In our practice, rhinoplasty is most commonly sought for improvement of nasal appearance, known as a “cosmetic rhinoplasty”. But, for many patients, a problem with breathing through the nose also exists. In fact, some patients have complaints about both appearance and breathing, and these two issues can certainly be related in terms of cause and treatment. If you would like to know about surgery to improve your breathing, known as “functional rhinoplasty”, then an understanding of the causes and treatments of nasal obstruction will be very helpful. This article will explain these points, and help you determine if surgery may be your best option.
Anatomy of Nasal Breathing. Your nose is not a big, empty chamber. Actually, the inside of your nose is quite crowded. As air moves through your nose, it encounters many structures that increase the surface area the air touches, and increase resistance. This way, the air flow is slowed, and the air is warmed and humidified before it enters the larger airway of your throat. For some people, though, the resistance ends up being too great, and they have decreased or blocked breathing through one or both nostrils.
The major structures inside your nose include the septum and the turbinates. These are highlighted below in figure 1, which represents a cross section of the inner nose (as if the soft tissues and skin of the nose were removed).
Figure 1. Cross section diagram of the inner nose, oriented as if you were looking at the patient. The air passages, shaded black, are actually relatively small in total area.
The most striking feature of figure 1 is that the total area of the nasal airways, shaded in black, is actually small compared to the overall size of the inner nose. This is due to the “turbinates” – three long, horizontal bones on each side of the nose, that protrude into the nasal air passages. They are referred to by their positions: inferior, middle, and superior. The other important structure, the septum, is a sheet of cartilage and bone that separates the right and left sides of the nose.
Collectively, the inner structures of the nose, along with the side walls, create two valves through which air must pass. The valves can actually close to partially or totally block air flow. They are displayed in figure 2, and understanding the location of these valves will help you understand how air can be blocked.
Figure 2. The regions of the external and internal valves are highlighted.
The first, called the “external” valve, is the air passage just inside the soft side wall of the nostril. The second is the “internal” valve, and represents the air space bordered laterally by the upper side wall of the nose.
Causes of Nasal Obstruction. When any of the nasal structures is too large, or has an abnormal shape, obstruction to airflow can result. This is called “anatomic” obstruction, and is quite common considering how small the airway is to begin with. Some patients simply develop anatomic obstruction as they grow, and others acquire it as a result of trauma. The septum may be crooked and extend into one air passage, blocking breathing on that side. Or, a turbinate bone may be simply too big, and obstruct breathing. This is most common with the inferior turbinate. These causes usually cause constant obstruction, since the anatomy of the nose does not change from day to day.
In other cases, the parts of the nose may be of a correct shape and size, but their orientation to each other can be abnormal. This would cause problems with the two nasal valves, and is referred to as “functional” obstruction. For example, if a nostril is too narrow, and the side wall of the nostril is weak, it can collapse in against the septum whenever a person breathes with force. This is called “external valve collapse”, and is shown in figure 3.
Figure 3. On the left, a patient is not breathing, and both nostrils are open. On the right, she is breathing with force and her left nostril wall is collapsing into the septum. This is referred to as “external valve collapse”.
A similar phenomenon can occur at the internal valve. If the upper wall of the nose forms a tight angle with the septum at the bridge of the nose, then the wall can collapse into the septum here. This is known as “internal valve collapse”.
As mentioned above, there is often a relationship between cosmetic and functional complaints. Some patients with very long and narrow noses might be bothered by this appearance, and are also more likely to have internal valve collapse and nasal obstruction. Other patients have a deviated septum at the bottom of the nose, so one nostril is much smaller. This cosmetic concern is related to obstructed breathing, as it can cause external valve collapse.
Both anatomic and functional obstruction are treatable with surgery. So, it is important to differentiate these from other causes of nasal obstruction, which are usually not treated with surgery. These would include environmental allergies, medication related swelling of the inner nose, upper respiratory infections, and acute sinusitis.
Surgical Treatments for nasal obstruction. Many surgical procedures are available to correct nasal breathing, and each addresses a specific anatomic structure. If the septum is deviated, it can be straightened with a “septoplasty”. This may involve removing the deviated portion, or releasing the bottom of the septum so it can be moved to the middle. If the turbinates are large, they can be addressed with a “turbinate reduction”. This procedure can be done many ways, but usually involves reducing the size of the turbinate bone, or of the pink soft tissue that covers this bone.
For functional causes, the procedures are more complicated but certainly effective. The goal of external valve collapse correction is the prevention of movement of the nostril wall. This wall can be strengthened during a rhinoplasty by placing a firm piece of cartilage (a “graft”) inside it. Or, if the lower septum is deviated, it can be straightened to prevent external valve collapse. The treatments for internal valve collapse are the most complicated, and often require an open rhinoplasty. In these cases, the side wall of the upper nose must be pushed away from the septum, so the angle that they form is increased. This is done by firmly placing a long cartilage graft between the wall and the septum, to spread them apart. This procedure is therefore called a “spreader graft” rhinoplasty.
Functional Rhinoplasty at the Aesthetic Facial Plastic Surgery Medical Clinic. We often correct breathing problems at our clinic, but this is usually done in conjunction with a cosmetic nasal surgery. This makes sense, because functional and aesthetic concerns are often related. During our nasal consultations, we always examine the airway function along with the appearance of the nose. This gives our patients the best chance to optimize appearance and airway function.
If you have difficulty breathing through your nose, we welcome you to come to our clinic and talk with Dr. Hicks or Dr. Kabaker. By using a facial plastic surgeon to evaluate and treat you nose, you will be assured that you are working with an expert who is well trained to give you the best possible care.
