Septoplasty, Turbinate Reduction, and Correction of Nasal Obstruction
Neal C. Gehani
Steven M. Houser
Nasal obstruction is one of the most common complaints in an otolaryngology practice. The differential diagnosis for this symptom is broad and can be multifactorial. There are a variety of both mucosal and structural abnormalities that can alter the sensation of nasal airflow, including septal deviation, turbinate hypertrophy, nasal cartilage deformity, sinus infections, sinonasal neoplasms, and systemic diseases. It is important for the otolaryngologist to be aware of the various etiologies of nasal obstruction while evaluating a patient and recommending appropriate treatment options.
EVALUATION AND ASSESSMENT
History
It is essential to obtain a thorough history when assessing a patient with nasal obstruction. The clinician should pay particular attention to unilateral versus bilateral symptoms, onset, seasonal variation, and associated nasal symptoms. The nasal cycle is a periodic alteration of engorgement of the erectile tissue in the inferior turbinates, typically cycling every 2 to 7 hours, with subsequent changes in nasal airflow. Mucosal inflammation caused by rhinosinusitis or allergic rhinitis may exacerbate the normal nasal cycle. Unilateral nasal obstruction, especially with epistaxis, could be a symptom of a sinonasal neoplasm. Obstruction, either unilateral or bilateral, following nasal trauma may indicate a fracture or structural abnormality of the nasal septum or pyramid. Obstruction that fluctuates seasonally or with environmental exposure indicates a reversible mucosal abnormality rather than a fixed structural obstruction. Associated symptoms, including facial pain or pressure, nasal discharge, and hyposmia may indicate rhinosinusitis. Nasal obstruction, associated with serous otitis media requires evaluation of the nasopharynx for possible neoplasm. Nasal obstruction can also cause nonnasal symptoms such as dry mouth, sore throat, snoring, halitosis, and decreased appreciation of taste sensation, presumably from impaired smell.
In addition to eliciting subjective complaints, one must also review the patient’s past medical and surgical history, current medications, and social habits. Numerous systemic diseases may have a nasal manifestation of obstruction, including aspirin-exacerbated respiratory disease, cystic fibrosis, Wegener granulomatosis, sarcoidosis, rhinoscleroma, fungal infections, and lymphoma. Normal fluctuations of estrogen during the menstrual cycle and pregnancy can also lead to temporary nasal obstruction. A prior rhinoplasty may cause nasal valve collapse, while a prior aggressive turbinectomy or reduction may lead to subjective nasal obstruction due to atrophic rhinitis or empty nose syndrome. Medications that may induce nasal obstruction include aspirin and other nonsteroidal anti-inflammatory drugs, angiotensin-converting enzyme inhibitors, alphaadrenoceptor antagonists, methyldopa, beta-blockers, and oral contraceptives. Lastly, alcohol can produce vasodilation with nasal obstruction, while smoking impairs mucociliary clearance, exacerbating rhinitis, and cocaine abuse can cause extensive destruction of nasal support structures, leading to obstruction (1).
Physical Examination
The physical examination of nasal congestion includes evaluation of the external framework of the nose, with attention to any bony or cartilaginous deformity or nasal dorsal deviation. Rarely, pyriform aperture narrowing or stenosis contributes to obstruction. A horizontal nasal crease at the supratip area usually indicates chronic nose wiping, as in the “allergic salute.” Tip ptosis contributing to obstruction can be assessed by pushing the nasal tip superiorly. The Cottle maneuver, in which the cheek skin and nostril are retracted laterally to assess changes in subjective nasal airflow, detects contributions to congestion at the nasal valve. In a modification of the Cottle maneuver,
an ear curette is used to selectively retract the upper lateral and then lower lateral cartilages to detect their contribution individually to nasal obstruction. The presence of alar collapse with inspiration indicates dynamic external nasal valve collapse, while supra-alar pinching indicates internal nasal valve collapse. Turbinate contribution to nasal obstruction can be assessed before and after topical decongestants with anterior rhinoscopy. Significant improvement following topical decongestants, indicates primarily a potentially reversible cause of nasal congestion such as allergy. Reddened, ulcerated, or friable nasal mucosa may indicate exposure to toxins, rhinitis medicamentosum, food allergy, or systemic disorders. Septal spurs, deviations, or perforations are the most common septal findings. Nasal polyps, purulence, excessive secretions, tumors, choanal stenosis, eustachian tube or nasopharyngeal pathology can usually be visualized with thorough rigid or flexible nasal endoscopic evaluation.
an ear curette is used to selectively retract the upper lateral and then lower lateral cartilages to detect their contribution individually to nasal obstruction. The presence of alar collapse with inspiration indicates dynamic external nasal valve collapse, while supra-alar pinching indicates internal nasal valve collapse. Turbinate contribution to nasal obstruction can be assessed before and after topical decongestants with anterior rhinoscopy. Significant improvement following topical decongestants, indicates primarily a potentially reversible cause of nasal congestion such as allergy. Reddened, ulcerated, or friable nasal mucosa may indicate exposure to toxins, rhinitis medicamentosum, food allergy, or systemic disorders. Septal spurs, deviations, or perforations are the most common septal findings. Nasal polyps, purulence, excessive secretions, tumors, choanal stenosis, eustachian tube or nasopharyngeal pathology can usually be visualized with thorough rigid or flexible nasal endoscopic evaluation.
Investigations
Further investigations to determine the etiology of nasal obstruction will vary depending on the suspected differential diagnosis. Blood tests, such as angiotensin converting enzyme level (for sarcoidosis), cytoplasmic-antineutrophil cytoplasmic antibodies (C-ANCA) level (for Wegener granulomatosis), erythrocyte sedimentation rate, and syphilis serology, may be helpful if systemic inflammatory disorders are suspected. In vitro assessment of specific immunoglobulin E (IgE), intradermal testing, or skin prick testing may be useful if allergy is considered. Subjective complaints of anosmia or hyposmia may be quantified using validated testing kits, including the University of Pennsylvania Smell Identification Test (Sensonics, Haddon Heights, NJ), the alcohol smell test, and Sniff’n sticks. Further assessment of smell is discussed in more detail in the chapter on olfaction. A directed nasal swab is considered if purulent drainage is noted during anterior rhinoscopy or nasal endoscopy to direct medical management.
Acoustic rhinometry and rhinomanometry have been used for many years to objectively assess nasal airway resistance and obstruction. Acoustic rhinometry measures the cross-sectional area (CSA) of the nasal cavity by presenting a shock wave to the nasal airway and measuring the reflected sound. The CSA is measured while the patient is apneic and during inspiration. Normally, the inspiratory to apneic CSA ratio should be around 1. A ratio significantly lower than 1 indicates nasal valve collapse during inspiration, while significantly low CSA during both apnea and inspiration may indicate a fixed obstruction. The limitation of acoustic rhinometry is the wide variation of normal CSA and therefore difficulty in interpreting results. Rhinomanometry, which was first described by Coutade in 1902, is a method of simultaneously measuring nasal airflow at a fixed pressure differential during the nasal respiratory cycle. A pressure-flow curve is then generated, yielding another objective assessment of nasal obstruction. Both acoustic rhinometry and rhinomanometry are obtained for experimental purposes; however, they are not considered standard of care when evaluating a patient for nasal obstruction (2).
Imaging is considered in certain patients presenting with nasal obstruction. Plain x-rays of the sinuses may be helpful in evaluating particular clinical entities, such as a nasal fracture; however, it has largely been replaced by computed tomography (CT) scan due to wide availability, rapidity of the study, and superior anatomic detail of structures. A CT scan is considered in patients with concern for rhinosinusitis, trauma, inflammatory disease, sinonasal neoplasm, or congenital abnormality. If malignancy is considered, magnetic resonance imaging may be obtained to provide enhanced soft tissue information.
Differential Diagnosis
Patients with a variety of conditions may present with a chief complaint of nasal obstruction. It is important for the otolaryngologist to keep the differential diagnosis in mind when obtaining further diagnostic studies or recommending therapeutic interventions (Table 42.1).
Treatment Options
The management of patients with nasal obstruction can be divided into medical or surgical interventions. In general, patients with an anatomic abnormality, such as septal deviation, inferior turbinate hypertrophy, nasal valve collapse, choanal atresia, or nasal polyposis will require surgical intervention; however, they may also benefit from medical
treatment before and after surgery to optimize outcomes. Patients with physiologic etiology, such as allergy, rhinosinusitis, and systemic inflammatory diseases, should be treated with medical therapies including local or systemic corticosteroids or avoidance, prior to considering surgical intervention (i.e., endoscopic sinus surgery) (Table 42.2).
treatment before and after surgery to optimize outcomes. Patients with physiologic etiology, such as allergy, rhinosinusitis, and systemic inflammatory diseases, should be treated with medical therapies including local or systemic corticosteroids or avoidance, prior to considering surgical intervention (i.e., endoscopic sinus surgery) (Table 42.2).
TABLE 42.1 DIFFERENTIAL DIAGNOSIS OF NASAL OBSTRUCTION | ||||||||||||||||||||||||
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TABLE 42.2 TREATMENT OPTIONS | ||||||||||||||||||||
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DEVIATED NASAL SEPTUM
Surgery for correction of a deviated nasal septum has evolved over the course of the years. Submucous resection of septal cartilage was initially described by Ingals in 1882, followed by Freer, who described resection of both the bony and cartilaginous portions of the deviated septum in 1902. Killian further modified the procedure in 1904; however, both Freer and Killian advocated not addressing deflections of the dorsal and caudal portions of the septum to prevent postoperative nasal deformities. In 1946, Cottle and Loring described removal of all deviated portions of the septum and replacement of bone and cartilage in the intramucosal space to prevent postoperative saddle nose deformities and a retracted columella (3). More recently, endoscopic septoplasty was introduced as a technique to address the deviated nasal septum for enhanced visualization during endoscopic sinus surgery.
A thorough understanding of the anatomy of the nasal septum is important when performing a septoplasty. The bony portion of the nasal septum is composed of the perpendicular plate of the ethmoid bone superiorly and the vomer inferiorly. Posteriorly, the bony septum defines the medial aspect of the nasal apertures, or choanae. Superiorly, the perpendicular plate of the ethmoid bone is contiguous with the cribriform plate of the skull base and the posteriosuperior aspect fuses with the sphenoid rostrum. Inferiorly, the vomer fuses with the maxillary crest. Anteriorly, the bony septum fuses with the cartilaginous septum. The cartilaginous nasal septum, also known as the quadrangular cartilage due to its shape, has attachments to the upper lateral and lower lateral cartilages anteriorly and maxillary crest inferiorly (Fig. 42.1). The keystone area, the junction of the quadrangular cartilage, perpendicular plate of the ethmoid, and paired nasal bones (4), is critical to the support of the nasal dorsum and should be preserved when performing a septoplasty.
 Figure 42.1 Septal anatomy in sagittal view |
Indications
There are numerous indications for the surgical correction of a deviated nasal septum, which are listed in Table 42.3.
Operative Procedure
Many techniques and variations of septoplasty have been described in the literature. Although the procedure can be performed under local or general anesthesia, the latter is
preferred, especially in anxious patients or those undergoing additional procedures, such as sinus surgery. The procedure is initiated with the infiltration of a hemostatic agent, such as 1% lidocaine with 1:100,000 epinephrine, in the subperichondrial plane to assist in raising submucosal flaps and maintaining hemostasis throughout the procedure. The nasal cavities are then packed with pledgets soaked with a decongesting agent such as 4% cocaine, oxymetazoline, or neo-synephrine.
preferred, especially in anxious patients or those undergoing additional procedures, such as sinus surgery. The procedure is initiated with the infiltration of a hemostatic agent, such as 1% lidocaine with 1:100,000 epinephrine, in the subperichondrial plane to assist in raising submucosal flaps and maintaining hemostasis throughout the procedure. The nasal cavities are then packed with pledgets soaked with a decongesting agent such as 4% cocaine, oxymetazoline, or neo-synephrine.
TABLE 42.3 INDICATIONS FOR SEPTOPLASTY | ||||||
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