S u r g i c a l M a n a g e m e n t of

N a s a l Ai r w a y Ob s t r u c t i o n
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 form
and 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.

The management and diagnosis of nasal airway

obstruction requires an understanding of the
form and function of the nose. Nasal airway
obstruction can be structural, physiologic, or a
combination of both. Thus, the management of
nasal airway obstruction must be selective and
often involves medical management. The goal of
surgery is to address the deformity and not just
enlarge the nasal cavity. This article reviews airway
obstruction and its treatment.

ANATOMY
The nasal airway is both a dynamic and rigid structure. It begins at the external nasal valve, which is
composed of the caudal edge of the lower lateral
cartilages, caudal septum, nostril sill, and the
soft tissue alae. The septum and the bone walls
provide the rigid structure of the nose. The septum
is made up of quadrilateral cartilage, nasal spine,
frontal spine, perpendicular plate of the ethmoid,

vomer, and maxillary crest. The narrowest portion

of the nose is the internal nasal valve (10 15 ),
which is formed by the septum, the inferior turbinate, and the upper lateral cartilage. Short nasal
bones, a narrow midnasal fold, and malposition
of the alar cartilages all predispose patients to internal valve incompetence.
The lateral wall of the nose contains 3 to 4 turbinates (inferior, middle, superior, supreme) and the
corresponding meatuses that drain the paranasal
sinuses. The nasolacrimal duct drains through
the inferior meatus, whereas the maxillary, frontal,
and anterior ethmoid sinuses articulate with the
middle meatus. The posterior ethmoid sinus opens
into the superior meatus. The nasal cavity ends at
the choanae as the airflow passes into the
nasopharynx.

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

Disclosures: The authors have no financial disclosures.

a
Division of Plastic & Reconstructive Surgery, University of Texas Health Science Center at Houston, 6410 Fannin Street #1400, Houston, TX 77030, USA; b Division of Plastic & Reconstructive Surgery, Stanford University,
Stanford, California, USA; c Division of Plastic & Reconstructive Surgery, North Shore LIJ Health System, 1991
Marcus Avenue, Suite 102, Lake Success, NY 11042, USA
* Corresponding author.
E-mail address: [email protected]
Clin Plastic Surg 43 (2016) 4146
http://dx.doi.org/10.1016/j.cps.2015.09.006
0094-1298/16/$ see front matter 2016 Elsevier Inc. All rights reserved.

plasticsurgery.theclinics.com

INTRODUCTION

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Teichgraeber et al
and warms the inspired air. It is also involved in
olfaction and speech. Inspired air passes through
the nose at 200 kph (125 mph) in a parabolic curve
moving vertically through the roof of the nasal vestibule and then through the internal nasal valve.
The nose is the site of nearly half of the total respiratory resistance; a third of the resistance occurs
at the external valve and two-thirds occur at the internal valve. The gatekeeper of nasal airflow is the
internal valve, which aids in respiration by limiting
the flow of air so that it does not exceed the noses
ability to process it. On deep inspiration the nostril
enlarges and the internal valve narrows, whereas
on expiration the nostril narrows and the internal
valve enlarges. Complete closure of the internal
valve is prevented by the action of the alae, which
flare outward and upward exerting a checkrein action on the connective-tissue aponeurosis of the
upper lateral cartilages.

CAUSES
Nasal obstruction can be physiologic and/or structural. The differential diagnosis of physiologic
nasal obstruction includes infections, allergies,
medications, vasomotor rhinitis, endocrine disorders, and chemical irritants.
The common cold is the most frequent cause of
physiologic nasal obstruction. It is usually selflimiting and treated with antihistamines and decongestants. Allergic rhinitis can be seasonal or
perennial. Seasonal symptoms can be managed
with antihistamines, decongestants, and topical
and/or systemic steroids. Perennial allergic rhinitis
requires a work-up, which includes nasal cytology,
blood tests for immunoglobulin E levels, and skin
test.
Rhinitis medicamentosa is most frequently seen
in patients who use long-term nasal sprays or
drops. However, it can also result from oral medications such as reserpine, propanol, and chlorpromazine. Its treatment requires stopping the
offending medication and providing airway support with decongestants and systemic and/or
topical steroids.
Pregnancy is a common endocrine cause of
nasal obstruction. However, rhinitis of pregnancy
usually resolves with the end of pregnancy. Interim
treatment depends on the stage of the patients
pregnancy and the approach that the patients
obstetrician has toward therapy during pregnancy.
Persistent irritants can cause chronic allergic
rhinitis, and pollution is the most common environmental cause. Other causes are primarily occupational, which include dust, fumes, and chemicals.
The treatment is preventative and avoidance of
the irritants.

DIAGNOSIS
The diagnosis of nasal obstruction begins with a
complete history, including several key elements,
including (1) duration and frequency of the symptoms, (2) whether they are unilateral or bilateral, (3)
whether they are perennial or seasonal, (4) history
of trauma, (5) history of surgery, (6) presence of
allergic symptoms, and (7) medication usage. Examination of the patients nasal cavities requires
good illumination and adequate decongestion.
The patient is initially observed at rest without a
speculum. The external nasal valve is first examined and noted for alar collapse. The internal valve
is also evaluated without a speculum, checking for
mucosal scarring and the relationship of the upper
lateral cartilage to the septum. The Cottle test is
used to evaluate nasal valve disorder. While the
patient breaths quietly, the cheek is retracted
laterally in order to open up the nasal valve. If
the patients breathing is improved, the Cottle
test is positive, indicating that the nasal valve is
a factor in the patients respiratory symptoms.
However, if the valve is scarred, the maneuver
may not alter the symptoms, and the test results
are designated as false-negative. In this case, a
Q-tip may be used to retract the nasal valve laterally. Although the Cottle test is specific for nasal
valve collapse, false-positive tests are seen in patients with flaccid valves. Gruber and colleagues
also described the use of a Breathe Right strip
test to evaluate the internal and external valves
separately.
The nasal structures are then examined with a
nasal speculum. The nasal septum is evaluated
for deviation, whereas the turbinates are evaluated
for hypertrophy (Fig. 1). The caudal end of the
septum is examined and deviations of the quadrilateral cartilage and bony septum are noted
(Fig. 2). The nasal mucosa is examined for scarring
or thinning. In addition, both inferior and middle
turbinates are evaluated.

TREATMENT
Correction of the nasal airway obstruction is
directed toward the anatomic source of obstruction. For septal deviation, a septoplasty can be
considered. The goal of the septoplasty is the correct septal deviation while at the same time preserving as much of the septum anatomy as
possible.
The septum can be approached endonasally
through a hemitransfixion or Killian incision. Alternatively, an open approach can be used. In complex nasal airway cases, the septum is best
treated with an open rhinoplasty. The open

Surgical Management of Nasal Airway Obstruction

Fig. 3. A spreader graft being placed to correct internal nasal valve dysfunction.
Fig. 1. Septal
hypertrophy.

deviation

and

left

turbinate

approach allows the surgeon to simultaneously

approach the caudal and dorsal septum. The upper lateral is separated from the septum after a
submucosal tunnel is developed on both sides of
the nose. The quadrilateral cartilage is usually approached dorsally through a mucoperichondrial
flap that is connected to a mucoperiosteal flap.
The quadrilateral cartilage is separated from the
perpendicular plate of the ethmoid, the vomer,
and the maxillary crest. Bilateral mucoperiosteal
flaps are developed, isolating the boney septum.
The obstructing bone is fractured with doubleaction scissors and repositioned. Cuts in the
boney septum are usually high on the perpendicular plate of the ethmoid and along the floor of
the nose. The septal cut on the ethmoid is to prevent fracturing of the cribriform plate.
Once the boney septum is repositioned, the
quadrilateral cartilage is approached. The quadrilateral cartilage is usually left attached to the anterolateral mucoperichondrium unless the caudal

Fig. 2. Caudal septal deflection obstructing the left

nasal cavity.

septum needs repositioning. In this case, the

caudal septum is freed from the ipsilateral and/or
contralateral mucoperichondrium as far as
needed. Vertical septal angulation is treated with
vertical resection and horizontal angulation with
horizontal resection. The thickened cartilage is
shaved and, if the deformity persists, it may be
necessary to weaken the deformed segment with
cross-hatching or conservative morcellation. The
area of deflection along the caudal and dorsal borders of quadrilateral cartilages is managed with incisions within 2 mm of the affected border.
Although this helps straighten the quadrilateral
cartilage it may also weaken it. In order to prevent
loss of nasal support, grafts (3 mm  1020 mm) of
septal cartilage or ethmoidal bone are sutured to
the concave side of the caudal and/or dorsal
septal borders, which helps reinforce and
straighten the septum as well as fixing it in the
midline. The authors have also used absorbable
plates made of polylactic and polyglycolic acid
(Synthes) (3 mm  20 mm) to reinforce or

Fig. 4. A suspension suture can also be used to correct

internal nasal valve narrowing.

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Teichgraeber et al

Fig. 5. A mattress suture is placed to improve the internal nasal valve.

straighten the deviated septum. The plates are sutured through preexisting holes to the quadrilateral
cartilages with through-and-through polydioxanone sutures. Following the septoplasty, a septal

suture of 4-0 plain on a Keith needle is used to

coapt the mucosal flaps.
After the septum is corrected, the upper lateral
cartilages and internal valve are approached. The
lower lateral cartilages have already been separated submucosally from the septum. Abnormalities of the medial portion of the upper laterals
may require conservation resection. If the internal
valve has collapsed, a spreader flap and/or
spreader grafts are used to laterally displace the
cartilages, in order to open up the internal valve.
The spreader grafts maybe be harvested from
the septum, ear, and/or rib in order of preference.
The grafts (24 mm  2030 mm) are sutured
2 mm below the septal border with polydioxanone
sutures (Fig. 3). Subsequently, the upper laterals
are sutured back to the septum with the same suture. A composite graft from the ear is used in patients with internal nasal collapse from mucosal
scarring. An alternative method to correct internal
nasal valve narrowing is to use a permanent
mattress suspension suture (Figs. 4 and 5).
The external valve is usually obstructed because
of a malposition of the lower lateral cartilage, inadequate underlying support, and/or mucosal scarring. Reconstruction of the external valve and
nasal tip begins with a columellar strut, which is
harvested from the septum, ear, or rib. It is sutured

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

Surgical Management of Nasal Airway Obstruction

Fig. 7. Rim grafts can be considered when concavity

of the rim exists.

between the medial crura with a polydioxanone

suture. Once the central limb of the tripod is stabilized, attention is directed to its lateral limbs. In
patients with adequate lower lateral cartilage,

repositioning of the lower lateral cartilage to the

upper lateral cartilages and septum often stabilizes the lower lateral cartilages and opens up the
valve. If the lateral crura are over-resected or
weak, they are reinforced with lateral crura spanning grafts from the septum or ear. These grafts
are placed lateral to the dome running one-half
to one-third the length of the lateral crura (1.0
1.5 cm) and sandwiched between the lower lateral
cartilages and the nasal lining. They are sutured
with polydioxanone sutures. Rim grafts have also
been advocated for supporting the external nasal
valve (Figs. 68).
If its external valve needs further opening or
support, a lateral crural spanning graft is used.
The graft is usually harvested from the septum or
the ear (2 mm  1618 mm) and helps expand
the intercrural space. The position of the nasal
valve and lateral crural spanning grafts are
adjusted by stabilizing the structures with two
27-gauge needles and redraping the retracted
skin. When both vestibular skin and cartilage are
needed, a composite graft from the ear is used.
The inferior turbinate often plays a major role in
nasal obstruction. The anterior third of the turbinate forms the internal valve, the narrowest portion
of the nasal airway. A multitude of destructive and
nondestructive turbinotomy techniques have been

Fig. 8. Preoperative (left) and postoperative (right) results with rim graft placement. The arrow shows the area of
preoperative external nasal valve narrowing.

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Teichgraeber et al

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

described to treat the enlarged turbinates. Treatment approaches include turbinectomy, submucous resection (Fig. 9), turbinate outfracture
(Fig. 10), radiofrequency ablation, submucous
diathermy, laser cautery, cryosurgical reduction,
and septoturbinotomy.
Septoturbinotomy is a noninvasive procedure
used to correct turbinate hypertrophy and septal
deviation. It can expand the nasal vault with insertion of a large and long speculum that outfractures
the turbinates and also centralizes the bony
septum when the handles are compressed. Alternatively, a large clamp can be passed into the
nasal cavity and expanded (in reverse nutcracker

fashion) to achieve a similar result. Mechanical

dilation (expansion) of the nasal vault with the
speculum or large clamp improves the airway
diameter of the nasal vault and may preclude the
need for further work on the turbinates. The nasal
vault is not necessarily expanded to the maximal
diameter that could be achieved with resection
procedures, but it may be to achieve satisfactory
air flow.
An enlarged middle turbinate can also cause
nasal obstruction and necessitate endoscopic
surgery. In some patients, nasal obstruction results from the loss of boney support. In these patients medial and lateral osteotomies with
bilateral spreader grafts are used to lateralize
the upper lateral cartilages and nasal bones. In
some cases, a cantilever costochondral graft is
required.

SUMMARY

Fig. 10. Turbinate outfracture is performed by lateralizing the turbinate.

The management of nasal obstruction requires a

clear understanding of nasal anatomy and function. Nasal obstruction can be physiologic,
anatomic, or a combination of both. The operative
treatment is aided by the open approach, which allows clear visualization of the nasal structures, and
enables surgeons to precisely address the underlying anatomic deformities. Even though the
septum is the key to treating nasal obstruction,
attention must also be given to the internal and
external nasal valves and the turbinates.