Nasal obstruction is a significant source of decreased productivity, decreased quality of life, and disruption in overall sleep and restfulness. There are many possible causes of nasal obstruction, including allergies, viral upper respiratory infections, nasal/sinus infections, or even very rarely sinonasal malignancies. Primarily, nasal obstruction is a factor of three sites that work together within the nose to create resistance to nasal airflow. Specifically, the nasal septum, nasal turbinates, and the nasal valve region determine patency of the nose, and subjective nasal obstruction.
ENT evaluation including detailed history and physical exam, anterior rhinoscopy, possible sinus/nasal endoscopy and/or CT scan to determine anatomic relationships is very important in determining underlying etiology of nasal or sinus obstruction.
Nasal septal deviation often demonstrates an asymmetry of airflow, occasionally presenting with nosebleeds on one side or the other. Patients will sometimes have a history of nasal trauma, whether this is related to falls, sports injuries, or motor vehicle accidents.
Nasal turbinate hypertrophy often presents with nasal congestion that increases or decreases throughout the day, may be related to specific allergens (allergic rhinitis), or may be more fixed (chronic rhinitis). There can also be a component of inappropriate nasal drainage production called vasomotor rhinitis. The significance of nasal obstruction and restriction of airflow from nasal turbinate hypertrophy cannot be overestimated.
Nasal valve collapse is a descriptive term to address restriction to airflow that happens because of anatomic relationships between the nasal septum, nasal sidewall, and nasal turbinates. Patients will generally complain of decreased airflow, which occasionally becomes worse with activity such as exercise. Specific questions to consider regarding nasal obstruction include whether there is any improvement with pulling the cheeks out to the side, using a Breathe Right nasal strip. If so, evaluation in the office will address the nasal valve using a technique called the modified Cottle maneuver. This opens the region between the nasal septum and the lateral nasal sidewall, providing for optimal airflow and preventing collapse both at rest and during dynamic inspiration.
Treatment for the previously mentioned sites of obstruction are all site-specific. If patients are noted to have a nasal septal deviation, nasal septal reconstruction may be offered to reset the septum in the midline and provide more symmetric airflow between the two nostrils. If nasal turbinate hypertrophy is identified, reduction in size may be accomplished through several different options such as submucous resection, or radiofrequency ablation either in clinic or in the operating room.
In years past, physicians treated nasal turbinate hypertrophy with complete resection of the turbinates which often resulted in an uncomfortable inability to sense nasal airflow. This is called empty nose syndrome (atrophic rhinitis), and patients complain mightily about restriction to airflow despite widely patent nasal passages. This procedure of turbinate resection is no longer performed, and the modern goal is to provide balanced/symmetric airflow between the two nasal passages.
Nasal valve collapse may be addressed several different ways, specifically targeting the internal or external nasal valve regions, as well as static versus dynamic collapse. Options include possible use of radiofrequency ablation to provide rigidity to the nasal sidewall, absorbable implants in the lateral nasal sidewall, or definitive cartilage grafting which may be performed in the operating room.
Overall management of nasal obstruction is both patient specific, and supremely site specific. Detailed and thorough history/examination are necessary to provide correct identification of obstruction, and management may include combination of medications, in office procedures, or surgical recommendations. In general, nasal surgeries have a recovery time of three to five days before proceeding with light/regular duties, and approximately two weeks before resuming exercise or heavy/strenuous duties. It is always recommended to use nasal saline irrigations and topical nasal steroid as a baseline when treating or addressing nasal obstruction patients.
Christopher Clark, MD practices with ENT Associates of Alabama. He has interests in a wide range of surgical and nonsurgical disorders of the head and neck, including: plastic and reconstructive surgery, rhinoplasty (functional nasal reconstruction), head and neck cancer, thyroid/parathyroid disease, salivary gland disease, sleep apnea, airway and voice disorders, chronic ear disease, and hearing loss.
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