSTEOTOMY An additional consideration for nasal obstruction in rhinoplasty involves complications secondary to osteotomy. Inadequate lateral osteotomies after removal of a dorsal hump may result in an open roof deformity. However, the lateral osteotomy required to correct nasal deformities while closing or preventing an open roof could lead to nasal valve obstruction. Webster and colleagues34 showed that the risk of nasal valve obstruction could be reduced by initiating the lateral osteotomy higher on the pyriform aperture. This risk reduction is thought to be caused by preservation of a triangular piece at the edge of the pyriform aperture that prevents medial displacement of fibromuscular tissues of the ala and possibly the inferior turbinate. Thus highlow-high osteotomies are performed whenever possible in order to ensure preservation of airway patency. Another complication of dorsal hump reduction (alluded to earlier) is the inverted V deformity, which is especially common in patients with short nasal bones. This deformity may be prevented by exact placement of spreader grafts in the manner discussed earlier. Preventative reconstruction and strengthening of the middle nasal vault with spreader grafts or other techniques in patients with short nasal bones are encouraged.
SUMMARY The key to a successful functional septorhinoplasty includes an understanding of nasal anatomy and physiology. History and physical are paramount in diagnosing and subsequently treating an epicenter of obstruction, which is commonly found in one of the following locations: internal or external nasal valve, caudal septum, or turbinate. Treatment of each of these centers is nuanced and multiple approaches are discussed to provide an understanding of the current surgical techniques that allow adequate correction and excellent functional results.
REFERENCES 1. Salem AM, Younes A, Friedman O. Cosmetics and function: quality-of-life changes after rhinoplasty surgery. Laryngoscope 2012;122:254–9. 2. Rohrich RJ, Raniere J Jr, Ha RY. The alar contour graft: correction and prevention of alar rim deformities in rhinoplasty. Plast Reconstr Surg 2002;109:2495–505.
3. Constantian MB, Clardy RB. The relative importance of septal and nasal valvular surgery in correcting airway obstruction in primary and secondary rhinoplasty. Plast Reconstr Surg 1996;98:38–58. 4. Mink PJ. Le nez comme voi repiratorie. Presse Otolaryngol Belg 1903;5:481–96. 5. Bridger GP. Physiology of the nasal valve. Arch Otolaryngol 1970;92:543–53. 6. Haight JS, Cole P. The site and function of the nasal valve. Laryngoscope 1983;93:49–55. 7. Constantine MB. The incompetent external nasal valve: pathophysiology and treatment in primary and secondary rhinoplasty. Plast Reconstr Surg 1994;93:919–31. 8. Cole P. The four components of the nasal valve. Am J Rhinol 2003;17:107–10. 9. Cottle MH. Rhino-sphygmo-manometry and aid in physical diagnosis. Intern Rhinol 1968;6:7–26. 10. Wexler D, Braverman I, Amar M. Histology of the nasal septal swell body (septal turbinate). Otolaryngol Head Neck Surg 2006;134:596–600. 11. Masing H. Rhinomanometry, different techniques, and results. Acta Otorhinolaryngol Belg 1979;33: 566–71. 12. Hilberg O, Jackson AC, Swift DL, et al. Acoustic rhinometry evaluation of nasal cavity geometry by acoustic reflection. J Appl Physiol 1989;66: 295–303. 13. Chisholm E, Jallali N. Rhinoplasty and septorhinoplasty outcome evaluation. Ear Nose Throat J 2012;91:E10–4. 14. Rhee JS, Poetker DM, Smith TL, et al. Nasal valve surgery improves disease-specific quality of life. Laryngoscope 2005;115(3):437–40. 15. Guida RA. Surgical approaches to the nasal skeleton. Oper Tech Otolaryngol Head Neck Surg 1999;10:228–31. 16. Deroee AF, Younes AA, Friedman O. External nasal valve collapse repair: the limited alar-facial stab approach. Laryngoscope 2011;121:474–9. 17. Menger DJ. Lateral crus pull-up: a method for collapse of the external nasal valve. Arch Facial Plast Surg 2006;8:333–7. 18. Friedman O, Ackcam T, Cook T. Reconstructive rhinoplasty: the three-dimensional nasal tip. Arch Facial Plast Surg 2006;8:195–201. 19. Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg 2006 May-Jun;8(3):156–85. 20. Kern EB. Surgery of the nasal valve. In: Sisson GA, Tardy ME Jr, editors. Plastic and reconstructive surgery of the face and neck: Proceedings of the Second International Symposium. vol. 2. New York: Grune and Stratton; 1977. p. 43–59. 21. Toriumi DM, Josen J, Weinberer M, et al. Use of alar batten grafts for correction of nasal valve collapse. Arch Otolaryngol Head Neck Surg 1997;123:802–8.
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29. Peer L. An operation to repair lateral displacement of the lower border of septal cartilage. Arch Otolaryngol 1937;25:475–7. 30. Surowitz J, Lee MK, Most SP. Anterior septal reconstruction for treatment of severe caudal septal deviation: clinical severity and outcomes. Otolaryngol Head Neck Surg 2015;153(1):27–33. 31. Passali D, Passali FM, Damiani V, et al. Treatment of inferior turbinate hypertrophy: a randomized clinical trial. Ann Otol Rhinol Laryngol 2003;112:683–8. 32. Lindemann J, Lieacker R, Sikora T, et al. Impact of unilateral sinus surgery with resection by means of midfacial degloving on nasal air conditioning. Laryngoscope 2002;112:2062–6. 33. Chhabra N, Houser SM. The diagnosis and management of empty nose syndrome. Otolaryngol Clin North Am 2009;42:311–30. 34. Webster RC, Davidson TM, Smith RC. Curved lateral osteotomy for airway protection in rhinoplasty. Arch Otolaryngol Head Neck Surg 1977;103:454–8.
KEY POINTS Nasal obstruction is an important consideration in both functional and aesthetic septorhinoplasty. For a successful surgical correction of nasal obstruction, diagnosing the precise anatomic point of collapse is fundamental. Recognition of the nature and location of nasal valve, septal, and turbinate disorders allows adequate correction and acceptable functional results.
Nasal obstruction is a common problem. Normal nasal breathing involves the interaction of static and dynamic forces, including the nasal septum, lateral nasal walls, and nasal mucosa. Although many patients who present for rhinoplasty evaluation have predominantly aesthetic concerns, many patients are also concerned for nasal airway obstruction. In addition, postoperative airway compromise can detract significantly from an otherwise good aesthetic surgical result. As such, preoperative analysis of the nasal airway is an imperative step in operative planning even if the patient does not necessarily raise concerns over this issue. Modern rhinoplasty techniques allow for success in both nasal aesthetics and function, improving the quality of life functionally and cosmetically as well as allowing for mutual satisfaction of patient and surgeon alike.1 It is therefore a paramount consideration in surgical planning. When evaluating patients with nasal obstruction, the most important variable of nasal airflow is the diameter of the nasal passage. The key to a
successful surgical correction of nasal obstruction is diagnosing the precise anatomic point of collapse.2 Causes of nasal obstruction with particular relevance for rhinoplasty surgeons are discussed later.
ANATOMIC CONSIDERATION Proper postoperative function of the inferior turbinates, septum, and nasal valves determines, to a large degree, the success of functional rhinoplasty. Although there are other anatomic aspects to consider, these structures largely contribute to the size and patency of the nasal airway. Constantian and Clardy3 performed nasal air flow measurements on patients with postrhinoplasty nasal obstruction and found septal deviation, internal nasal valve obstruction, and external nasal valve collapse to be the primary causes.
The Nasal Valves The nasal valve area has been the subject of numerous studies because of its functional
Disclosures: The authors have no financial disclosures. Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA, USA * Corresponding author. 18th Floor, 800 Walnut Street, Philadelphia, PA 19004. E-mail address: [email protected] Clin Plastic Surg 43 (2016) 29–40 http://dx.doi.org/10.1016/j.cps.2015.09.007 0094-1298/16/$ – see front matter Ó 2016 Elsevier Inc. All rights reserved.
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INTRODUCTION
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Ghosh & Friedman importance. It was first described by Mink4 in 1903, and in 1970 Bridger5 further described this area as the flow-limiting segment of the nasal airway.4–6 The nasal valve area represents the area bound by the septum, the caudal aspect of the upper lateral cartilages and lower lateral cartilages, the lateral nasal wall, the nasal floor, and sometimes the head of the inferior turbinate. The valves, classified as external and internal, represent the narrowest portion of the nasal airway and account for half the total nasal airway resistance. Distinguishing between the internal valve and the external nasal valve helps to direct treatment among the different regions of the nasal sidewall.
The External Nasal Valve The external nasal valve is supported by the caudal aspect of the nasal side wall and is delineated by the nostril rim; it is referred to as the nasal inlet. It is defined medially by the medial crus of the lower lateral cartilage and inferiorly by the nasal spine and the soft tissues over the nasal floor.7 External nasal valve collapse is described as collapse of the alar margin of the nose on moderate to deep inspiration, caused by negative pressure during inspiration under the influence of Bernoulli forces.5 The collapse of the external nasal valve is most often seen in patients with narrow nostrils; an overprojected tip; and thin, weak sidewalls. It is often seen in patients with cephalically malpositioned lower lateral cartilage in whom the absence of cartilage support along the nostril rim leads to weakness of the sidewall. The external valve may also be narrow at rest, unrelated to dynamics of inspiration.
The Internal Nasal Valve The internal nasal valve angle is the angle created by the junction of the caudal border of the upper lateral cartilage and the nasal septum (Fig. 1). The valve angle measures 10 to 15 . However, the importance of this valve rests primarily with its area. The area of the internal nasal valve is the narrowest portion of the nasal airway and therefore it is the primary determinant of nasal air flow. Cole8 describes the 4 functional components of the internal nasal valve area as being the structural elements, which include the internal nasal valve angle and the bony pyriform aperture; and the mucovascular elements, which include the anterior head of the inferior turbinate and the erectile body of the septum. Internal nasal valve collapse is usually observed after previous reductive rhinoplasty or in patients with weakening of the supportive structures of the nose, such as the upper and lower lateral cartilages.
Fig. 1. Internal nasal valve area. (From Lam SM, Williams EF. Comprehensive facial rejuvenation. Philadelphia: LWW, 2003; with permission. Available at: http://www. lamfacialplastics.com/dallas-plastic-surgery-learningmodules/rhinoplasty-tutorial/.)
The Septum The septum is a midline nasal structure. Posteriorly, the bony nasal septum is formed by the perpendicular plate of the ethmoid bone and the vomer. Anteriorly, the quadrangular cartilage forms the cartilaginous septum, which articulates with the upper lateral cartilages. Septal deviation off the midline can result in structural blockage of nasal air flow during inspiration or it may cause turbulent airflow. This condition can be congenital or a result of previous nasal trauma. Specifically for nasal valve surgery, the important areas of the nasal septum are the caudal aspect at the nasal vestibule (which would narrow the external valve) and the internal nasal valve area (which relates to Cottle area 2). Cottle’s9 subdivision of the nasal cavities in 5 areas, based on morphologic and rhinomanometric observations, provided a practical scheme that is still useful to understand the relationship between obstruction and anatomic considerations, thus benefiting modern understanding of functional nasal surgery. In addition, deflection of the posterior septum can result in significant narrowing of the nasal airway and should not be overlooked when evaluating for causes of nasal obstruction. Nasal septal perforations may also contribute to the sensation of nasal airway obstruction.
The Turbinates The arteries of the nasal mucosa branch off to capillary vessels, which drain into the venous sinusoids of the erectile tissues of the mucosa. A major component of these erectile tissues contributes to the volume of the nasal mucosa; these are especially well developed at the interior part of the inferior turbinate and on the nasal septum. This expansile tissue can regulate nasal air flow because congestion of this entity can cause changes to the nasal cross-sectional area and resistance to airflow10; it is also a functional
Surgical Treatment of Nasal Obstruction component of the nasal valve as described by Cole.8 Inferior turbinate hypertrophy is a common contributor to nasal obstruction, but the inferior turbinates are also an essential functional component of the nose and should be approached cautiously.
PHYSICAL EXAMINATION As with any preoperative planning, the history and physical examination are key to identifying the causes of nasal airway obstruction. Although most rhinoplasty planning is based on study of the standard preoperative photographic images (frontal, base, lateral, oblique), an anterior rhinoscopy with headlight allows visualization of the nasal septum and the inferior turbinate as well as any disorders associated with these structures, especially after the decongestion of nasal mucosa. Nasopharyngoscopy is often useful to further assess the disorders of the posterior septum, middle turbinate, middle meatus, nasopharynx, and all regions that are in limited view with anterior rhinoscopy. It is also extremely important, when surgery is considered, to identify all intranasal disorders, to determine the amount of cartilage available for grafting and to rule out tumors, perforations, or nasopharyngeal lesions that could contribute to the patient’s symptoms. Approaching surgery with the greatest possible amount of information can help ensure the best outcome. An inspection of the base view of the nose yields important information. On base view, special attention should be given to triangularity and symmetry for sources of nasal obstruction as well as cosmesis. The nasal base should be configured as an isosceles triangle with a gently rounded apex at the nasal tip and subtle flaring of the alar sidewalls (Fig. 2). The caudal septum may be seen protruding into one of the nostrils (Fig. 3). The base view on normal breathing and deep inspiration can reveal collapse of the alar margin of the nose, which is diagnostic of external nasal valve collapse (Fig. 4). During physical examination, some patients report marked improvement in nasal obstruction when the nasal sidewall is distended with the wooden end of a cotton-tipped applicator or other device, or lateral retraction of the cheek. This maneuver, known as the Cottle maneuver, allows reliable identification of an internal nasal valve disorder and helps in identifying appropriate surgical candidates (Fig. 5). Objective obstruction measures include rhinomanometry and acoustic rhinometry. Rhinomanometry is the most commonly used objective test of the nasal airway. Although there are various
Fig. 2. Base view. (Courtesy of John Hilinski, MD, San Diego, CA.)
Fig. 3. Base view of septal deviation. (From Haack J, Papel ID. Caudal septal deviation. Otolaryngol Clin North Am 2009;42(3):427–36; with permission.)
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Fig. 4. Base view of external nasal valve collapse (A, normal breathing and B, inspiration). (From Becker D. Revision rhinoplasty. New York: Thieme; 2008; with permission.)
methods of rhinomanometry distinguished by the varying placement of the pressure sensor, anterior active rhinometry is the most commonly used in the clinical setting. The purpose of this testing is to measure airflow as a function of air pressure for each nasal cavity separately. To isolate one nasal cavity, the contralateral naris is occluded with a pressure-sensing plug, and the nasal airflow through the unoccluded cavity is quantified by a flow sensor embedded in a tight-fitting face
mask.11 Acoustic rhinometry, developed by Hilberg and colleagues12 in 1989, measures intranasal volume, the size and location of minimal cross-sectional area, and dimensional changes using sound reflections created by a sound generator and microphone coupled to a patient’s nose with a flexible silicon tube. Despite considerable interest and research, use of these objective tests is limited and rhinoplasty surgeons instead favor patient-reported subjective symptoms as well as the validated Nasal Obstruction Symptom Evaluation (NOSE) questionnaire as subjective assessments of patient breathing. Previously published research validates the practice of relying on patient subjective assessment of breathing along with the clinician’s physical examination in determining nasal obstruction and surgical candidacy.13,14 Once the history and physical examination have revealed the potential sources of nasal obstruction, operative planning can begin.
EXTERNAL NASAL VALVE Fig. 5. Cottle maneuver. (From Payam V, Behnam B. Contemporary rhinoplasty techniques. In: Motamedi MHK, editor. A textbook of advanced oral and maxillofacial surgery. vol. 2. Croatia: InTech; 2015. p. 750.)
Nasal obstruction from a narrowing or collapse of the external nasal valves can occur as a consequence of congenital malposition of the lower lateral cartilages, pyriform aperture stenosis, caudal septal deviation, facial paralysis, normal
Surgical Treatment of Nasal Obstruction aging, or complication following rhinoplasty. In most cases, the lateral crura of the lower lateral cartilages does not support the nasal ala effectively because of innate or acquired weakness, cephalic malposition, and/or protrusion of the distal part into the vestibule. Overresection of the lateral crura of the lower lateral cartilage is cited as the most common cause of external nasal valve collapse following rhinoplasty. To prevent collapse, the cross-sectional area of this segment needs to increase and the lateral component of the external nasal valve area needs to gain rigidity and strength. Various techniques to restore the external nasal valve strength and stability have been reported, most commonly cartilage grafts such as alar rim graft, alar batten graft, and shield-tip type grafts. An alar batten graft, which is a common surgical technique, is harvested from septal cartilage or ear cartilage and provides strength and structural support to the lateral crura. This graft can be achieved during rhinoplasty through a marginal incision (Fig. 6) or through a limited alar-facial stab approach (Fig. 7). In the marginal incision, an intranasal incision coursing along the caudal margin of the lower lateral cartilage is made. A sharp wide double hook is placed just inside the nostril margin retracting the skin. A pocket is then created with blunt scissors dissecting toward the alar-facial groove15 and the graft is placed in this pocket. The marginal incision is then closed with interrupted 5-0 chromic sutures. In the alar-facial stab method, described in 2010,16 a 2-mm stab incision is made in the alar-
Fig. 6. Marginal incision, alar rim. (From Deroee AF, Younes AA, Friedman O. External nasal valve collapse repair: the limited alar-facial stab approach. Laryngoscope 2011;121:475; with permission.)
Fig. 7. Facial stab, alar rim. (From Deroee AF, Younes AA, Friedman O. External nasal valve collapse repair: the limited alar-facial stab approach. Laryngoscope 2011;121:475; with permission.)
facial groove. Blunt dissection through the alar fibrofatty tissue is carried superiorly to create a pocket extending to the soft tissue triangle of the alar rim. Cartilage grafts are cut to appropriate dimensions (3–4 mm by 1.5 cm long) and inserted into the pocket using Brown-Adson forceps. The external stab incision is then closed with two 5-0 chromic sutures. Although suspension sutures are more commonly used for internal nasal valve repair, the lateral crus pull-up suture is described for isolated external nasal valve collapse. It has been described through an endonasal delivery approach to rotate the lateral crus of the lower lateral cartilage in a superolateral direction, held in place with a permanent spanning suture through the pyriform aperture. This technique is thought to supply strength and firmness to the lateral wall as a result of the continuous traction of the permanent spanning suture.17 Internal recurvature of the lateral crus to obstruct the nasal airway at the external nasal valve is commonly seen as a significant cause of nasal obstruction. Lateral crural strut grafts and lateral crural transposition techniques may be used to correct this problem. Structural shield tip–type grafts are often used to maintain stability of the restructured lateral nasal crura.18 In addition, cephalic malpositioning of the lower lateral cartilages often results in poorly supported alar sidewalls. Repositioning the lower lateral cartilages in a more caudal location helps improve nasal vestibule support.19
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Ghosh & Friedman These procedures strengthen the alar sidewall and provide both static and dynamic force to prevent external nasal valve collapse (Fig. 8).
INTERNAL NASAL VALVE When discussing internal nasal valve surgery, it is important to understand that maintaining structural integrity of the central pillar of the Anderson tripod (the combined medial crura, membranous septum, and caudal end of the septum) is imperative to a successful repair, such that any undertaking to perform internal nasal valve surgery should focus on strengthening the medial crura or expanding the nasal valve angle by repositioning the lateral cartilages, including the upper lateral cartilage and the alar cartilages (lateral crura). Kern20 described causes of nasal valve obstruction according to the affected functional component of the valve, including septal disorders, mucocutaneous disorders, and upper lateral cartilage disorders. Common septal disorders are discussed later. If the relationship between the upper lateral cartilage and the septum is appropriate and there is no mucocutaneous disorder, then the lateral aspect of the valve along the nasal sidewall is addressed.
In patients presenting after previous surgery, previous resection of the cephalic border of the lower lateral cartilages or dome division may lead to structural weakness at the transition of the upper lateral cartilage and lower lateral cartilage, as well as structural weakness at the domal angle between the intermediate crus and the lateral crus. In these cases, batten grafts are a valuable mechanism in correcting these deficiencies. These grafts, consisting of curved septal cartilage or auricular cartilage, can be applied into a precise pocket at the site of maximal lateral nasal wall collapse via a limited intercartilaginous endonasal incision or via the external rhinoplasty approach.21 The convex surface of the graft is oriented laterally to allow maximal lateralization of the collapsed portion of the lateral nasal wall and the graft may be fixated with mattress sutures to the upper lateral cartilage. One limitation of batten grafts is that they cannot correct valve obstruction associated with deformities of the middle vault and the valve angle. The middle vault is critical for nasal breathing. The insertions of the upper lateral cartilages into the septum typically form a rounded arch that shapes the nasal valve angle at its caudal margin (Fig. 9). Following dorsal reduction, in which the upper lateral cartilage has been resected and
Fig. 8. (A) Before and (B) after correction of external nasal valve collapse. (From Becker, D. Revision rhinoplasty. New York: Thieme; 2008; with permission.)
Surgical Treatment of Nasal Obstruction
Fig. 9. Middle nasal vault. (Courtesy of John Hilinski, MD, San Diego, CA.)
separated from the dorsal septum, the natural wide and convex relationship between the upper lateral cartilage and the septum may become concave and narrowed. Therefore during rhinoplasty, separation of the upper lateral cartilages from the septum is frequently followed by spreader graft placement (fashioned from septal or auricular cartilage), to reapproximate, stabilize, and widen the nasal valve angle (Fig. 10). Spreader grafts can be bilateral or unilateral to correct asymmetries.22 Another technique to reconstruct the middle vault is described by Alsarraf and Murakami23 and involves a dorsal onlay graft sutured to the edges of the upper lateral cartilages to widen the nasal valve (Fig. 11). A type of onlay graft that is gaining popularity is the butterfly graft, which is composed of
curved auricular cartilage. The butterfly graft can be placed through an endonasal or external approach, and is placed symmetrically over the nasal dorsum. If necessary, the dorsal septum can be shaved to accommodate the thickness of the graft to avoid a polly-beak deformity. The graft is then secured with a suture to the upper lateral cartilage on each side,24 which flares the upper lateral cartilages and widens the internal nasal valve angle (Fig. 12), thereby enlarging the nasal valve area. Autospreader grafts, or spreader flaps, are created by using the redundant dorsal portion of the upper lateral cartilage as the spreader graft. One advantage of this technique is that it obviates the harvesting of septal cartilage.25 Another method that allows excellent functional and cosmetic results is the placement of a longitudinal graft along the septum after the septum is slightly reduced in height. The upper lateral cartilages are then sutured along their entire length to the undersurface of this graft, resulting in a smooth dorsal contour and upward pull on the upper lateral cartilages. In addition, some surgeons advocate the use of suture techniques to repair nasal valve disorders. The flaring suture across the upper lateral cartilages may be useful when used in conjunction with other techniques of valve repair.26 Paniello27 described the suspension suture technique, in which external sutures attached to the maxillary periosteum are used to pull out the nasal sidewalls. However, this technique requires external incisions and drilling anchor locations. These techniques can be used as alternatives to definite anatomic repair for patients who are poor candidates for rhinoplasty. There are a
Fig. 10. Middle vault (A) with spreader grafts. (B) Separation of upper lateral cartilages (ULC). (C) Placement of spreader grafts between septum and ULC. (From Gassner HG. Structural grafts and suture techniques in functional and aesthetic rhinoplasty. GMS Curr Top Otorhinolaryngol Head Neck Surg 2010;9:Doc01.)
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Fig. 11. Middle vault (A) with dorsal only. (B) Separation of ULC. (C) Placement of spreader graft between septum and ULC. (D) Placement of dorsal onlay grafts. (From Gassner HG. Structural grafts and suture techniques in functional and aesthetic rhinoplasty. GMS Curr Top Otorhinolaryngol Head Neck Surg 2010;9:Doc01.)
variety of other techniques described for the repair of internal nasal valve collapse, and interested readers are encouraged to pursue additional sources.
DEVIATED SEPTUM Although the general techniques of septoplasty are discussed elsewhere, there are several critical
Surgical Treatment of Nasal Obstruction
Fig. 12. Middle vault with butterfly graft. (From http://noserevisionsurgeryandsurgeons.blogspot.com/2010/10/ mystery-of-different-types-of-nose.html; with permission.)
aspects to consider when performing septoplasty for nasal obstruction. For posterior septal deviations and septal spurs, standard septoplasty techniques are effective. However, it is important to understand the relationship of the dorsal septum to the upper lateral cartilages and to appreciate caudal septal deviation. In the former case, marked dorsal septal deformities may require separation of the upper lateral cartilages from the septum; this disarticulation may lead to both functional and aesthetic deformities when this area becomes weak and causes blunting of the internal nasal valve angle. Spreader grafts may be required at the time of the septoplasty to straighten the dorsal septal deviation, prevent internal nasal valve collapse, and/or correct preexisting valve defects that may be present. Furthermore, spreader grafts help the aesthetic deformity caused by dorsal septal deviation, which often causes crooked nose deformity. Caudal septal deviation should also be recognized early as a source of nasal obstruction, and one that can be challenging to correct. The goal of surgical treatment of caudal septal deformities is to reduce or eliminate the deviation while maintaining support of the nasal tip to prevent tip ptosis. Several maneuvers are at the surgeon’s disposal for treating caudal septal deviation. Traditional approaches include scoring the septal cartilage on the concave side, thereby relaxing the spring of the cartilage. Another traditional
approach is the swinging-door repositioning technique described by Gubisch28 and Peer,29 which involves excising a wedge of cartilage along the maxillary crest to release the caudal septal attachments and allow the septum to swing to the midline. The midline position may be secured with an absorbable suture attached to the periosteum adjacent to the opposite side of the nasal spine or attached to the midline maxillary crest. In severe cases, it may be necessary to perform a septal transplant. During this procedure, the surgeon may completely resect the anterior septum keeping a dorsal strut in place and subsequently reconstruct the caudal strut from a septal cartilage graft harvested during the septoplasty30 or, alternatively, rib cartilage or other grafting material. This neostrut is placed within the septal space and secured to the intact dorsal strut and maxillary spine, acting as both a strut graft for nasal tip stability and as a spreader graft within the middle nasal vault (Fig. 13). Additional strength may be created through the use of extended spreader grafts, which help secure the newly positioned caudal septal replacement. Another location of septal disorders less commonly seen is an elongated membranous septum resulting in tip ptosis and bilateral nasal valve obstruction. During the history and physical, the patient may indicate that pushing the nasal tip up relieves the obstruction. In addition to correcting any middle nasal vault disorders, recreation of
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Fig. 13. Anterior septal reconstruction (ASR). (From Surowitz J, Lee MK, Most SP. Anterior septal reconstruction for treatment of severe caudal septal deviation: clinical severity and outcomes. Otolaryngol Head Neck Surg 2015;153(1):27–33; with permission.)
the relationship between the columella and the caudal septum is important to correct such a deformity.
INFERIOR TURBINATE Although turbinate hypertrophy has not been well defined and is still poorly understood, recent literature suggests that there is some merit to addressing this entity. Before attributing nasal obstruction to turbinate hypertrophy, the integrity of the nasal valve should be verified, and the straightness of the septum should be ensured. Once this is complete, turbinate hypertrophy can be considered as a contribution to nasal obstruction. Turbinate hypertrophy should be refractory to antiinflammatory medical therapies before surgical intervention is considered. Because of the physiologic function of the turbinates, we also recommend that all other disorders be addressed in correcting nasal obstruction first. If the patient continues to have an obstructive airway, the surgeon may proceed with turbinate procedure.
Various techniques of turbinate reduction have been reported in the literature. Passali and colleagues31 showed that submucous resection with or without lateralization of the inferior turbinate via outfracture resulted in longer-lasting reduction of nasal airway resistance compared with turbinectomy, laser cautery, electrocautery, or cryotherapy. However, risk of atrophic rhinitis as a result of removal of this mucosa is substantial and should be considered in all patients who develop nasal congestion, crusting, and dryness secondary to turbinate surgery; this is known as empty nose syndrome. These symptoms occur when the humidifying function of the nasal mucosa decompensates after removal of important nasal mucosa.32 Lateral outfracture and selective submucous resection of bone seem to be the only surgical maneuvers that allow reduction of the impact of the turbinates on nasal resistance without destruction of their physiologic function. Because the excision of turbinate tissue has been associated with major morbidity such as empty nose syndrome, the resection of healthy functionally important turbinate tissue should be approached in extreme cases only.33 In almost all cases,
Surgical Treatment of Nasal Obstruction correction of septal and nasal valve disorders provides patients with extremely satisfying nasal airways and turbinate reduction is rarely required.
OSTEOTOMY An additional consideration for nasal obstruction in rhinoplasty involves complications secondary to osteotomy. Inadequate lateral osteotomies after removal of a dorsal hump may result in an open roof deformity. However, the lateral osteotomy required to correct nasal deformities while closing or preventing an open roof could lead to nasal valve obstruction. Webster and colleagues34 showed that the risk of nasal valve obstruction could be reduced by initiating the lateral osteotomy higher on the pyriform aperture. This risk reduction is thought to be caused by preservation of a triangular piece at the edge of the pyriform aperture that prevents medial displacement of fibromuscular tissues of the ala and possibly the inferior turbinate. Thus highlow-high osteotomies are performed whenever possible in order to ensure preservation of airway patency. Another complication of dorsal hump reduction (alluded to earlier) is the inverted V deformity, which is especially common in patients with short nasal bones. This deformity may be prevented by exact placement of spreader grafts in the manner discussed earlier. Preventative reconstruction and strengthening of the middle nasal vault with spreader grafts or other techniques in patients with short nasal bones are encouraged.
SUMMARY The key to a successful functional septorhinoplasty includes an understanding of nasal anatomy and physiology. History and physical are paramount in diagnosing and subsequently treating an epicenter of obstruction, which is commonly found in one of the following locations: internal or external nasal valve, caudal septum, or turbinate. Treatment of each of these centers is nuanced and multiple approaches are discussed to provide an understanding of the current surgical techniques that allow adequate correction and excellent functional results.
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3. Constantian MB, Clardy RB. The relative importance of septal and nasal valvular surgery in correcting airway obstruction in primary and secondary rhinoplasty. Plast Reconstr Surg 1996;98:38–58. 4. Mink PJ. Le nez comme voi repiratorie. Presse Otolaryngol Belg 1903;5:481–96. 5. Bridger GP. Physiology of the nasal valve. Arch Otolaryngol 1970;92:543–53. 6. Haight JS, Cole P. The site and function of the nasal valve. Laryngoscope 1983;93:49–55. 7. Constantine MB. The incompetent external nasal valve: pathophysiology and treatment in primary and secondary rhinoplasty. Plast Reconstr Surg 1994;93:919–31. 8. Cole P. The four components of the nasal valve. Am J Rhinol 2003;17:107–10. 9. Cottle MH. Rhino-sphygmo-manometry and aid in physical diagnosis. Intern Rhinol 1968;6:7–26. 10. Wexler D, Braverman I, Amar M. Histology of the nasal septal swell body (septal turbinate). Otolaryngol Head Neck Surg 2006;134:596–600. 11. Masing H. Rhinomanometry, different techniques, and results. Acta Otorhinolaryngol Belg 1979;33: 566–71. 12. Hilberg O, Jackson AC, Swift DL, et al. Acoustic rhinometry evaluation of nasal cavity geometry by acoustic reflection. J Appl Physiol 1989;66: 295–303. 13. Chisholm E, Jallali N. Rhinoplasty and septorhinoplasty outcome evaluation. Ear Nose Throat J 2012;91:E10–4. 14. Rhee JS, Poetker DM, Smith TL, et al. Nasal valve surgery improves disease-specific quality of life. Laryngoscope 2005;115(3):437–40. 15. Guida RA. Surgical approaches to the nasal skeleton. Oper Tech Otolaryngol Head Neck Surg 1999;10:228–31. 16. Deroee AF, Younes AA, Friedman O. External nasal valve collapse repair: the limited alar-facial stab approach. Laryngoscope 2011;121:474–9. 17. Menger DJ. Lateral crus pull-up: a method for collapse of the external nasal valve. Arch Facial Plast Surg 2006;8:333–7. 18. Friedman O, Ackcam T, Cook T. Reconstructive rhinoplasty: the three-dimensional nasal tip. Arch Facial Plast Surg 2006;8:195–201. 19. Toriumi DM. New concepts in nasal tip contouring. Arch Facial Plast Surg 2006 May-Jun;8(3):156–85. 20. Kern EB. Surgery of the nasal valve. In: Sisson GA, Tardy ME Jr, editors. Plastic and reconstructive surgery of the face and neck: Proceedings of the Second International Symposium. vol. 2. New York: Grune and Stratton; 1977. p. 43–59. 21. Toriumi DM, Josen J, Weinberer M, et al. Use of alar batten grafts for correction of nasal valve collapse. Arch Otolaryngol Head Neck Surg 1997;123:802–8.
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29. Peer L. An operation to repair lateral displacement of the lower border of septal cartilage. Arch Otolaryngol 1937;25:475–7. 30. Surowitz J, Lee MK, Most SP. Anterior septal reconstruction for treatment of severe caudal septal deviation: clinical severity and outcomes. Otolaryngol Head Neck Surg 2015;153(1):27–33. 31. Passali D, Passali FM, Damiani V, et al. Treatment of inferior turbinate hypertrophy: a randomized clinical trial. Ann Otol Rhinol Laryngol 2003;112:683–8. 32. Lindemann J, Lieacker R, Sikora T, et al. Impact of unilateral sinus surgery with resection by means of midfacial degloving on nasal air conditioning. Laryngoscope 2002;112:2062–6. 33. Chhabra N, Houser SM. The diagnosis and management of empty nose syndrome. Otolaryngol Clin North Am 2009;42:311–30. 34. Webster RC, Davidson TM, Smith RC. Curved lateral osteotomy for airway protection in rhinoplasty. Arch Otolaryngol Head Neck Surg 1977;103:454–8.