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Functional Rhinoplasty

"I have trouble breathing through my nose, particularly when I am trying to sleep, but doctors have told me that my septum is fine. Is this normal?" ~ Jim C. Worcester, MA

What you are describing is an airway obstruction. A full history and physical exam will help us determine the cause of your obstruction and let us lay out the options for you. The airway is the corridor for air to get from the outside into your lungs and back out again. By definition, an airway obstruction is a blockage of any part of the airway. The airway can further be divided into upper airway (mouth, nose and throat) and the lower airway (the trachea, bronchi, bronchioles and alveoli within the lungs). The tongue is a common cause of upper airway obstruction, frequently seen after cardiac arrest or trauma. Other common causes of upper airway obstruction are edema and trauma to the oropharynx and larynx, foreign bodies and infections. Severe allergic reactions can also compromise the airway and can lead to near or complete airway obstruction within minutes – this is the reason people with severe food or bee sting allergies carry Epi Pens! Milder allergic rhinitis, a group of nasal symptoms including a runny nose and perhaps difficulty catching your breath, particularly when trying to fall to sleep, are caused by allergens such as dust, animal dander or pollen, and cannot be helped surgically.

Nasal breathing normally contributes 70% of the airflow to the lungs. Nasal airway obstruction affects more than 20 million Americans, occurring because of a structural abnormality in the nose or due to inflammation and swelling of the nasal passages. But the focus of this presentation will be a nasal airway obstruction which we can improve as plastic and reconstructive surgeons. These surgically correctable causes of nasal obstruction include the septum, the turbinates or a collapsing lateral wall with inspiration.

The septum is the cartilage wall between the two nostrils that can block the nasal airway if it is excessively bent. First, we must point out that no one has a perfectly straight septum - not every septal “deviation” influences the airway and has to be fixed! But if a patient cannot inhale air though a blocked airway we can surgically improve that airway with a septoplasty in which the obstructing cartilage is surgically remodeled and the airway opened up.

The inferior turbinates are ridges of bone covered with mucosa comprising the lateral wall of our nasal airway. These turbinates may be enlarged to the point where they touch the septum and cause airway obstruction. In such cases, the turbinates may be surgically reduced, to improve the airway. This procedure is frequently done together with a septoplasty, as the two conditions seem to go hand in hand.

In our experience, the most common source of airway obstruction are weak or excessively flexible cartilages in your nasal rim, allowing them to collapse every time you inhale. Usually this occurs symmetrically on both sides. From your description, it sounds like this is what you are suffering from, and you are not alone – this is a very common cause for airway obstruction. If you have used external nasal strips and they have helped you breath, your issue most likely is lack of lateral wall support with inspiration. A simple test we use in the office is called a Cottle test – if your airway improves when we place a finger on your cheek at the level of the nostril and pull laterally, you probably have lateral wall collapse. Another simple test involves a Q-Tip. If your airway improves when we put a Q-Tip just inside the nose and lift up the alar rim while you are inhaling, you have lateral wall collapse. Traditionally, this has been treated by suturing in grafts of ear or rib cartilage to shore up the lateral wall of the nose. These procedures improved airways but made the nose look bulkier. But today we have a much simpler way of improving lateral wall integrity by inserting a lateral wall implant called Latera®, which are made by Stryker. The Latera® implant is a small, absorbable strip of Poly (L-lactide-co-D-L-lactide) 70:30 copolymer which is absorbed in the body over a period of approximately 18 months. The implant can be placed in an office procedure under local anesthesia and is repeated every 18 to 24 months to maintain the improvement. The patient you see in this brief video was having an unrelated procedure and we inserted her Latera® implants in an OR but usually we do this in the office:



After numbing up the nose, the implant is inserted by placing a hollow needle into the side of the nose that collapses, and the implant is delivered into the desired site with the Latera® Implant Delivery system. Studies show that nine out ten patients get a very satisfactory improvement of their obstruction with such a procedure. Insertion of the Latera® implants can cause the nose to look a little wider, or if your nose is very deviated, fixing the septum may cause the nose to look straighter, but in general, airway correction procedures do not leave you with a nose that looks significantly different – it will just work better!

In short, an accurate diagnosis of the cause of your obstruction has to be arrived at before a surgical correction can be offered. But once diagnosed properly, yes, there is help for most patients with airway obstruction.

Please feel free to join us for our virtual rhinoplasty seminar on May 8th. You can sign up at the link above, share this with a friend, and enjoy!

functional rhinoplasty ocps photo

(Photo of a previously used Latera® insertion apparatus as an illustration. The T-shaped green device (horizontal part exactly same size and shape as the implant) is used to mark desired implant position on the skin. Once the patient has been marked and the implant loaded in the delivery device, the needle is placed in the correct location through a poke inside the nose and deposited by pressing the green trigger on the handle.)

functional rhinoplasty ocps photo

If you have any other questions about Functional Rhinoplasty, please join us for our next complimentary virtual seminar on May 6th on YouTube. The topic will be Rhinoplasty Surgery. Please sign up for this free event on Eventbrite.

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If you have difficulty breathing or any specific questions about rhinoplasty procedures, your best bet would be to see a qualified plastic surgeon to review your options.

If you would like to reach Dr. Ekstrom or Dr. Bunkis, please call 949-888-9700 or visit our websites at:

www.orangecountyplasticsurgery.com

Or for MA location, call 508-755-4911 or visit
www.salisburyps.com

You can respond in the comment section below or write to me at bunkis@ocps.com or Dr. Ekstrom at mds@salisburyps.com

Thanks for staying in touch and for your feedback!