Nasal airway obstruction and its management

Dr. T. Balasubramanian
6/3/2010 Otolaryngology online drtbalu

Nasal air way obstruction and its management
Introduction: Nasal obstruction is an important symptom of many underlying disorders, and is the most common cause for visiting an otolaryngologist. It should be borne in mind that nasal obstruction is a symptom and not a diagnosis. These patients hence should be evaluated for both subjective / objective nasal obstruction. Nasal patency these days can be evaluated objectively based on the anatomy of the nasal cavity and physiology of nasal air flow which can be studied using a Rhinomanometer. Subjective feeling of nasal block could be due to the following factors: 1. 2. 3. 4. Sensitivity of pressure receptors in the nose Sensitivity of thermal receptors in the nose Sensitivity of pain receptors in the nose Presence of excessive secretions in the nose

The cause for nasal obstruction is considered to be multifactorial which includes both subjective and objective causes. Anatomic causes of nasal block: Nasal valve area problems: Nasal valve area is considered to be the narrowest portion of the human airway. Anatomically it has two components i.e. External and internal nasal valves. The anatomy of internal nasal valve was first described by Mink in 1903. Boundaries of internal nasal valve include: 1. 2. 3. Dorsal portion of nasal septum medially Inner caudal edge of upper lateral cartilage laterally Anterior head of inferior turbinate posteriorly

The internal nasal valve area is supposedly the narrowest portion of human airway has a cross sectional area of approximately 40 – 60 mm2. This area accounts for nearly 2/3 of the whole airway resistance. Hence collapse / stenosis of this area accounts for one of the commoner causes of nasal block. External nasal valve is also known as nasal vestibule. It is bounded by the caudal edge of the lateral crus of the lower lateral cartilage, fibrofatty tissue over the ala and the membranous septum.

Diagram showing the nasal valve areas The nasal vestibule should be considered to be the first component of the nasal resistance mechanism. If the nasal airflow rate exceeds 30 litres / minute, the vestibule of nose collapses causing a reduction in the rate of nasal airflow. This collapse of ala increases the nasal resistance. On inspiration, the increased velocity of air flowing through the nasal valve area will cause a drastic decrease in the introluminal pressure causing a vacuum effect on the upper lateral cartilages. This inward pull causes collapse of upper lateral cartilage (Bernoulli's principle). Total collapse of the internal nasal valve area duing this scenario is prevented only by the reselience of the upper and lower lateral cartilages. Collapse of external nasal valve area (alar area) is by contraction of dilator nari muscles during inspiration. During expiration the positive pressure prevailing inside the nasal cavity keeps the nasal valve area open. Causes of nasal obstruction: 1. Previous trauma / rhinoplasty surgical procedure are the common causes of nasal obstruction due to weakening of nasal valves 2. If there is associated nasal septal deviation then nasal obstruction becomes exponentially increased 3. Mucociliary clearance mechanism in patients with deviated nasal septum is slowed considerably when compared to that of normal individuals. Stagnant secretions inside the nasal cavity may aggravate nasal obstruction

4. Penumatization of middle turbinate (Concha bullosa) an anatomical variant can cause significant amount of obstruction in the middle meatal area. Massive concha may cause middle meatal nasal obstructive syndrome leading on to symptoms like headache, nasal block and anosmia. Commonly majority of these patients also have deviated nasal septum which may aggravate nasal block. 5. Neuromuscular causes like facial palsy and aging. Facial palsy may cause paralysis of dilator naris leading on to nasal obstruction. Aging on the other hand could weaken the fibroareolar tissues present in the lateral nasal wall leading to collapse of nasal valve area leading on to nasal obstruction. 6. Sinonasal inflammatory diseases. Commonly allergic rhinitis causes congestion and enlargement of nasal turbiantes and mucosa causing nasal bock. These patients classically have nasal obstruction on lying down. 7. Drug induced iatrogenic nasal block (Rhinitis medicamentosa). Rebound nasal congestion is very common in these patients. These patients also have loss of ciliated columnar cells and increase in capillary permeability causing interstitial oedema. During early phases of rhinitis medicamentosa this oedema is reversible. If it continues for a period of more than 3 months it gradually becomes irreversible leading to difficult situations to manage. Systemic medical therapy like reserpine (antihypertensive), beta blockers, antidepressents can cause nasal block due to their actions on the autonomic nervous system. 8. Hypothyroidism may lead to nasal congestion and block due to unknown reason. Supplements of thyroxine will mitigate these symptoms. 9. Pregancy rhinitis – (Rhinopathia gravidorum) seen commonly during the first trimester of pregnancy can cause nasal block due to unknown mechanism. Generalized fluid retention during pregnancy and exposure of nasal mucosa to persistently elevated levels of oestrogen leads to persistent intertitial oedema. It has also been suggested that elevated levels of oestrogen and progesterone during pregnancy may cause rhinits by causing a shift in the level of neurotransmitters like substance P and nitirc oxide. 10. Trauma may cause nasal block due to the following factors: tissue oedema causing physical blockage to airflow, secondary sinusitis, and impaired sensation to air flow due to damage sustained by nasal receptors. 11. Neoplams involving the nasal cavity can cause nasal block. Nasal block in these patients may be associated with other non specific symptoms like epistaxis and anosmia prompting the patient to seek medical attention. Patients with fixed anatomical nasal obstruction may experience intermittent symptoms secondary to nasal cycle and other autonomic phenomenon. By and large normal nasal cycle is usually unnoticed by the patient. When there is associated anatomical fixed nasal obstruction then the patient becomes aware of the presence of nasal cycle.

Factors controlling nasal resistance:

In normal healthy subjects the nasal airway resistance is determined by the degree of engorgement of venous erectile tissue, as well as the accessory muscles of respiration which keep the nasal airway patent. The venous erectile tissue of nasal mucosa has dense adrenergic innervation which when stimulated cause intense vasoconstriction thereby decreasing the nasal airway resistance. Normally there is a continuous sympathetic vasoconstrictor tone to the nasal erectile tissue keeping the nasal airway resistance under check. Reduction in this sympathetic tone increases the nasal airway resistance. The parasympathetic tone in the nose controls nasal secretion, but has little role in nasal resistance.

Role of complete history / clinical examination in diagnosing the cause for nasal obstruction: It is very important to elicit a complete history from the patient. This will invariably point towards the correct cause for nasal block. These patients must be diligently quizzed for prolonged use of drugs, nasal drops which could cause iatrogenic nasal obstruction. History of previous surgeries in the nose which includes cosmetic surgery should be sought. This can invariably point towards the possible cause of block. Presence of midface deformities (congenital / due to injuries) should also carefully

sought for. History of mouth breathing and halitosis will invariably confirm the problem of nasal block. Nasal cavities should be examined for evidence of sinusitis. Any discharge from the nasal cavity indicates infection. Adenoid hypertrophy should be ruled out in young children with nasal obstruction as it is the commonest cause in them. Assessment of facial nerve function: Facial nerve integrity should be assessed in these patients. Facial nerve paralysis will hamper the splinting muscles of the ala of the nose causing collapse of the airway on inspiration. Examination of the nasal cavity pertaining to airflow dynamics: Nasal cavity should be examined with specific focus on the probable sites of nasal resistance. Evaluation should begin with specific focus on external support structures followed by a detailed assessment of internal support sturctures. Nasal valve area should be carefully assessed by performing Cottle's test. In this test the cheek of the patient is pulled outwards and upwards. If it affords relief from nasal block then obstruction should be considered to be due to anamalous / abnormal nasal valve area. False negative Cottle's test is possible when the presence of synechiae in the nasal valve area prevents opening up of this zone when this test is being performed. As a first step the internal nasal valve area should be examined endonasally as this area contributes the maximum to the airway resistance. This area should be examined just by lifting the tip of the nose. Introduction of nasal speculum would distort this area and hence should be avoided.

CT scan showing a large concha occupying the whole nasal cavity

Malignant nasal mass seen occupying the nose

CT scan showing hypertrophied nasal mucosa on both sides due to allergy A simple technique which can be used as an alternative to Cottle's test is using a nasal speculum to lateralize the upper lateral cartilage from the inside of the nose and the patient is asked whether there is improvement in symptoms. This test has the added advantage of direct observation of the nasal valve area as it is widened. Diagnostic nasal endoscopy: This is the most efficient way of completely examining the interiors of the nasal cavity. 30 degrees 4 mm nasal endoscope is preferred for this purpose because of its wide viewing angle. Ideally speaking the nasal endoscopic examination should be performed before and after nasal decongestion. If nasal obstruction improves on decongestion alone then nasal obstruction could be due to mucosal inflammatory disorder affecting the inferior turbinates. If there is no response to nasal decongestion then the probable cause for nasal obstruction could be: 1. 2. 3. 4. Nasal valve area obstruction Septal deviation Bony hypertrophy of inferior turbinate Rhinitis medicamentosa

During diagnostic nasal endoscopy the presence of anatomical variations should also be observed. Common anatomical variations that could cause nasal block include:

1. 2. 3. 4.

Septal deviation Presence of concha bullosa Intranasal masses Presence of adenoid enlargement

Diagnostic alogrithm for nasal block

Nasal endoscopy is an useful tool in assessing subtle nasal mucosal inflammatory changes like mucosal nodularity, friable mucosa and synechiae.

Role of radiology in assessing patients with nasal block: CT scan is helpful in evaluating bony structural abnormalities like deviated nasal

septum, choanal atresia, concha bullosa, inferior turbinate hypertrophy, F.B., rhinolith etc. MRI because of its excellent soft tissue imaging capacity is very useful in identifying lesions like meningocele, encephalocele etc. Objective evaluation of nasal block: The following tests would help us to objectively evaluate nasal block. 1. Hygrometry: This is one of the first methods to objectively assess nasal airway patency. This technique was first described by Zwaardemaker in 1884. This procedure is performed by asking the patient to breathe on a mirror. A comparison is made between the diameter of the fog produced by each nasal airway. 2. Hum test: This test was first performed by Spiess in 1902. He assessed the nasal airway by the change in timbre of the sound caused due to nasal block. He performed the test after decongesting one nose, blocking the decongested nose and asking the patient to hum a tune. The change in timbre caused due to block in the non decongested nose is appreciated. 3. Peak nasal inspiratory flow 4. Acoustic rhinometry 5. Rhinomanometry

Peak nasal inspiratory flow: This is a very simple, cost effective, reliable and objective measure of nasal airflow obstruction. In 1980 Youlten developed a peak nasal inspiratory flow meter which was non invasive, portable, simple to use and economical to own. The peak nasal inspiratory flow rate is determined by two factors i.e. Nasal obstruction and the maximum negative pressure generated by the lower airway. Hence changes in inspiratory effort or lower airway resistance will alter the peak nasal inspiratory air flow independent of nasal obstruction. To overcome this problem Taylor suggested to assess Blockage index. Blockage index = Peak oral flow – Peak nasal flow / Peak oral flow. According to Taylor Blockage index correlated well with Rhinometry values.

Figure showing equipment to record Peak nasal inspiratory flow

Acoustic Rhinometry: This was first introduced by Hilberg in 1989. This technology was originally used for oil exploration. It was only in 1970's this technology was started to be used for medical diagnosis. This is the most common method used to assess the nasal cavity air way geometry. This can be used for studying: 1. Anatomical variations of nasal cavity 2. Post surgical changes inside the nasal cavity 3. Effect of drugs on nasal resistance 4. Assessing the changes in the mucovascular component of the nasal erectile tissues. Components of acoustic rhinomanometer: 1. 2. 3. 4. 5. 6. 7. Sound source Wave tube Microphone Filter Amplifier Digital converter Computer

Sound waves generated by acoustic rhinomanometer is transmitted through the nasal cavity, these sound waves get reflected back from the nasal passages and is recorded by the microphone placed at the entrance of the nasal cavity. These sound waves are converted to digital signals and a computer recording is made which is known as the

“Rhinogram”. Rhinogram usually provides a two dimensional assessment of the nasal airway. The cross sectional area of nasal cavity varies at different points from the nasal rim and these variations are detected by changes in acoustic impedance. Each notch in a rhinogram represents a constriction inside the nasal cavity. The first notch represents the nasal valve area. This is infact the minimal cross sectional area in the normal nasal cavity. The second notch represents the anterior portion of the inferior / middle turbinate. The third notch represents the area of the middle and posterior end of middle turbinate. Each notch indicates the site of nasal airway resistance and is hence a very sensitive indicator for identifying the area causing nasal block.

Figure showing the Rhinogram. Note the three notches as described above

Figure showing acoustic rhinomanometer

CT volumetry: This imaging modality is very senstitive in measuring nasal cavity volumes. This imaging modality is highly accurate in measuring the volume of anterior nasal cavity but its accuracy reduces while measuring the volume of posterior nasal cavities.

Rhinomanometry: This investigation involves the functional assessment of airflow inside the nasal cavity. It involves measurement of transnasal pressure and airflow. Resistance from each nasal cavity can be compared. There are two types of rhinomanometry, active and passive rhinomanometry. Active rhinomanometry involves the generation of nasal airflow and pressure with normal breathing. Passive rhinomanometry involves the generation of nasal airflow and pressure from an external source, such as fan or pump which drives air through the nose. Active rhinomanometry: can be divided into anterior and posterior methods according to the siting of the sensor tube. In active anterior rhinomanometry, the pressure sensing tube is taped to one nasal passage. This method measures resistance of one nasal cavity at a time and must be repeated on the other side. The total air flow through the nose is measured with the help of the sensor tube. In active posterior rhinomanometry, the pressure sensing tube is held within the mouth and it detects the post nasal pressure. Air flow through each nose can be measured by taping the opposite nose. While performing rhinomanometry pressure in the post nasal space can be measured in three ways: Anterior rhinomanometry involves palcement of a tranducer in the nostril not being tested. This concept was first introduced by Coutade in 1902. Because there is no airflow in the non test nose, the pressure at the anterior end of this nostril is roughly equal to the pressure at the post nasal space. In this method transnasal pressure differences and nasal airflow can be recorded at the same time. Major draw back of this method of recording is that it cannot be relied in patients with septal perforation.

Another method of measuring nasal pressure is by peroral method. This method was popularized by Spiess in 1899. In this method the transducer is placed in

the posterior portion of oropharynx through the mouth. This method accurately assesses the contribution of enlarged adenoid tissue to the nasal block. The major problem with this method is that it is poorly tolerated. The third method of measurement of nasal airway is by placing the sensor in the postnasal space. This is again not very well tolerated by the patient.

Precautions taken while performing rhinomanometry: a. The use of face mask is desirable than a nasal cannula. The face mask should form a soft air tight seal and must not effect pull on the cheek. b. Calibration of the equipment must be performed regularly. c. Series of readings must be taken as a single reading is unreliable.

Nasometry: During speech sound is transmitted through both the oral and nasal cavities. Nasal obstruction causes a reduction in the amount of sound transmitted through the nose. By measuring the nasal components of speech the patency of the nasal airway can be assessed. This is known as nasalance. It is the ratio of sound energy from the nasal and oral passages and can be measured by placing two microphones one over the nose and the other over the mouth. Infact the measure of nasalance has been proposed as a useful method of selecting children for adenoidectomy. It is also useful in measuring the nasal airway patency. Odisoft rhino: This new technique converts the frequency of sound generated by airflow into cross sectional area measurements. This technology was based on the premise that the sound generated by airflow in the nose has a higher frequency depending on the turbulence created. This technique was first developed by Serene. The equipment has a microphone, nasal probe, sound card and a computer. The nasal probe is connected to a microphone and is placed about 1 cm from the nostril of the patient. The sound created by breathing is measured by the probe.

Figure showing areas of nasal cavity contributing to normal nasal resistance

Management: Nasal obstruction due to mucosal congestion can be managed medically by topical / systemic nasal decongestants. Treatment of acute infections with antibiotics should take precedence over nasal decongestants. To decide whether medical / surgical management is preferred mucosal congestion index should be assessed. Nasal mucosal congestion is an important determinant in deciding whether the patient needs medical / surgical therapy. It goes without saying that if the nasal mucosa is thickened due to mucosal oedema than it would respond better to nasal decongestants, while if the thickening is due to underlying submucosal fibrosis then it doesn't respond to decongestants and needs to be surgically removed to improve nasal airway patency. Nasal mucosal compliance cannot be estimated by CT scans alone. It has been demonstrated that tissue remodelling which is the repair response of nasal mucosa to insults is characterised by decrease in vascular density, and an increase in fibrosis causing the nasal mucosa to thicken irreversibly. This thickened mucosa reduces drug permeability through osmosis causing a reduction in the effectiveness of the drug.

This measurement helps in identifying mucosal oedema from mucosal thickening due to fibrosis involving submucosa. This can be measured by performing acoustic rhinomanometry before and after decongesting the nose with epinephrine. If the nasal mucosal congestion index is large then medical management is preferred and if the index is small then surgery should be resorted to in the management of chronic rhinosinusitis. For sake of objectivity congestion index of the nasal mucosa can be classified as normal, mild, moderate, severe and very severe. Surgical management of nasal obstruction: 1. 2. Septal correction – if nasal block is attributed to septal deviation / spurs Anatomical abnormalities like concha bullosa should also be corrected surgically

3. Obstruction to nasal valve area as prooved by Cottle's test should be managed surgically. Procedure: This procedure can be performed under local anesthesia. Nasal cavity is first packed with ribbon gauze dipped in 4% xylocaine with 1 in 100,000 units adrenaline. Xylocaine in 1% concentration mixed with 1 in 100,000 units adrenaline is infiltrated over the prominence formed by the caudal portion of the upper lateral cartilage. Parallel incisions are made on either side of the caudal portion of the upper lateral cartilage. The caudal portion of the upper lateral cartilage is exposed after removing a strip of mucosa with the underlying fibrous tissue. A 2 mm cuff of mucosa along with overlying fibrous tissue is also removed to prevent redundant tissue formation. About 1-2 mm of the terminal portion of the upper lateral cartilage should be resected and removed. The wound is closed with absorbable suture like catgut. This procedure is safe to perform bilaterally also if necessary.

Diagram illustrating surgery in the nasal valve area

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