When patients can't breathe through their nose THESE 5 factors could be the cause
One common area of concern for patients who present for rhinoplasty or revision rhinoplasty regards functional consequences of those procedures. In patients who have little or no nose or sinus complaints, they often verbalize concerns about possibly creating those issues after surgery. Sinus issues are rarely the consequence of rhinoplasty or revision rhinoplasty, but breathing issues are not uncommonly seen. These issues arise from patients whose noses are made purposely smaller during the rhinoplasty or revision rhinoplasty surgery without meticulous attention to maintaining the integrity of the structural framework of the nose.
In patients who present with complaints that they can't breathe through their nose, these issues become even more critical to address. The five areas that require addressing in these patients are the nasal septum, the internal nasal valve, the external nasal valve, the inferior turbinates and the sinuses. The best rhinoplasty surgeon or revision rhinoplasty surgeon is one who addresses and diagnoses the cause of these functional complaints prior to surgery.
Many patients equate can't breathe through nose with a deviated septum. While the deviated septum is often a contributory issue with nasal obstruction, it is only one of the five factors. The septum is the structure comprised of cartilage and bone which separates the right side of the nose from the left. Significant deviations in this structure are often an important part of the obstructive etiology.
The internal nasal valve is the junction of the nasal septum with the outer wall of the nose. There is a left internal nasal valve and a right internal nasal valve. Patients who present for revision rhinoplasty have often had the lateral wall of the nose separated from the septum during their prior procedure(s). This can create a decrease in function of one or both of the internal nasal valves. Patients without previous rhinoplasty may also have internal nasal valve collapse. This is determined by manually supporting the lateral wall at the valve (with a q tip) and determining if this partially or totally corrects the breathing issue. Again, the valve issue might be unilateral or bilateral. Correction of the internal nasal valve involves a procedure called ‘spreader graft to the internal nasal valve’, where a cartilage spacer is permanently implanted to restore the integrity of the valve(s).
The external nasal valve is further lateral than the internal nasal valve. Anatomically, this region is comprised of the cartilage of the tip as well as the cartilage of the sidewall of the nose. These patients often respond to the placement of a breathe rite strip which pulls the sidewall of the nose away from the nasal septum, relieving external nasal valve incompetency. In patients seeking revision rhinoplasty, this issue can be caused by too much cartilage being removed at the previous procedure(s). In patients without prior nasal surgery, it can be caused by anatomical issues where there is insufficient space between the lateral wall of the nose and the septum. In either event, treatment is geared towards reinforcing the lateral wall so that the collapse during inspiration does not occur. In patients not seeking purely functional correction of an external valve issue, the latest advance in treatment is the Spirox Latera implant. This is a pin thin implant which is placed in a minimally invasive fashion along the sidewall of the nose. It works as a cantilever, supporting the lateral nose cartilage by supporting itself on the nasal bone. This often provides immediate relief in these patients. The implant itself dissolves over 18 months. Early studies have shown that it is replaced by the body’s own tissue. Further studies are underway to determine the absolute longevity of its effect.
The inferior turbinates exist on the inside of the nose on the opposite side of each nasal cavity from the septum. The air is channeled between the septum in the midline and the lateral wall and inferior turbinates. The turbinates are unique in that they tend to get very large in patietnts with environmental allergies. Diagnosis of symptomatic inferior turbinate hypertrophy is often suggested by the response of the patient’s obstruction to decongestant spray used during the exam. Patients who notice a significant improvement in their breathing following the spray usually have an issue with this. Inferior turbinates are often reduced at the same time as septum or valve surgery.
The paranasal sinuses are the fifth and perhaps most complicated factor in nasal breathing. There are eight of these sinuses, and any or all may be involved. As sinuses become edematous or even produce polyps, the airway can become effected. Sinus blockage as an etiology of airway issues is often made by history, endoscopic examination, and a CAT scan of the sinuses. Minimally invasive procedures including balloon sinuplasty with or without removal of polyps can be performed along with any of the other mentioned procedures.
Before undertaking rhinoplasty or revision rhinoplasty, a thorough analysis of the functional health of the nose is important. In cases where the nose and sinuses are functioning normally, then one goal of the rhinoplasty surgery is to maintain that excellent function. In cases where patients have an existing issue with their septum, valves, turbinates, or sinuses, it is important to diagnosis and bring that under control prior to surgery. Selecting the best rhinoplasty surgeon requires finding a surgeon well versed in both of these areas.