Nasal Obstruction

Nasal obstruction is a common complaint for patients that visit their primary care physician or ear, nose and throat doctor. It can severely affect one’s quality of life by impacting his or her comfort breathing. In addition, it is a significant component of obstructive sleep apnea (OSA) and can greatly affect sleep quality. For athletes with nasal obstruction, it can negatively impact their performance and ability to perform at their potential.

At Mount Sinai, we offer multiple treatment options for patients with nasal obstruction ranging from minor in-office procedures all the way to complex nasal reconstruction utilizing advanced techniques such as autologous rib grafting and nasal reconstruction. In addition to this, we actively participate in research and track our surgical outcomes in an effort to provide the highest quality of care for our patients.

About Nasal Obstruction

Nasal obstruction is the inability to breathe and pass air through the nasal passages. In the majority of cases this is due to abnormalities in the normal anatomy of the nose. These abnormalities can be due to structural changes, stemming from normal development or trauma that lead to blockage of the nasal passage, or inflammatory changes that can lead to swelling and enlargement of the tissues in the nose.

Most patients with nasal obstruction complain of an inability or decreased ability to breathe through one side or both sides their nose. In addition they often notice difficulty sleeping, breathing through the mouth, snoring, and frequent runny nose.

Septal Deviation and Turbinate Hypertrophy

Nasal obstruction can occur through a variety of ways but the two main structures that are almost always involved are the septum and the inferior turbinates. The septum is the midline structure in the middle of the nose between both nostrils and is made of both cartilage and bone. The septum functions as of the main support mechanisms of the nose to maintain its shape and function.

A common cause of nasal obstruction is ‘septal deviation.’ This is when the bone and/or cartilage portion of the nose is deflected to one side of the nose or the other causing a mechanical obstruction. This deflection is often just a consequence of normal development. However, in some individuals a history of facial or nasal trauma will indicate that there was a septal fracture which could have caused the deflection. Regardless there are many individuals with septal deviation that do not have nasal obstruction.

Another structure that contributes to nasal obstruction is a normal structure that is called the ‘turbinate.’ These are paired structures on each side of the nose made of bone covered with a mucosal lining that function to help warm and humidify the air that we breath. Often times patients develop ‘turbinate hypertrophy,’ when these structures grow or enlarge due to normal development or chronic inflammation and block the passage of air in the nose.

Complex Nasal Obstruction: Nasal Valve Stenosis

A more complex reason for nasal obstruction is called nasal valve stenosis. The ‘nasal valve’ is an area within the nose defined by soft tissue in the nose that represents the narrowest portion of the nasal passage. Because it is the narrowest portion it often represents the site of nasal obstruction. The nasal valve nasal valve can be weak or collapsed due to a variety of reasons. One of these reasons is weakness in the cartilage and the soft tissue of the nose. When this weakness is present the sides of the nose can collapse especially on inspiration of air causing a nasal obstruction. The nasal valve can also be narrow due to normal development in certain individuals. Finally, internal nasal valve collapse can also be the result of prior nasal procedure such as a rhinoplasty where the cartilage supporting the valve is inadvertently weakened due to a prior surgical procedure.

Nasal Obstruction Treatments

• Turbinate Reduction: This is a common procedure performed by most otolaryngologists that can be performed in an in-office setting or in the operating room depending on the surgeon. Most patients are able to go home to the same day and return to normal activity immediately.

This procedure is done when the turbinate is enlarged or swollen and subsequently blocks the passage of air through the nose. Most patients are treated with topical nasal sprays and decongestants prior to this and failure to improve with medication often requires turbinate reduction.

There are multiple techniques that have been described to shrink or reduce the turbinate tissue.

• One method which can be done in the office employs a technology called ‘coblation’ which allows the turbinate tissue to be shrunken by passing a thin metal needle into the turbinate and delivering energy to shrink the tissue. The patient is anesthetized in the office using a topical spray which will numb the lining of the nose. Once this is achieved the small prob is placed thru and into the deep tissue of the turbinate. The coblation energy is then delivered to the tissue and causes a shrinking effect on the tissue. The results are often immediately noticeable.
• A more common and traditional method is performed in the operating room. A small incision is placed in the front of the turbinate and a special instrument is placed inside the turbinate. Under the guidance of an endoscope the soft tissue inside the turbinate is precisely removed using a specialized instrument. The excess soft tissue is removed while preserving the fragile lining of the nose. In addition the bone portion of the turbinate is gently fractured and placed in a position to allow for even more passage of air.
• Both methods are generally tolerated very well and associated with minimal pain after surgery. Most patients do not require pain medication afterwards and can begin normal activity immediately after surgery.

Septoplasty:

• Septoplasty is one of the most common procedure a ENT performs. It is usually done under general anesthesia and often times is done often in conjunction with a turbinate reduction and a rhinoplasty.
• The goal of the surgery is to reposition the deviated cartilage and bone in the septum the middle or ‘midline’ of the nose. By precisely placing it this can open the nasal airway and relieve any physical obstruction. In addition, depending on where the septum is deviated both bone and cartilage may be removed to allow for the passage of air. As long as enough cartilage and bone is preserved to support the nose, there is usually no consequence of removing this cartilage. There is a small incision that is created on the inside of the nose to allow the surgeon to remove the bone and cartilage without damaging the fragile lining of the nose. This incision is closed or sutured with special material that dissolves over time. It is not unusual for a patient to see these sutures, however within time they will go away. Sometimes, surgeon will place a plastic ‘stent’ inside the nose that is sutured into place. This can help the septum heal in a straight position however it can be accompanied with a great deal of discomfort. These stents are often removed at the first post-operative visit.

Repair of the internal nasal valve:

• Treatment of the nasal valve range from a simple surgery to a very complex procedure and sometimes requires the expertise of a facial plastic surgeon.
• The goal of treatment is to open the internal nasal valve by strengthening the supporting structures of the nose. There have been a variety of procedures that have been described to do this.
• The majority of these procedures require a more extensive approach that that of a septoplasty or turbinate reduction. Because of this healing time is often longer and there can be more swelling and pain than that of a septoplasty. Often times cartilage has to be used to strengthen the nose and this can be borrowed from existing cartilage in the patients septum, ear or rarely from their rib.
• The two main methods to approach the nose are the open and closed rhinoplasty.
• In the open rhinoplasty incisions are made inside the nose and on the small soft tissue bridge at the bottom of the nose called the collumella. The soft tissue of the nose is then dissected away and the bone and cartilage supporting structures are exposed. This exposure allows the surgeon to manipulate and strengthen the cartilage precisely in an effort to open and support the nasal valve. The down-side of this procedure is that there is increased swelling of the nose following the procedure but this can be prevented by taping the nose and also by placing ice packs on the nose.
• The closed rhinoplasty approach involves incisions that are placed inside the nose only. Thru these incisions the cartilage and support structures of the nose are identified and like the open rhinoplasty, precise placement of cartilage borrowed from the septum or ear are positioned into place to help strengthen the weak areas of the nose. This method can be technically more challenging because the cartilage is not fully exposed, however in skilled hands the results are the same.