Editors: Bailey, Byron J.; Johnson, Jonas T.; Newlands, Shawn D.

Title: Head & Neck Surgery - Otolaryngology, 4th Edition

Copyright 2006 Lippincott Williams & Wilkins
> Table of Contents > Volume One > II - Rhinology and Allergy > 23 - Surgical Management of
Septal Deformity, Turbinate Hypertrophy, Nasal Valve Collapse, and Choanal Atresia
23
Surgical Management of Septal Deformity, Turbinate Hypertrophy, Nasal Valve Collapse, and
Choanal Atresia
Michael Friedman
Ramakrishnan Vidyasagar
Nasal obstruction is a common presenting symptom in the practice of otolaryngology. The most
common diagnoses of nasal obstruction are presented in Table 23.1. Sometimes multiple
contributing processes cause nasal obstruction. Strategies for the management of nasal
obstruction are based primarily on history, physical examination, and results of laboratory tests,
where applicable. It should also be understood that some of the obvious findings, such as septal
deviation, may not be the only contributing cause for the nasal obstruction, and may just be an
incidental finding. Care should always be taken to analyze the patient as a whole, rather than the
nose as a separate organ. Patients with systemic disorders [such as obesity, hypothyroidism,
obstructive sleep apnea/hypopnea syndrome (OSAHS), and Sjgren syndrome] can present
with nasal obstruction as a part of their medical disease with or without any localized nasal
finding. A thorough assessment of all potential causes of nasal obstruction is essential before
definitive treatment of a single anatomic obstruction.
Several factors may influence the sensation of comfortable nasal breathing, including the amount
and type of nasal airflow, the sensation registered from the intranasal skin or mucosa by the
passing air, and the condition of the nasal mucosa. Many physiologic and pathologic conditions
affect the amount of airflow through the nose. The nasal pathologic conditions include mucosal
hyperactivity, septal or other structural deformities, polyps, tumors, sinus infection, granulations,
and synechiae. Any one of these or many of these together may be the factors that limit airflow
in a person who complains of nasal obstruction.
History

The first step in assessing any symptom is to obtain a thorough history. The clinician should pay
particular attention to the time of onset, severity and duration of symptoms, and recourse the
patient has taken to alleviate symptoms. The history should determine if the obstruction is
unilateral, bilateral, or alternating; the duration of the obstruction (recurrent or chronic);
aggravating factors;
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and contributing factors in the patient's environment. A complete history also includes the
presence or absence of the following symptoms: (a) rhinorrhea, if any, that includes
characteristics such as purulence, odor, consistency, and color; (b) epistaxis or blood in the nasal
secretions; (c) nasal pain, or facial or orbital pain; and (d) middle ear disease or symptoms
relating to the middle ear. The past medical history should focus on (a) respiratory illness, such
as chronic obstructive pulmonary disease or asthma; (b) any allergy; (c) drug, alcohol, or tobacco
use; (d) nasal surgery or trauma; and (e) current use of medications, especially nasal
corticosteroids, aspirin, or other medications that alleviate or exacerbate symptoms of nasal
obstruction.
TABLE 23.1 COMMON CAUSES OF NASAL OBSTRUCTION
Diagnosis
Symptoms
Test
Allergy
Bilateral nasal obstruction, history ofSkin tests, RAST, food allergen
seasonal obstruction, pale or bluish nasaltesting
Vasomotor

mucosa
Clear, glary mucus

rhinitis
Septal

Septal deviation at physical examination,CT of sinuses and septum

deviation
Turbinate

unilateral nasal obstruction

Turbinate enlargement (usually inferior) atDirect inspection

hypertrophy
Polyps

physical examination
Unilateral or bilateral nasal obstruction,Direct inspection

Valvular

impaired sense of smell

Nasal valvular collapse on deepCottle

collapse
Sinusitis

inspiration
inspiration
Mucopus on anterior rhinoscopy, painCT of sinuses

Adenoid

during percussion of involved sinus

Unilateral or bilateral nasal obstruction,Posterior rhinoscopy, nasal endoscopy,

Rule out other causes

test,

observation

of

deep

hypertrophy

mouth breathing, snoring, crowding ofx-ray nasopharyngeal-lateral view

OSAHS
Septal

teeth
Thick palate, hypertrophic tonsils
Polysomnography
Septal perforation at physical examination Direct inspiration

perforation
Neoplasm
Obvious mass at physical examination
CT scan of sinuses, biopsy
Choanal atresia Unilateral or bilateral nasal obstructionSagittal CT through nasopharynx
with clear rhinorrhea
CT, computed tomography; OSAHS, obstructive sleep apnea/hypopnea syndrome; RAST,
radioallergosorbent test
Most patients with nasal obstruction describe generalized stuffiness; however, nasal
obstruction can have more obscure, nonnasal manifestations. Common nonnasal manifestations
of obstruction include dry mouth; chronic sore throat; frontal, cheek, or orbital pain indicating
acute or chronic sinusitis; localized facial pressure indicating sinusitis; excessive snoring;
halitosis; parental concern about a child's lethargy or disinterest; inability to sleep soundly that
results in hypersomnolence during the day; and decreased sense of taste or smell.
Differential Diagnosis
The surgeon should have a complete list of differential diagnoses in mind before proceeding to
the physical examination. Systemic diseases that can cause nasal obstruction, such as obesity,
hypothyroidism, OSAHS, and Sjgren syndrome, should be excluded before proceeding to the
local examination. External factors such as tip ptosis, caudal dislocation of septum, nasal valve
obstruction, saddle deformity, and crooked nose should be evaluated. Intranasal causes of nasal
obstruction include septal deviation, turbinate hypertrophy, and nasal polyposis. Choanal and
nasopharyngeal obstruction may be caused by adenoid hypertrophy, OSAHS, or choanal atresia
(Table 23.1). Although no clinical evidence is available to document obesity as a cause of nasal
obstruction, it is a common observation that patients with morbid obesity (body mass index
greater than 40 kg/m2) have nasal obstruction without obvious anatomic deformities. The
presence of systemic factors contributing to nasal obstruction is not a contraindication to
correction of identified local areas of obstruction.
Physical Examination
External Contour
A physical examination begins with evaluation of the external nose. This examination is focused
on the size and shape of the nose. The presence of any deformity or deviation that displaces the

nasal midline laterally is documented. Bony fractures can depress the nasal vault and narrow the
radius of the nasal passage, and can cause saddle deformity. Trauma to the distal upper lateral
nasal cartilage (the upper lateral wings of the quadrilateral
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cartilage of the nasal septum) can dislocate these cartilages and involve the nasal septum
intranasally. A crooked nose or narrow nose and midfacial complex should also be noted. The
appearance of a nasal crease on the nasal dorsum suggests frequent nose wiping and upward
movement of the nose from chronic or allergic rhinorrhea (allergic salute). Congenital anatomic
variation can manifest as thin, weak upper lateral cartilaginous support and an incompetent nasal
valve. Tip ptosis and caudal deviation of the septum should be assessed by visual inspection
before manipulation. Tip elevation to eliminate ptosis should improve the airway if tip ptosis is a
factor.
Nasal Valve
While examining the nasal valve, both the external and the internal valve should be visualized
for obstruction. Although the term nasal valve collapse is frequently used, we prefer to identify
the problem as nasal valve obstruction, because some patients have fixed obstruction, whereas
others have a normal valve area during exhalation and have collapse. Obstruction is on
inspiration only. The inclusive term obstruction refers to both fixed and inspiratory obstruction.
The internal valve, which is located between the lower border of the upper lateral cartilage and
piriform aperture, can be easily distorted during anterior rhinoscopy and completely overlooked
with nasal endoscopy; hence, it should be examined before introducing the speculum into the
nose. Two types of obstructions are described in the nasal valve area: (a) inspiratory nasal valve
obstruction and (b) fixed nasal valve obstruction. The inspiratory valve obstruction occurs only
during the inspiration phase, whereas fixed obstruction is evident even at rest. Fixed obstruction
and inspiratory obstruction can be present together. Asking the patient to take a deep inspiration
while observing the nasal valve will identify inspiratory obstruction, when present. Normally
during inspiration, the external dilators of the nose widen the nasal alae and the nasal valve area
is widened. In patients with inspiratory nasal valve obstruction, the nasal valve collapses or
narrows the nasal valve area. These patients can feel immediate restoration of nasal patency by
bilaterally widening the alae with the index finger and thumb (Cottle maneuver). Testing with

nasal strips (Breathe Right, CNS, Inc., Whippany, NJ) can also result in an improved airway, by
widening of the nasal valve area in patients with nasal valve obstruction.
Tip Ptosis and Caudal Deflectionof the Septum
Tip ptosis is more common in the elderly patient. These patients often complain of diminished
nasal airflow due to loss of tip support. These patients often demonstrate to the surgeon that by
lifting up their nose they can improve their nasal airway. Factors extrinsic to the septal cartilage
itself may also be responsible for the nasal septal deviation. For instance, an abnormally large or
lateralized premaxillary spine can cause the displacement of the base of the caudal septal
cartilage and in doing so, distort the symmetry of the nasal tip. Sometimes tip ptosis and caudal
deflection present external clues to identify the etiology of nasal obstruction. Proper attention
and careful examination of the tip may aide in definitive management of patients' symptoms.
Rhinoscopy
Anterior rhinoscopy can be accomplished with a nasal speculum and head mirror. During
anterior rhinoscopy, the examiner documents the characteristics of rhinorrhea; septal deviation;
or septal spurs, turbinate hypertrophy, the extent to which the nasal mucosa is edematous or
obstructive, and any polyps or mass in the nasal cavity. The examination of the nasal cavity
should be done both before and after the application of local decongestants. The reduction in the
size of the turbinates and changes in the mucosa should also be documented. The posterior
rhinoscopic examination of the nasopharynx and posterior choanae may be accomplished
through the oral cavity with a head mirror for illumination and a nasopharyngeal mirror for
visualization. During the posterior rhinoscopic examination, the examiner documents the
presence or absence of eustachian tube patency, hypertrophic adenoid tissue, and abnormal
epithelial lesions. In both examinations, a rigid or flexible fiberoptic nasopharyngoscope can
provide superior illumination with magnification and aid in the identification of pathologic
conditions of the nasal or nasopharyngeal space. It also provides information about the middle
meatus and sphenoid ethmoid recess that would not be seen with anterior and posterior
rhinoscopy. It should not, however, be a substitute for external examination and anterior
rhinoscopy but should be complimentary to the standard examination.
Muller maneuver is also performed to assess coincidental velopharyngeal narrowing and
hypopharyngeal narrowing in suspected OSAHS patients. Examination of the soft palate is
essential as well. A thick, soft palate and uvula associated with snoring and OSAHS may be a

cause of nasal obstruction even during awake hours. Identification of all areas of obstruction is
essential before proceeding to the surgical correction of a single factor.
Investigations
Investigations to assess nasal airway dysfunction depend on the suspected differential diagnosis.
In many situations, a thorough history and physical examination are adequate
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to establish a diagnosis and to proceed with a treatment plan.
TABLE 23.2 TREATMENT CHRONIC NASAL OBSTRUCTION
Diagnosis
Treatment
Septal deviation
Septoplasty
Nasal fracture
Reduction
Turbinate
Decongestants, turbinoplasty, turbinate resection, radiofrequency reduction,
hypertrophy
microdebrider-assisted turbinate reduction
Septal perforation Septal button, advancement flaps, inferior turbinate flap
Nasal
valveAdhesive supporting strips, naso-orbital suspension of the nasal valve,
collapse
Choanal atresia
Neoplasm
Nasal polyposis
Tip ptosis
Allergic rhinitis

valvular reconstruction with spreader grafts

Transpalatal repair, endoscope assisted repair
Resection
Polypectomy, topical corticosteroids
Cartilage graft to support tip
Avoidance of or desensitization to the allergen, antihistamine, topical steroid,

etc.; evacuation
Septal hematoma Incision and drainage, antibiotics
Septal abscess
Incision and drainage, antibiotics
Nasal foreign body Foreign body removal
Rhinoscleroma
Tetracycline early or surgical resection of fibrotic material later
Rhinitis
Glucocorticoids (temporary) and avoidance of nasal decongestant sprays
medicamentosa
Mucormycosis
Radical debridement, antifungal
OSAHS
Treatment of obstructive palate and tonsils (uvulopalatopharyngoplasty)
OSAHS, obstructive sleep apnea/hypopnea syndrome.
Roentgenogram of the sinuses has become less helpful in diagnosing the cause for nasal
obstruction. Radiologic screening using a computed tomography (CT) scan could provide vital
information when inflammatory disease, sinusitis, trauma, neoplastic growth, or congenital
abnormality is suspected. A CT scan can also document septal deformity and turbinate
hypertrophy but is not essential for the diagnosis.

Acoustic rhinometry and rhinomanometry have been used to objectively assess nasal airway
resistance and obstruction since the 1980s. Recently, acoustic rhinometry has more often been
used in the objective diagnosis of nasal valve obstruction. Acoustic rhinometry measures the
cross-sectional area (CSA) of the nasal cavity, in which a shock wave is presented to the nasal
airway and the reflected sound is measured. Recent articles describe the dual-mode acoustic
rhinometry in the diagnosis of nasal valve collapse. First, the CSA area is measured when the
patient is apneic, and then the CSA measurement is repeated during the inspiration. The ratio
between the two is used as a guide to determine if the patient has valve collapse or not. In a
normal nasal valve, the inspiratory/apneic CSA ratio should be close to 1.0. A significant drop in
CSA during the inspiratory phase will give an inspiratory/apneic CSA ratio of less than 1,
indicating inspiratory valve collapse. A very low CSA, measured both in apnea and inspiratory
phase, may indicate a fixed valve obstruction. The range of normal CSA, however, is quite large,
and therefore any single measurement is not completely diagnostic (1).
Rhinomanometry is a method of simultaneous recording of the transnasal pressure and airflow.
This technique of recording pressure and flow simultaneously over a given time interval allows
for study of the relationship between pressure, airflow, and time, to give the most complete
objective assessment of the passage of air through the nose. Although helpful as support data,
neither rhinomanometry nor acoustic rhinometry is considered standard in the evaluation and
treatment of septal deformity and valve collapse. Biopsy is indicated when a neoplasm or an
unusual inflammatory process, such as fungal infection or Wegener granulomatosis, is suspected.
Management
The most common therapies for nasal obstruction are shown in Table 23.2.
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Deviated Nasal Septum

Deviated septum is the most common cause of nasal obstruction. Among patients with nasal
septal deviation, a history of nasal or midfacial trauma often indicates the original alteration of
normal nasal anatomic features. Improper forceps placement through an unusually narrow pelvic
canal can cause septal deviation early in anatomic development. Internal deviation can be caused
by singular or concerted alteration of the bony portion or cartilaginous portion of the septum;

however, bony alteration of the posterior septum (the vomer or perpendicular plate of the
ethmoid) is less frequent. Patients with unilateral septal deviation may have nasal obstruction of
the contralateral side. It is critical for a successful outcome in septal surgery to do a thorough
preoperative evaluation that identifies the areas where the symptoms arise. Septal deviations tend
to progress over a period of years, and usually symptoms will arise with no clear history of
trauma, or many years after trauma.
Clinical Indications
Septoplasty alleviates nasal obstruction by means of surgical resection of impinging anterior
cartilaginous or posterior osseous septal deviation. The clinical indications are tabulated in Table
23.3.
Operative Procedure
Septoplasty involves the surgical correction of a deviation of the septum. The surgeon resects
only the deviated portion of the septum, allowing maximal preservation of this important
structural component of the nose. Whereas the submucosal resection of the septum involves
removal of the septum except for a 1-cm wide dorsal and caudal strut that remains for the nasal
support, we prefer the concept and term septoplasty, because each procedure should be
individualized and limited to conservative resection of abnormal cartilage only.
Septoplasty can be performed with either a local or a general anesthetic. The latter is preferred
for operations on patients who are apprehensive about surgery, or when a long procedure such as
endoscopic sinus surgery, is combined with septoplasty. The infiltration in the subperichondrial
plane is the key step in the operative procedure. This is performed with a hemostatic solution,
such as lidocaine 1% with 1:100,000 epinephrine. The infiltration can be done from either
anterior to posterior, or posterior to anterior, although the authors prefer the former. Multiple
injections may be needed over the spur, but the first injection is the key in elevating the flaps,
because the injection must be in the right plane with high pressure to elevate the perichondrium.
This is usually accomplished with injection at dorsal anterior injection point. Waiting 10 minutes
after injection maximizes the effect of vasoconstriction.
TABLE 23.3 CLINICAL INDICATIONS FOR SEPTOPLASTY

Deviation of the nasal septum, with partial or complete unilateral or bilateral obstruction
of airflow

Persistent or recurrent epistaxis

Evidence of sinusitis secondary to septal deviation

Headaches secondary to septal deviation and contact points

Anatomic obstruction that makes indicated sinus procedures difficult to perform

efficiently

Obstructive sleep apnea/hypopnea syndrome

As an approach to transseptal transsphenoidal approach to pituitary fossa

Incision
Placement of incision depends on the specific area of the septum that needs to be addressed.
Freer's hemitransfixation is preferred if the caudal quadrangular cartilage is dislocated. This
incision passes through the membranous septum, between the medial crura of the lower lateral
cartilages and the caudal quadrangular cartilage. The Killian incision (vertical incision about 1 to
2 cm from columella) is preferred if the obstruction is in the posterior cartilaginous septum or the
bony septum (Fig. 23.1). The third type of incision, is an endoscopic septoplasty incision, in
which the incision is made just parallel to the spur that needs to be removed.
The side of incision depends on multiple factors. Usually the right-handed surgeon prefers a leftsided incision. Sometimes, the surgeon may prefer to use the incision on the convex side of the
septal deviation. Therefore, even a right-handed surgeon may need to make a right
hemitransfixation incision if the caudal septum is convex towards the right. After the incision is
made, a mucoperichondrial-mucoperiosteal flap is raised on the side of the incision (Fig. 23.2).
The confluence of the septal cartilage, the perpendicular plate of the ethmoid, and the vomer is a
difficult area to raise without perforating the mucosa. It requires meticulous dissection with a
Freer or Dunning elevator. The mucoperichondrium-mucoperiosteum on the
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contralateral side is also raised. Access to the contralateral side is either via an incision through

the septum or around the caudal septum, depending on the exposure required. Deviated portions
of the septum are identified and removed. If the cartilage is normal and only a ventral cartilage,
maxilla or vomer deformity is the problem, complete flap elevation of the contralateral side is
not always essential. A knife is used to incise the cartilage above the ventral deformity. Septal
spurs that are due to overgrowth of the maxillary crest can be removed with a Freer chisel.
Resection of vomer deformity can be accomplished with an osteotome. Care is taken not to rock
the perpendicular plate of ethmoid bone. Rocking can cause fracture at the cribriform plate and
can cause cerebrospinal rhinorrhea. Care also is taken to avoid tearing the septal flaps, because
bilateral tears can cause septal perforation. Occasionally, torn mucosa and perichondrium can
inadvertently be removed with bone and cartilage. Loss of mucosa will obviously delay healing
and increase the risk of septal perforation.
Figure 23.1 Hemitransfixion incision made on caudal tip of the septum through mucosa and
perichondrium.
Figure 23.2 Elevation of mucoperichondrium flap from septum.
When deviation involves the dorsal strut of the septum or the caudal end of the septum, the initial
approach is to release the septum by excision of a small strip of ventral cartilage, which may
allow the septum to return to a midline position. An overhanging septal cartilage may also be
shortened by minimal resection (2 to 4 mm) of the caudal septum. With severe deformity,
extended cartilage removal may require cartilage grafting to avoid loss of nasal tip and dorsal
support. While conserving as much cartilage as possible, the surgeon needs to be wary of leaving
deformed cartilage in place, which can cause renewed obstruction. Deformed cartilage can be
crushed or scored to reduce the likelihood of memory in the cartilage, which can cause poor
results. After the cartilaginous structure is fixed, septal flaps are approximated with a horizontal
mattress (plicating) absorbable suture. If the field is not completely dry, an incision is made
along the ventral aspect of the mucoperichondrial flap, to provide a drainage site to avoid a
hematoma. Obviously, if the flap has any tears from the elevation, this step is unnecessary.
Silastic septal splints can aid in preventing synechiae, especially when septoplasty has been
combined with turbinate resection or endoscopic sinus surgery. The splints are held in place with
simple transseptal suture of 5-0 nylon. Splints are by no means, however, essential. The

hemitransfixation incision is closed with two mattress sutures of 4-0 chromic catgut. Nasal
packing is often used to prevent the postoperative septal hematoma.
Endoscopic Septoplasty
The advent of the nasal endoscope has widened the horizons of otolaryngology. Its value in
approaching the sinuses, skull base, orbit, and pterygopalatine fossa is unquestionable. Often
during common nasal procedures and during these special occasions, the surgeon's view is
obstructed with narrow access due to septal spurs or septal deviations. These occasions dictate a
localized removal of the spurs or the deviation. In these situations, the surgeon may prefer to use
the endoscope to assist in localized removal by making an incision just over the spur (Fig. 23.3).
The flap is then elevated above and below the spur and the spur is removed (Figs. 23.4 and 23.5).
Although the use of endoscope may limit the surgeon's ability to use both hands during surgery,
the advantages of good visualization and magnification surpass its limitation. This technique is
limited to localized areas of obstruction due to a spur. The incision usually does not need to be
closed.
Figure 23.3 Endoscopic septoplasty: incision is made over the septal spur under endoscopic
guidance.
Figure 23.4 Endoscopic septoplasty: mucoperichondrial flaps are elevated above and below the
septal spur.
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Revision Septoplasty
The most challenging septal surgery is the revision septoplasty, in which previous surgical
resection and scarring alters the surgical plane. In these situations, elevation of the
mucoperichondrial flaps is taxing and often results in perforation of the septal flaps.
Figure 23.5 Endoscopic septoplasty: the spur is resected and the flaps are approximated.
Meticulous dissection with a sharp knife and the careful separation of flaps are key in the
procedure. Once the flaps are separated, the deflected portion is addressed. Prior to the revision
surgery, the surgeon should discern the cause for the persistent deviation. Sometimes it is wise to
address the issue of nasal obstruction by performing an endoscope-assisted localized spur

removal, as mentioned previously. In cases in which there is persistence of caudal deflection

following previous septal surgery, an option may be to widen the area by orbital suspension of
the nasal valve (described later in the chapter), instead of elevating septal flaps in an area that is
already scarred by previous surgery.
When revision septoplasty is essential, the surgeon should first palpate the septum and outline
areas of absent cartilage. The flap elevation should begin in areas where cartilage or bone is
present. This may require the use of a nonstandard incision more posterior to the Killian incision.
Sometimes the incision may be made over the bony septum. Once flap elevation is
accomplished, the prior steps of repair are the same as standard septoplasty.
In combination with septoplasty, nasal fractures can also be reduced. It can be combined with
rhinoplasty, which serves as an external compliment. This can be performed either through the
intranasal or external route. Rhinoplasty is extensively discussed later in the textbook.
Results
The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF)
performed a nationwide study: Nasal Obstruction Septoplasty Effectiveness (NOSE) study. This
was a multicenter study performed in 14 sites, involving 16 investigators from July 2001 through
January 31, 2003. Fifty-nine patients underwent nasal surgery. Only 6% of patients reported that
they were not pleased by the procedure, and the rest were satisfied with the improvement. This
improvement was unchanged at 6 months. Patient satisfaction was very high, and patients used
significantly fewer nasal medications (2).
Complications
The major complications following septoplasty are tabulated in Table 23.4. Although
complications are rare, they can be very significant. Failure to correct the patients' symptoms is
not considered a complication, and this should be stressed to the patient. Hemorrhage and the
potential morbidity associated with control of the bleeding is probably the most common
complication. Anosmia is rare but is the most serious permanent complication. Loss of dorsal
support and subsequent saddle deformity is a serious cosmetic complication. Septal perforation is
always a risk and may cause significant morbidity. Every patient is at risk for all these and the
other listed complications.
TABLE 23.4 COMPLICATIONS SEPTOPLASTY

Failure to resect adequate cartilage or bone and hence persistent nasal obstruction

Hemorrhage

Septal hematoma/abscess

Synechia

Septal perforation

Anosmia

Excessive resection of dorsal strut can lead to saddle deformity

Cerebrospinal fluid fistulas may result from too much traction on the perpendicular plate
of ethmoid bone

Toxic shock syndrome is possible, particularly if packing is used

Rare incidences of aspiration pneumonitis have been reported

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Septal Perforation
Septal perforation usually results when there are bilateral opposing tears in the septal flaps.
Septal perforations can be asymptomatic; however, this condition often is associated with
crusting and bleeding around the defect and, if the perforation is small, whistling during
inspiration or expiration. The turbinate adjacent to the septal perforation can become
hypertrophic from an increase in the intensity of nasal turbulence. If the perforation is tolerable
and causes no serious detriment to nasal function, management is oriented toward alleviating the
symptoms of perforation. Antibiotic ointment can be used to control crusting and bleeding
around the perforation. A polymeric silicone button can be used to stop the whistling during

inspiration or expiration. These buttons can be shaped to the individual perforation and usually
are well tolerated.
Repair of septal perforation limited to defects less than 3 cm in diameter can be accomplished
with surgical flaps. With an intranasal approach, septal repair frequently necessitates sliding or
rotating mucoperichondrial or periosteal flaps across the defect. Fairbanks et al. (3) have
described an advancement flap for the repair. However, large perforations cannot be repaired
with advancement flaps.
The use of an inferior turbinate flap for septal perforation repair has been published by our group
(4). It essentially involves the freshening of the margins of the perforation (Fig. 23.6), followed
by the harvesting of an anterior-based turbinate flap under endoscope guidance. The inferior half
of the turbinate actually forms the donor tissue, and the flap includes mucosa, submucosa, and
variable amounts of bone depending on the size of the turbinate (Fig. 23.7). The distal portion of
the flap is opened to create mucosal surface on one side and submucosal surface on the other side
(Fig. 23.8). This flap is sutured to the freshened margins of the perforation (Fig. 23.9). The
contralateral side is left open for healing by secondary intention. Three weeks later, the pedicle is
taken down, and usually by 3 weeks the contralateral side is also reepithelialized (Fig. 23.10).
Figure 23.6 The septal perforation is rimmed using a no. 12 blade. (From Friedman M, Ibrahim
H, Ramakrishnan V. Inferior turbinate flap for repair of nasal septal perforation. Laryngoscope
2003;113:14251428, with permission.)
Additional procedures involve bilateral mucosal advancement flaps freed from adjacent septal
cartilage or bone, the nasal floor, and the lateral nasal wall. Surgical repair of large perforations
is difficult, often necessitating external rhinoplasty or lateral alotomy (incision along the alar
cartilage and maxillary crease) for sufficient access to the nasal area. Septal perforation due to
nose picking often is easy to close, because of the preservation of health adjacent cartilage,
whereas perforation due to overzealous resection of septal cartilage has a dismal
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repair prognosis. Similarly, perforations caused by cocaine use are difficult to repair. In these
cases, extensive sections of septal cartilage can be lost, owing to extensive vasoconstriction and
irritation of nasal mucosa by cocaine and substances with which it is diluted, such as talc or
strychnine.

Figure 23.7 The intended incision site. The anterior attachment of the turbinate is left intact.
(From Friedman M, Ibrahim H, Ramakrishnan V. Inferior turbinate flap for repair of nasal septal
perforation. Laryngoscope 2003;113:14251428, with permission.)
Figure 23.8 The turbinate flap is retracted anteriorly, and the free edge is unfolded to slightly
exceed the size of the perforation. (From Friedman M, Ibrahim H, Ramakrishnan V. Inferior
turbinate flap for repair of nasal septal perforation. Laryngoscope 2003;113:14251428, with
permission.)
Figure 23.9 The flap is sutured in place using plain 4-0 catgut. (From Friedman M, Ibrahim H,
Ramakrishnan V. Inferior turbinate flap for repair of nasal septal perforation. Laryngoscope
2003; 113:14251428, with permission.)
Septal Hematoma and Septal Abscess
Septal abscess can follow septal surgery if a septal hematoma is unnoticed during the initial
postoperative period. It should be understood that the septal cartilage is avascular and receives its
blood supply from the adherent mucoperichondrium. Other causes of septal abscess include blunt
trauma, bleeding diathesis, sports injury, and child abuse. Iatrogenic septal hematoma and
abscess following nasal septal surgery are probably more common than they are reported. Septal
hematoma is characterized by severe localized nasal pain, tenderness on palpation of the nasal
tip, and a cherrylike swelling or bluish discoloration of the nasal mucosa emanating from the
septum, which obstructs all or a portion of the nasal passage. Septal abscesses generally are
larger and more painful than uncomplicated septal hematoma. The overlying nasal mucosa is
inflamed and occasionally has inflammatory exudates. Local extension of the infection, if left
untreated into the cavernous sinus with subsequent intracranial infection is the most serious
potential complication. The most common complication of a septal abscess is cartilage necrosis
that results in nasal structural collapse and a saddle-nose deformity.
Technique
Most hematomas and abscesses can be adequately evacuated with topical anesthesia
supplemented by local infiltration. Confirm the presence of hematoma by compressing the area
with a cotton-tipped applicator. The bulge
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from the hematoma is compressible with the applicator. It should not shrink with the application
of a topical vasoconstrictor.
Figure 23.10 The site of pedicle transection (3 weeks after surgery) is denoted by the dotted line.
(From Friedman M, Ibrahim H, Ramakrishnan V. Inferior turbinate flap for repair of nasal septal
perforation. Laryngoscope 2003;113:14251428, with permission.)
As soon as the diagnosis is confirmed, the sutures should be removed and the hematoma should
be drained. The clot or the abscess is then evacuated with suction irrigation if needed. A bilateral
hematoma can usually be evacuated from one side by gentle pressure to the contralateral side. A
ventral incision along one side of the septal mucoperichondrium may help in drainage and may
prevent reaccumulation. A wick of 1/8-inch iodoform gauze is inserted through the incision. Care
should be taken to ensure that the wick is flat between the mucoperichondrium and the
cartilaginous septum. One should not pack the cavity with the wick. This will allow continuous
drainage. Apply bilateral nasal packs following the successful drainage of a septal hematoma.
Packing inhibits reaccumulation of the hematoma. Proper follow-up is vital to preventing any
infectious process or cosmetic deformity. All patients should be reevaluated within 24 hours and
again in 48 hours for removal of the nasal packs. These patients will require pain control and
broad-spectrum antibiotic coverage.
Turbinate Hypertrophy
Edematous turbinates, whether they are a primary or secondary cause of nasal obstruction, often
can be managed by medical or surgical means. Medical treatment targets hypertrophic turbinates
that are primarily mucosal in origin. Surgical treatment usually is reserved for structural (bony)
abnormalities, or if the mucosal hypertrophy is irreversible with local vasoconstriction. The
formation of bony abnormalities may be the long-term result of prolonged hypertrophy of
mucosal tissue or the result of traumatic injury to the septum with associated enlargement of the
nasal turbinates. Physiologic models of nasal airflow show 50% of inspired airflows along the
inferior turbinate or between the middle and inferior turbinates, that is, the middle airway (5).
Inferior turbinate hypertrophy that constricts the middle and inferior airways has a marked effect
on basal airflow.
Conditions that produce hypertrophy include infectious, allergic, and vasomotor rhinitis. Surgical
treatment ranges from lateral repositioning without resection (out fracture) to submucosal

resection, removal of redundant mucosa, or both. Inferior turbinectomy frequently is combined

with septoplasty to manage contralateral exacerbation of septal deviation. Although inferior
turbinectomy is indicated when mucosal hypertrophy is not responsive to medication, resection
should be conservative. Morbidity associated with radical inferior turbinate resection includes
hemorrhage, ozena, and atrophic rhinitis. The surgeon must weigh the extent of the proposed
resection against the nature of nasal obstruction; longer-lasting obstruction may necessitate more
extensive resection.
The goals of ideal turbinate reduction surgery are cited in Table 23.5. Unfortunately, there is no
single ideal procedure for all patients. Hence, the surgeon has to choose from the array of
surgical options that are available and has to select the best procedure to address the pathology in
a given patient. The current procedures that are most commonly used to treat bony hypertrophy
are (a) submucous resection of the inferior turbinate-classical technique and (b) submucous
microdebrider-assisted turbinate reduction. The most common procedure that is now used to treat
the mucosal hypertrophy is radiofrequency-assisted turbinate reduction. The other procedures
that are less commonly used or that were used in the past are (a) cryotherapy, (b) electrocautery,
and (c) laser ablation of the inferior turbinate.
Anesthesia
Most of these procedures can be performed on an outpatient basis unless they are combined with
other operative procedures, such as septoplasty, wherein they can be performed in the operating
room. In an outpatient setting, the patient is placed in the sitting position. The anterior
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nasal cavity is anesthetized with a topical local anesthetic with epinephrine, and then cotton
pledgets with the same solution are placed along the anterior and middle aspects of the inferior
turbinate. Transpalatal sphenopalatine ganglion blocks are then performed bilaterally with 1%
lidocaine within 1/100,000 epinephrine. After approximately 5 minutes, the anterior aspect of the
inferior turbinate is injected with 3 to 5 mL of 1% or 2% lidocaine with epinephrine. The
injection provides anesthesia and enlarges the diameter of the turbinate to prevent mucosal injury
if radiofrequency is used. It also assists in hydrodissection and elevation of the plane, in cases of
submucosal turbinate reduction.
TABLE 23.5 GOALS OF IDEAL TURBINATE REDUCTION

Mucosal preservation

Controlled reduction

Submucous scarring to reduce the erectile nature of the mucosa

Bony reduction when necessary

Minimal complications

Submucosal Turbinate Reduction: Classical Technique

Conservative submucous turbinate resection, also known as inferior turbinoplasty, has been
shown to yield at least 3 to 5 years of relief from mucosal and bony hypertrophy. However,
submucosal turbinate resection alone cannot be used to manage nasal obstruction, because of
chronic hypertrophy of the nasal mucosa. The physician must address the underlying cause of
mucosal hypertrophy to achieve good surgical success.
Submucous resection is performed when the inferior turbinate projects medially and obstructs the
nasal cavity or when hypertrophic turbinate mucosa remains unresponsive to vigorous medical
management. When performed as an isolated procedure, inferior turbinate resection proceeds
after vigorous anesthesia and vasoconstriction of the turbinate and lateral nasal wall. After a
posterior to anterior incision is made along the inferior aspect of the inferior turbinate (Fig.
23.11), the mucoperiosteum is elevated off the medial and lateral aspects of the turbinate bone.
The turbinate bone is fractured and reduced with Jansen-Middleson rongeur (Fig. 23.12),
Takahashi forceps, or turbinate scissors. We prefer the turbinate scissors. The superior and
inferior mucoperiosteal flaps are carefully preserved, redundant mucosa is trimmed from the
inferior mucoperiosteal flap, and the superior mucoperiosteal flap is placed laterally over the
resected inferior turbinate. The mucoperiosteal flap is gently packed in place for 24 to 48 hours
with antibiotic impregnated petrolatum gauze, to ensure proper adhesion and healing of the
mucoperiosteum to the resected turbinate bone. An alternative is to place horizontal (plicating)
mattress sutures through a minimally resected turbinate, to obviate uncomfortable nasal packing.
Figure 23.11 Limit incision to anterior two-thirds of turbinate bone.

Figure 23.12 Cottle elevator used to elevate mucoperiosteum from medial, lateral, and inferior
surfaces of turbinate.
Submucosal Microdebrider-Assisted Turbinate Reduction
Most of the techniques described involve treatment of submucous tissue with sacrifice of mucosa
for access to the target area. Techniques such as partial or total inferior turbinectomy,
cryosurgery, electrocautery, and laser destroy the mucosa, thereby interfering with nasal
physiology. Classic submucous resection of the inferior turbinates is a technique designed to
preserve the mucosa, but it is a misnomer because the resection includes some mucosa. The main
goal of this type of surgery should be the preservation of mucosal surfaces, with reduction of the
submucosal and bony tissue. Powered instrumentation used in a functional approach to inferior
turbinates offers advantages over traditional techniques with regard to complications and
mucosal preservation. In addition, resection with classical technique can often result in
overcorrection and possible atrophic rhinitis.
An incision is made with a no. 15 blade in a vertical manner, in the anterior aspect of the inferior
turbinate. A submucosal pocket is created with sharp dissection on the medial surface of the bony
turbinate. The straight microdebrider (4-mm tip with tricut blade) is applied through the incision.
Alternatively, a specially designed turbinate microdebrider blade is available from Medtronics
(Minneapolis, MN). It includes a knife for sharp elevation and a 3-mm blade for turbinate
reduction. The bony turbinate and some of the submucosal tissue is debrided at
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5,000-cps oscillating mode in a ventrocaudal manner. Debridement should be performed with the
blade positioned laterally from the submucosal plane. The 6,000-cps forward mode is used when
the bony turbinate is hard to debride. Particular attention should be paid to preserve the mucosal
flap. Hemostasis can be achieved under direct vision with suction electrocautery, when
necessary. The incision need not be closed. The reduction in size of the inferior turbinate is
usually recognized immediately after the procedure. This technique allows for incremental
controlled submucosal turbinate reduction. Light nasal packing is helpful for 24 hours, to avoid
postoperative bleeding. As in any procedure, the technique requires a learning curve, to know
how much of the tissue or the bone can be resected to achieve an effective airway, without
leading to complications such as atrophic rhinitis.

Results of Microdebrider-Assisted Turbinate Reduction

Studies conducted by the senior author indicate that out of 120 patients who underwent this
technique, 75% had complete resolution of their symptoms of nasal obstruction, and the rest had
some resolution of their symptoms (complained of minimal nasal obstruction postoperatively).
Synechiae occurred in 5% of the patients. None of the patients studied suffered crusting, foul
odor, or nasolacrimal duct injury complications (6).
Radiofrequency-Assisted Turbinate Reduction
The recent advance of radiofrequency energy has given further advantage for otolaryngologists
in the reduction of turbinate hypertrophy. Temperature-controlled radiofrequency delivers a
current of 460 kHz, by a high-frequency alternating current flow into the tissue, creating ionic
agitation. This ionic agitation heats the tissue, and as the temperature rises higher than 47C,
protein coagulation and tissue necrosis ensue. Collagen deposition begins approximately 12 days
after injury, and at 3 weeks, chronic inflammation, fibrosis, and tissue volume reduction from
scar contracture occur. This can be performed either by using unipolar or bipolar radiofrequency
probes that can be delivered to the anterior, and if required, to the middle aspects of the inferior
turbinate. Approximately 300 to 550 J of energy is delivered, and after the probe is removed, a
cotton pledget with oxymetazoline is placed along the anterior turbinate for hemostasis. Some
advocate a bipolar probe as better in terms of instant tissue reduction, but no study has clearly
shown that one technique is superior.
Results of Radiofrequency-Assisted Turbinate Reduction
The posttreatment findings after inferior turbinate radiofrequency include nasal swelling for 24
to 72 hours. Final reduction is complete in 3 to 4 weeks, and retreatment can be performed if
nasal obstruction persists. Bleeding, crusting, dryness, adhesions, and infection are rare
complications. The advantage of this procedure is that it is less time-consuming and more
efficient than other historical procedures for chronic mucosal hypertrophy, such as cryotherapy,
electrocautery, and laser ablation. It does not require nasal packing, which is an advantage over
submucosal microdebrider reduction.
Carbon dioxide laser vaporization of the turbinate had previously been accepted as a common
treatment for allergic rhinitis. Usually, only a single procedure is applied to minimize trauma.
However, repeated procedures on separate days are often required to achieve an adequate effect.
Holmium (Ho): Yttrium aluminum garnet (YAG) laser treatment is used in the turbinate

reduction and is efficacious, but has poor long-term efficacy (7). Potassium-titanyl-phosphate
(KTP/532) laser, a useful tool in endoscopic intranasal operations, has been investigated in
endoscopic inferior turbinate reduction and appears to be an alternative in the management of
turbinate hypertrophy. Although it achieves better results in controlling nasal obstruction, the
results are less promising in treating postnasal drip and rhinorrhea (8). Further, many of these
laser techniques ablate the mucosa, whereas ideally one would always want to preserve the
mucosa to preserve the mucociliary function.
Comparison of the effects of radiofrequency tissue ablation, CO 2 laser ablation, and partial
turbinectomy applications on nasal mucociliary functions was performed by Sapci et al. (9).
They found that at 12 weeks after surgery, the nasal mucociliary transport time was 25.60
minutes on the side where laser ablation was applied and 11.40 minutes on the side where partial
turbinectomy was applied. In the patients on whom radiofrequency tissue ablation and partial
turbinectomy were applied, the average nasal mucociliary transport time was 10.33 minutes on
the radiofrequency tissue ablation side, whereas it was 11.33 minutes on the partial turbinectomy
side. They concluded that radiofrequency tissue ablation to the turbinate is effective in improving
nasal obstruction objectively and in preserving nasal mucociliary function. Laser ablation of the
turbinate is effective in improving the nasal obstruction; however, it disturbs the mucociliary
function significantly. With the partial turbinectomy technique, results obtained were similar to
the results with the radiofrequency tissue ablation technique.
Ablative turbinate surgery, such as radiofrequency and laser ablation, is used only to reduce
obstructive hypertrophic nasal mucosa. Used alone, these procedures reduce nasal obstruction
due to mucosal hypertrophy but not anatomic deviation. After turbinate ablation, if the source of
nasal irritation and mucosal hypertrophy is not eliminated, such as removal of sources of dust or
mold allergy or alteration of diet to exclude suspected allergens, the physician should anticipate a
recurrence of mucosal hypertrophy.
Nasal Valve Obstruction
The nasal valve is the narrowest portion of the nose. When insufficient cartilaginous support is
present, negative
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(inspiratory) pressure within the nasal cavity can collapse soft tissue in this region. Nasal valve

collapse is a common cause of nasal airway obstruction. The valve area is commonly weakened
secondary to rhinoplasty, aging, trauma, and other causes. Fixed valve obstruction may be
secondary to trauma, scarring, previous rhinoplasty, or a narrow valve area secondary to
persistent caudal septal deviation.
TABLE 23.6 EMERGENCIES NASAL OBSTRUCTION
Diagnosis
Emergency
Complications
Septal
Elevation
of
mucosalSeptal cartilage necrosis, development of a
hematoma

perichondrium

with

cartilagesaddle-nose deformity

devascularization
Septal abscess Intracranial extension of infectionSeptal cartilage necrosis, development of a
saddle-nose

deformity,

cavernous

sinus

thrombosis, intracranial infection

Mucormycosis Tissue destruction
Extension to brain or orbit
Surgical reconstruction of an incompetent nasal valve can be undertaken with an open approach
that allows clear assessment of operative augmentations. The most successful operative
techniques include systematic alteration of all surrounding valve spreader cartilage grafts
(widening the apex if the internal valve); suture repair of the drooping upper lateral cartilage (a
frequent complication after dorsal hump excision in rhinoplasty), autogenous cartilage grafts, or
allografts as needed to support the columella; and spanning grafts or simple lateral crus onlay
grafts to support the lateral crura (10). Grafts can be composed of cartilage or conchal bone from
concurrent inferior turbinectomy. The bony or cartilaginous graft serves as both an inherent
structural support and a method for inducing site-specific scarring, which enhances the stiffness
of this region. The results of these techniques are quite variable and depend on the surgeon's
experience. The complications of open procedure range from hematoma to graft rejection (Table
23.6). Most of these complications are similar to open rhinoplasty. Please refer to the chapter on
rhinoplasty for avoidance and management of these complications.
The complexity of nasal valve repair techniques and its variable results, combined with the fact
that patients with valve obstruction have often had previous surgery or are of advanced age, are
some of the reasons that this problem often goes untreated. Paniello (11) published a preliminary
report on 12 patients in which a simplified technique for nasal valve repair was used that
involved suspension of the valve to the orbital rim.
The author (M.F.) modified his technique, which is simpler, safer, and equally effective. It is
based on the use of a soft tissue bone anchor system that provides a simplified support of the

valve area to the orbital rim, and the author has published data on 240 patients who have
undergone the revised procedure (12,13). The procedure can be performed under local anesthesia
(office-based), or with general anesthesia if combined with other surgical procedures.
Surgical Technique
The nasal valve area is examined prior to injection of local anesthesia to avoid distortion of
tissue. Two points representing the caudal and cephalad margins of the collapsed area are
marked. An incision is made through the mucosa connecting the two points (Fig. 23.13). A
natural skin crease along the orbital
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rim is marked (Fig. 23.14). We have used an external incision in almost every patient, with no
significant scarring. The incision is so small, and its placement within a natural skin crease
makes the external incision the recommended choice. Local anesthesia with epinephrine is then
injected into the valve area, along the maxilla, near the infraorbital nerve, along the orbital rim. A
3-mm incision is made in the medial aspect of the orbital rim. The skin incision is through skin
only, orbicularis oculi muscle fibers are pushed, and periosteum is incised and elevated. Rarely is
bleeding encountered, but if it is, bipolar cautery is used to control it. The periosteum is elevated
away from the orbital rim to expose a 3 3 mm area. The Mitek soft tissue anchor system (1.3
mm Micro Quick Anchor, Ethicon, Inc., Piscataway, NJ), which includes the drill bit, bone
anchor, and attached suture, is used to anchor a suture to the orbital rim. A small drill hole is
made into the bone (Cordless Driver 2, Stryker Corporation, Kalamazoo, MI) and the Mitek
anchor is then easily inserted into the bone (Fig. 23.15). The longer end of the suture is then
passed with a curved needle (Richard-Allan 1/2-inch, curved, tapered needle) to the nasal valve
area and passed through the cephalic point. It is important to place the hole medial and high at
the orbital rim where the bone is thick enough so that the anchor does not enter the sinus. The
needle pass should be as close to the maxillary bone as possible and not in the soft tissue of the
face. The incision that was made initially connecting the two points buries the suture. After
identifying the collapse site and the intended site of suspension, the needle is then rethreaded and
passed from the caudal point toward the anchor (Fig. 23.16). The suture is then tightened and tied
with the proper amount of tension to open the valve but to avoid significant distortion of the

external valve area (Figs. 23.17 and 23.18). Occasionally, two bone anchors and four points of
fixation are needed for adequate correction.
Figure 23.13 Intranasal incision connecting the two sides of suspension to allow for
subcutaneous/submucosal placement of suture. The incision was not closed. (From Friedman M,
Ibrahim H, Lee G, Joseph NJ. A simplified technique for airway correction at the nasal valve
area. Otolaryngol Head Neck Surg 2004;131:519524, with permission.)
Figure 23.14 Incision site: 3 mm placed in skin crease. (From Friedman M, Ibrahim I, Syed Z.
Nasal valve suspension: an improved, simplified technique for nasal valve collapse.
Laryngoscope 2003;113:381385, with permission.)
Figure 23.15 Medial to the intraorbital nerve and slightly below infraorbital rim, the anchor is
drilled. (From Friedman M, Ibrahim I, Syed Z. Nasal valve suspension: an improved, simplified
technique for nasal valve collapse. Laryngoscope 2003;113:381385, with permission.)
Complications
The most common complication following the procedure is the foreign body reaction to the
Mitek anchor system. Sometimes, abscesses can form over the incision site. This requires
aspiration of the abscess, which should be subjected to culture and sensitivity and treated with
the appropriate antibiotic. In other cases, granuloma formation has been known to occur. In 5%
of these patients, suture removal is required. Other, less common complications include
hematoma following injury to the angular vein during placement of the anchor into the maxillary
sinus (Table 23.6).
Results
Our experience with the orbital suspension technique was from 2001 to 2004. All patients had
minor changes in their external appearance that were either considered an improvement or
inconsequential. Nearly all patients (91.7%) had significantly improved airways in a short-term
study. The only complication reported was the foreign body reaction following the procedure that
eventually required removal. Long-term results are not available (13).
Choanal Atresia
Choanal atresia is a genetic disorder in which the posterior choanae unilaterally or bilaterally fail
to develop properly. It occurs in 1 in 5,000 births; choanal atresia is more
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common among girls (2:1), and unilateral atresia is more common than bilateral atresia. This
disorder can be transmitted as an autosomal recessive trait (14). Because newborns are obligate
nose breathers, bilateral atresia is immediately apparent as respiratory distress. An endotracheal
tube is inserted, and the infant is examined. Characteristics in the history that are found at failure
to pass a rubber catheter or nasogastric tube into the pharynx can provide enough information for
a diagnosis. Symptoms of choanal atresia include failure to thrive due to poor feeding and
mucoid discharge from the affected side. The presence of choanal atresia can be confirmed with
visualization of retention material in the posterior part of the nose on a lateral radiograph with
the patient in the supine position. Anatomic characterization of the deformity with CT scanning
can be important for planning surgical procedures.
Figure 23.16 After identifying the collapse site and the intended sites of the suture suspension,
the curved needle is passed through the incision and the subcutaneous tissue into the nose. (From
Friedman M, Ibrahim I, Syed Z. Nasal valve suspension: an improved, simplified technique for
nasal valve collapse. Laryngoscope 2003;113:381385, with permission.)
Figure 23.17 Prior to tying the suture, the nasal valve is shown in its collapsed position. (From
Friedman M, Ibrahim I, Syed Z. Nasal valve suspension: an improved, simplified technique for
nasal valve collapse. Laryngoscope 2003;113:381385, with permission).
Figure 23.18 The suspension suture after tying and prior to skin closure. (From Friedman M,
Ibrahim I, Syed Z. Nasal valve suspension: an improved, simplified technique for nasal valve
collapse. Laryngoscope 2003;113:381385, with permission.)
In the care of an infant, surgical methods for membranous atresia include puncture of the choanal
membrane and placement of a stent for 6 weeks. If the bony atresia is present, the bony wall can
be taken down transnasally with microsurgical or endoscopic techniques followed by placement
of a stent. When suboptimal resection for atresia of choanal stenosis occurs, transpalatal repair at
3 or 4 years of age is advised.
Unilateral atresia can go unrecognized until adulthood, at which time the patient seeks medical
attention because of possible septal deviation. The septum usually deviates to the affected side;
however, more posterior examination shows atresia. Computed tomographic scans of this region

provide enough information for the diagnosis. Transpalatal repair is being replaced by
endoscopic techniques of repair of atresia in children and adults (15).
Highlights

Nasal obstruction is one of the most common symptoms in otolaryngologic practice. In

the United States, medical expenditures to relieve nasal obstruction or congestion
approximate $5 billion annually.

It is crucial to recognize that nasal septal deformity is not the only cause for obstruction.
Systemic diseases, nasal valve obstruction, turbinate hypertrophy, polyps, and neoplasm
are other common causes.

In addition to the history, physical examination of the nose by means of direct and
endoscopic visualization discloses most cases of nasal obstruction and allows
confirmation through tests for common causes of nasal obstruction.

Computed tomography of the sinuses without contrast material is the most helpful
auxiliary examination for evaluating nasal obstruction.

There is no universally accepted functional test of nasal obstruction. Acoustic rhinometry

is promising in identification of inspiratory nasal valve collapse.

Septal hematoma and abscess are the two causes of nasal obstruction that necessitate
emergency management.

Septal correction offers effective symptomatic relief in cases of marked septal deviation.

Mucosal turbinate hypertrophy can be effectively managed by radiofrequency reduction;

bony or mixed turbinate hypertrophy can be reduced by microdebrider-assisted reduction.

Nasal valve collapse can be effectively treated with naso-orbital suspension, as well as
other techniques.

Bilateral choanal atresia is a medical emergency in infants and needs immediate

diagnosis and management.

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