Upper airway obstruction caused by a double-cuffed nasal balloon after extubation

This case report highlights a situation in which a double-cuffed nasal balloon tamponade device can cause an upper airway obstruction. An 89-year-old female required general anesthesia for an emergent embolization for right-sided epistaxis. The patient had no signs of upper airway obstruction when a double-cuffed nasal tamponade balloon was in place prior to general anesthesia. However, upper airway obstruction occurred immediately after extubation and was corrected by cuff deflation. The mechanisms of upper airway obstruction as a result of cuff dysfunction and management are discussed.     

Treatment of nasal obstruction from nasal valve collapse with alar batten grafts

Nasal obstruction may require treatment with rhinoplasty techniques. One cause of nasal obstruction is known as nasal valve collapse. This refers to narrowness and weakness at the nasal valve, the narrowest part of the nasal airway. There are a number of surgical approaches available to treat nasal valve collapse. Selection of the appropriate surgical intervention depends on proper identification of the anatomic cause of the collapse. Alar batten grafts are especially useful for addressing nasal valve collapse caused by a weak nasal sidewall. In this report, we review the senior author's experience with the use of alar batten grafts for nasal valve collapse. Twenty-one patients had septoplasty with placement of alar batten grafts; all patients noted improvement in their nasal breathing. Seven patients underwent ear cartilage harvest with alar batten grafts, and five of them noted improvement, one noted partial improvement, one noted no improvement. Six patients underwent revision septorhinoplasty with alar batten grafting, and ten patients underwent revision septorhinoplasty with ear cartilage harvest and alar batten grafting. These patients all reported improvement in their nasal breathing postoperatively. Six patients underwent revision rhinoplasty (no septoplasty) with ear cartilage and battens. These patients hold special interest because no other intranasal procedures were performed that affected nasal breathing. All six of these patients reported significant improvement of their nasal breathing and all patients were satisfied with their postsurgical cosmetic appearance. The nasal valve area is considered to be the location of the least cross-sectional area in the nose. When narrowing of the nasal valve is a result of collapse of the nasal sidewall, alar batten grafts are a useful technique to address the patient's nasal obstruction.     

Paradoxical nasal obstruction

Objectives: The majority of nasal surgery takes place with symptoms of unilateral or bilateral nasal obstruction. A large cohort of patients seen at the Nasal Airflow Laboratory at Prince of Wales Hospital (University of New South Wales) has been found to have normal physical examination, normal anterior rhinoscopy, normal nasendoscopy, and normal nasal airflow studies. This cohort has been considered to have the phenomenon of paradoxical nasal obstruction. The nasal cycle first described by Kayser in 1895 is the reciprocating cycle of congestion and decongestion alternating between the anterior nares, which is present in 80% to 100% of individuals having remarkably regular periodicity being affected by posture, exercise, and recumbency.Methods: This paper outlines their subsequent investigation by the use of extended symptom evaluation sheets, nasal airflow studies, and CT scans. The patients were randomized into 2 groups. Group A was treated with Alkalol (Taunton, MA) Nasal Spray and group B with low-dose self-administered capsaicin spray.Results: Of 1000 patients studied at the Nasal Airflow Laboratory, 27.5% were found to be complaining of significant symptoms of nasal obstruction with normal physical examination, anterior rhinoscopy, nasendoscopy, and airflow studies.Conclusions: The conclusions of the study were that paradoxical nasal obstruction occurs in about 25% of the population whose main symptom is nasal obstruction. Appropriate treatment for this subset is explanation of the physiology of their symptomatology and supramaximal stimulation of intranasal trigeminal nerve afferents.     

A maneuver to improve the nasal airway

The functional sequelae of rhinoplastic surgery are emphasized and the functional and anatomical causes of postoperative nasal obstruction are discussed. A maneuver to improve the airway and decrease the incidence of postoperative nasal obstruction is presented.     

Management of the nasal dorsum

Profile alignment, including nasal dorsal reduction, is one of the most common maneuvers in aesthetic rhinoplasty. Techniques often include cartilaginous excision and bony hump reduction with a chisel or a rasp. Cartilaginous nasal vault excision can result in separation of the junction between the upper lateral cartilages and the dorsal septum. This separation can cause an inferior-medial repositioning of the upper lateral cartilages and overall weakening of middle vault infrastructure. Furthermore, surgical interruption of this key region can also damage the internal nasal valve configuration and function and create static and dynamic airway obstruction. This article outlines the anatomy and function of the middle nasal vault and internal nasal valve. In addition, it provides an overview of aesthetic complications of dorsal hump removal including inverted-V deformity, saddle nose deformity, hourglass deformity, and their functional consequences. Preoperative individual risk factors for middle-third deformities are mentioned. Preventive and corrective surgical techniques including cartilage grafting and reconstructive sutures are also detailed.     

The assessment and treatment of nasal obstruction after rhinoplasty

Complaints of nasal obstruction after rhinoplasty and nasal surgery are disheartening for both the patient and the surgeon. When a patient presents with complaints of nasal obstruction after rhinoplasty and nasal surgery, the surgeon must reassess the history of symptoms and physical attributes contributing to nasal airway narrowing. The patient's expectations from surgery must also be discussed. The goal is total management of mucosal and anatomic contributors to nasal obstruction. This article describes various causes of nasal obstruction so as to provide rhinoplasty surgeons with the background needed to enhance their preoperative evaluations and avoid future surgical complications.     

Look and nasal ventilation

Ophthalmic manifestations of nasal obstruction can involve palpebral, orbital and ophthalmic disturbances. They can be the consequence of: directly with the nasal obstruction because the orbital cavity drains partly in the nasal fossae: rings, lipoptosis, blepharochalasis, fat protrusions, aggravation of exophthalmy in Grave's disease, enophthalmia. Oral breathing: there are modifications in the shape of the palpebral fissure ("round eye") by stretching of the facial mask and modifications of the orbital rims ("sad eye") due to lack of naso-sinusal expansion, often associated to malocclusion, there is a biomechanical correlation between the dental occlusion and the orbital area because of the presence of the maxillary sinus. Every occlusal disorder have an influence on projections of the supra and infraorbital rims.     

A nasal adhesion following prolonged nasotracheal intubation

A patient who presented with nasal obstruction 4 months after prolonged pernasal tracheal intubation is described. The cause of the obstruction was an adhesion which extended from the septum to the inferior turbinate. The evidence in support of long-term pernasal tracheal intubation is presented and the aetiology of this complication is discussed.     

Auricular composite grafting to repair nasal vestibular stenosis.

Nasal vestibular stenosis is defined as a narrowing of the nasal inlet resulting in airway obstruction. Causes include nasal trauma, infection, and iatrogenic insults. The objectives of this article are to illustrate nasal vestibular stenosis and to analyze common causes and surgical treatments. The operative technique of the senior author (M.S.K.), will be presented. Donor site morbidity and patient outcomes will be discussed. Sixteen patients were seen during a 5-year period. Eleven women and 5 men were evaluated and found to have nasal vestibular stenosis. Three patients had stenosis as a result of nasal fracture or laceration. Stenosis developed in the remaining 13 as a result of nasal surgery. All patients underwent auricular composite grafting, and grafts took in 100%. Partial skin slough occurred in up to 50%; however, re-epithelialization was seen within 3 weeks. Complications were seen at the donor site. Immediate patient satisfaction was seen and continues during long-term follow-up.     

Intranasal Z-plasty for internal nasal valve collapse

OBJECTIVE: To describe the technique of intranasal Z-plasty and early results for this minimally invasive method to repair internal nasal valve collapse. Intranasal Z-plasty has been well described for nasal valve stenosis and cleft nasal deformities but poorly described for idiopathic nasal valve collapse, the most common indication for nasal valve surgery. DESIGN: A retrospective medical record review was performed for 12 patients undergoing intranasal Z-plasty for nasal valve collapse. Medical records were evaluated for age, sex, indication for surgery, prior surgical procedures, complications, results, and length of follow-up. A visual analog scale was used to rate nasal obstruction preoperatively and postoperatively. RESULTS: A total of 8 men and 4 women underwent surgery, and the procedure was bilateral in 10 of the 12 patients, for a total of 22 nasal valves. Eleven patients noted subjective improvement in airflow on both sides, with the remaining patient noting improvement on one side and no change in the opposite side. Mean follow-up was 16.8 months (range, 5-32 months). The mean preoperative nasal obstruction score was 7.2, and the mean postoperative nasal obstruction score was 3.3 (on a scale of 0 to 10, with 10 being total obstruction). No complications were reported, and no patients complained about postoperative nasal appearance. CONCLUSION: Intranasal Z-plasty appears to be a safe, effective, and relatively noninvasive technique to repair internal nasal valve collapse.     

Relationships between nasal obstruction, observed apnea, and daytime sleepiness.

OBJECTIVE: We administered a questionnaire survey to a working population in an attempt to clarify the relationships between self-reported nasal obstruction, observed apnea during sleep, and daytime sleepiness. STUDY DESIGN: A total of 7980 daytime workers were asked to complete questionnaires about nasal obstruction, apnea during sleep, and daytime sleepiness. Of the 7702 responses, the data from 4818 subjects were analyzed. Nasal obstruction and observed apnea were graded into 3 categories. Daytime sleepiness was assessed by the Epworth Sleepiness Scale. RESULTS: Subjects with chronic nasal obstruction had 5.22 and 2.17 times higher odds for having habitual observed apnea and excessive daytime sleepiness (EDS), respectively, compared with those without nasal obstruction (P < 0.001). After adjusting for 3 potential confounding factors (age, sex, and body mass index) and the presence of habitual observed apnea, odds ratios for having EDS decreased, but still remained significant. CONCLUSION: Nasal obstruction is likely to cause daytime sleepiness, at least in part, by causing sleep-disordered breathing including apnea during sleep.     

The use of porous polyethylene implants to correct nasal valve collapse.

OBJECTIVE: To evaluate the long-term outcome of correction of nasal valve collapse with a porous polyethylene implant. STUDY DESIGN AND SETTING: Retrospective review from November 1999 to December 2005. Nasal valve collapse was corrected with a porous polyethylene implant in 12 adults. Main outcome measures included relief of nasal obstruction and complications. Independent variables included other causes of nasal obstruction and need for revision surgery. Simple statistical analysis was performed. RESULTS: Median follow-up was 5.6 years (58 months). 75% had complete resolution of nasal obstruction. 100% had complete resolution of nasal obstruction at 6 months and had coexisting causes of nasal obstruction. The implant extrusion rate was 21%. 42% went on to have revision surgery. CONCLUSION: Correction of nasal valve collapse with a porous polyethylene implant provided good long-term symptomatic relief of nasal obstruction, but with significant incidence of infection, implant extrusion, and need for revision surgery. The use of this implant should be reserved for cases in which autogenous graft material is not available.     

Craniopharyngioma invading the nasal and paranasal spaces, and presenting as nasal obstruction

A case of craniopharyngioma invading the nasal and paranasal sinuses and presenting as nasal obstruction is reported. Imaging showed a destructive mass of the skull base with involvement of the nose and paranasal sinuses. In the excised mass mitoses were frequent and the proliferation index was high. Invasion of the nasopharynx and presentation as a nasopharyngeal mass is uncommon for a craniopharyngioma.     

The physiologic treatment of nasal obstruction.

Although criticisms of the submucous resection of the nasal septum and turbinectomy have been given, this is not to discredit these procedures when they are truly indicated. Certainly there are anatomic deformities causing nasal obstruction wherein a submucous resection of the septum or a submucous resection of the anterior portion of the inferior turbinate would be of benefit. The surgeon performing rhinoplastic surgery must be aware of the physiologic causes of nasal obstruction. Often a combination of structural deformity and rhinitis is blocking the airway. Intranasal, intramucosal injections of long acting corticosteroids have proven to be of great benefit in the treatment of chronic allergic, vasomotor, and hypertrophic rhinitis, and they are a useful adjunct to rhinoplastic surgery.     

Effect of nasal surgery on the nasal cavity as determined by acoustic rhinometry.

Acoustic rhinometry (AR) was used to objectively measure the success of septoplasty in relieving nasal obstruction caused by septal deviation. In addition, the patients were given a questionnaire to subjectively assess symptoms of congestion, rhinorrhea, and sneezing. Patients diagnosed with a septal deviation requiring surgery to eliminate obstruction were enrolled in this study. A septal deviation often results in concomitant sinonasal or respiratory problems that require septoplasty plus other surgeries to treat the patient effectively. AR measurements for patients who underwent septoplasty or septoplasty plus other surgeries were taken before and after surgery. To avoid confounding results caused by different levels of congestion, we used only postdecongestant values to analyze the data and only the side of the nose with the smaller volume for analysis. Patients in the septoplasty-only group showed a statistically significant (P < 0.01) increase in volume as measured by AR, a decrease in the symptom of congestion, and a decrease in the symptom of rhinorrhea. Patients who had septoplasty plus other sinonasal procedures showed significant increases in volume and cross-sectional area (CSA) 3, whereas CSAs 1 and 2 increased also, but not significantly.     

Functional rhinoplasty: treatment of the dysfunctional nasal sidewall

Treatment of nasal obstruction caused by nasal valve dysfunction requires a thorough evaluation of the mechanics of normal nasal anatomy and function. Surgical correction of nasal valve dysfunction is based on determining the epicenter of dysfunction, whether it is a static obstruction of the internal nasal valve or a dynamic collapse of either the external nasal valve or the intervalve area. Spreader grafts, flaring sutures, and butterfly grafts are used to widen and support the narrow internal nasal valve. Alar batten grafts will add support to the collapsing nasal sidewall seen in external nasal valve and intervalve dysfunction. Correction of dynamic collapse from paradoxical concavity of the lateral crura may be obtained from the lateral crural flip-flop graft or by reconstructing the lateral crura using cartilage grafts. A strut graft may correct dynamic obstruction caused by a malformed, easily collapsible lateral crura. This article discusses the evaluation, treatment, and correction of the dysfunctional nasal sidewall and emphasizes the avoidance of iatrogenic damage to the sidewall while performing cosmetic rhinoplasty.     

Pseudonasolacrimal duct obstruction caused by nasal allergy

While mechanical obstruction of the nasolacrimal duct is the most common cause of acquired unilateral epiphora, it is not the only one. Of the 94 patients evaluated with this symptom, 22 cases (23%) were caused by primary nasal changes in the form of nasal allergy. Many of the characteristic findings of mechanical obstruction were present. Several patients had previous nasolacrimal duct surgery, which failed to eliminate the epiphora. Nasal allergy was not initially considered either by previous examiners or the patients themselves, because of the absence of typical allergic symptoms. All of these patients, however, obtained relief from their unilateral tearing with treatment directed toward the nasal pathology only. Oral sympathomimetics and antihistamines were the most effective. Two patients improved with primary nasal surgery.     

Triple-procedure technique in internal nasal valve surgery

In cases of narrowing of the internal nasal valve angle, we address all structures that commonly contribute to the internal valve area obstruction. We term this the “triple-procedure technique”. The aim of this study was to assess the efficacy of this technique in improving patients' subjective nasal patency. A prospective longitudinal case study was conducted in a tertiary hospital in northeast of England. All consecutive patients who complained of nasal obstruction and were diagnosed with the internal nasal valve angle narrowing due to septal deviation were offered to have a triple-procedure operation (septoplasty, turbinate surgery and internal nasal valve surgery). Patients completed a validated nose-related questionnaire (Nasal Obstruction Symptom Evaluation (NOSE)) preoperatively, which was repeated 3?months after the operation. The change in NOSE score was the outcome measure. Eight of the nine patients recruited to the study completed the questionnaires (88% response rate). The total and the domain scores improved after the operation, which were clinically and statistically significant. The effect size proved to be very large (total NOSE score effect size, 4.0). Our study shows that addressing all three structures commonly affecting the internal valve area is an effective technique in improving the obstruction caused by the narrow internal nasal valve angle.     

Rhinomanometry for preoperative and postoperative assessment of nasal obstruction

In this retrospective study we used active, anterior mask rhinomanometric methods to measure nasal resistance before and after surgery for nasal obstruction. The study group comprised 60 patients with nasal obstruction who had 63 preoperative and postoperative rhinomanograms and the control group contained 14 asymptomatic patients who underwent rhinomanometric studies before transnasal, transsphenoidal pituitary surgery. Before surgery the study group had significantly higher total and combined unilateral nasal resistances than either the control group before surgery (p less than 0.05 and p less than 0.01, respectively) or the study group after surgery (p less than 0.0001 for both comparisons). Surgery normalized the nasal resistances of the study group in relation to the control group. A total nasal resistance greater than 1 cm H2O/L/sec or a unilateral resistance greater than 3.5 cm H2O/L/sec suggests clinically significant nasal obstruction. Airway narrowing and obstructive symptoms correlated with airway resistance in the preoperative patient, but symptoms did not correlate well with postoperative resistance.     

Congenital nasal pyriform aperture stenosis: a rare cause of neonatal nasal obstruction

Congenital nasal pyriform aperture stenosis has been described as an unusual cause of neonatal nasal obstruction. Clinical suspicion is based on respiratory distress, cyclic cyanosis, apneas, and feeding difficulties. A bony overgrowth of the maxillary nasal processes is thought to be responsible for this deformity. This anomaly has been reported as an isolated feature or can be associated with craniofacial or central nervous system anomalies. Surgery is indicated in cases of severe respiratory distress, feeding difficulties, and when conservative methods fail.