Tang Ho, MD
Nasal obstruction secondary to anatomic nasal deformities is a fairly routine problem seen by the otolaryngologists in the office, usually in the setting of someone who has failed medical management.
While routine septoplasty and inferior turbinate reduction can improve the nasal obstruction symptoms for many patients, these procedures may not always be sufficient for all patients with symptoms of nasal obstruction.
It is important to consider two issues in evaluating a patient presenting with nasal obstruction who has not responded to medical treatment:
First, if septal deviation is present, where is the area of septal deviation that is contributing to the nasal obstruction symptoms? As we all know, we need to preserve the L-strut to maintain the structural integrity of the nose so the patient will not end up with a significantly deprojected tip or a saddle nose. However, what happens if the area of deviation is located in the L-strut, as is often the case? Left uncorrected, these patients will continue to have nasal obstruction problems after a septoplasty, as I have seen often in clinical practice.
While a dislocated caudal septum can sometimes be repositioned onto the anterior nasal spine via suturing and a mild caudal septal deflection be straightened with conservative maneuvers such as cartilage scoring, this is not always the case. If these conservative measures do not do the trick, then a formal functional septorhinoplasty should be considered employing structural grafting. These techniques may include a columellar strut, caudal septal extension graft, extracorporeal septoplasty, or a combination of these techniques. While this may sound somewhat extreme, it certainly beats having an unhappy patient who may question the effectiveness of the surgery, or worse, you as a clinician, after experiencing continued nasal obstruction problems after the procedure.
Next, what if the deviation involves the dorsal portion of the L-strut? If this is the case, there is by definition impingement of the internal nasal valve. Studies have shown that nasal obstruction problems occur when the internal nasal valve is constricted to less than 10 °. Diagnosing internal nasal valve collapse can be easily done on routine nasal exam either by visualizing the internal nasal valve directly with an endoscope or by a modified Cottle maneuver with the back-end of the Q-tip. I find the modified Cottle maneuver to be much more specific than the traditional Cottle maneuver (pulling the cheek skin laterally) in diagnosing internal nasal valve collapse problems.
When internal nasal valve collapse is present, formal functional septorhinoplasty can effectively address the problem. Either an open approach or an endonasal approach can be used. If spreader grafts are planned, then an open approach will allow accurate placement of the grafts. If alar batten or butterfly grafts are considered by harvesting the conchal cartilage, then endonasal approach is perfectly suitable for the placement of these grafts, although an open approach can certainly be used as well with great ease.