Nasal airway obstruction, nasal congestion and a stuffy nose are some of the names given to the most common symptom resulting from abnormalities of the nose and sinuses. Nasal breathing abnormalities are highly symptomatic, can negatively impact one’s quality of life and, in some cases, may contribute to more serious medical problems like obstructive sleep apnea. There is an enormous variety of conditions, ranging from unfavorable nasal architecture to sinusitis and from seasonal allergies to sinus tumors, that can result in nasal airway obstruction. Achieving an accurate diagnosis is the first step in directing the treatment for the nose and sinuses. Below we discuss the most common conditions resulting in nasal airway obstruction and general treatment strategies for each.
Approximately 10-15% of the US population carries a diagnosis of chronic rhinosinusitis, and the vast majority of these patients experience difficulties in breathing through the nose. Nasal airway obstruction is a cardinal symptom of chronic rhinosinusitis, in addition to nasal drainage, diminished sense of smell and headache/facial pain and pressure. Endoscopic examination of the nose in conjunction with a CT scan can help a physician determine the presence of an inflammatory process within the sinuses and better direct subsequent treatment. Chronic rhinosinusitis is best treated medically, and the majority of patients will not need surgery to resolve their symptoms. Recently published long-term studies suggest that patients with chronic sinusitis who undergo surgery experience significantly greater levels of symptom improvement than patients managed with medical therapy alone.
Patients with nasal polyps and those that have undergone prior operations with scarring or other structural changes that obstruct the nasal passage or sinus drainage pathways are a more likely population to require endoscopic sinus surgery. Modern endoscopic sinus surgery is performed using small telescopes and specially designed instruments that allow the surgeon to remove bony partitions, scar tissue, and obstructions from the sinuses. This facilitates both the improved natural drainage of mucous from the sinuses as well as to enhance the penetration of medicated irrigations into the sinuses following surgery. Chronic rhinosinusitis is a condition that requires long term medical therapy and surveillance by the physician; however, a greater than 90% success rate in improving sinus symptoms is usually achieved.
Deviated Nasal Septum
While many patients are concerned about having a deviated septum, it has been estimated that 80% of nasal septums are deviated... making the straight nasal septum the more unusual condition. Although a deviated nasal septum can result in nasal airway obstruction, it is frequently the combination of a deviated nasal septum with other structural or medical abnormalities within the nose that produce nasal congestion that warrants treatment. While medical therapy will not straighten a deviated septum, prescription medication and irrigations are available to manage coexisting swelling of the nasal mucosa from allergic rhinitis, sinusitis, and other conditions that impact the nasal anatomy. Oftentimes, medical treatment of coexisting conditions will resolve the nasal congestion. Patients that are considering septal surgery to treat nasal airway obstruction are always evaluated for the wide variety of inflammatory and structural abnormalities that must be addressed in addition to straightening the nasal septum.
Nasal Valve Collapse
The most common reason to undergo revision nasal surgery after septoplasty is an untreated or progressive structural change in the nasal sidewall. The greatest area of resistance to airflow, the “internal nasal valve,” is located between the septum and the cartilage that comprises the sidewall of the nose. The correct use of an over-the-counter Breathe Right strip will widen this area and improve nasal airflow. Surgical maneuvers that mimic the action of a Breathe Right strip are performed to increase the nasal passage dimensions and thereby remedying nasal obstruction. Oftentimes, patient’s concern regarding a deviated septum will bring their nasal obstruction to attention; however, the more significant problem resides in the nasal valves. Functional rhinoplasty operations using cartilage grafts are quite successful in restoring and augmenting nasal function, and in some cases can be combined with surgical procedures that make cosmetic improvements in the appearance of the nose.
Inferior Turbinate Hypertrophy
The inferior turbinates are “shelves” of bone lined with mucosa that are located along the walls of the nasal passage. The function of turbinates is largely considered to be the conditioning of nasally inspired air, control of nasal humidification, heat exchange, and direction of airstreams through the nose, amongst other lesser roles. Encroachment into the nasal passage by horizontally oriented turbinates or by their abnormally enlarged mucosa can decrease airflow and create the sensation of nasal airway obstruction. Medical management with topical corticosteroid sprays and allergy therapy are frequently successful in managing nasal obstruction resulting from turbinate abnormalities. Surgical interventions may introduce a more rapid and durable method of improving the nasal airway while limiting the degree to which the inferior turbinates impinge on the nasal passage.
While a wide variety of conditions can be responsible for the impairment of nasal function, appropriate evaluation with endoscopic examination and CT scan will typically reveal an etiology amenable to medical and/or surgical therapy with a high degree of success.