Understanding the nasal airway: principles and practice

Anatomy and Physiology of the Nasal Valves

The nasal valves are not simple, 2-dimensional cross-sections but rather a complex, 3-dimensional, collapsible, and heterogeneous structure. Historically, the internal nasal valve (INV) is defined by the septum medially, the caudal margin of the upper lateral cartilage laterally, and the inferior turbinate inferiorly. Typically located 1.3 cm deep into the nasal cavity, the INV angle delineated by the upper lateral cartilage and septum typically measures 10° to 15° in the Caucasian population. As computational methods reveal new insights into nasal valve function, a new conceptual framework is needed to guide rhinoplasty surgical decision-making.

Management of Nasal Valve Dysfunction

Nasal valve dysfunction can substantially impact nasal airflow and overall quality of life. This review provides a comprehensive examination of nasal valve dysfunction, including its mechanisms, classification, and surgical management. The nasal valves include internal and external valves, each of which plays a crucial role in regulating nasal airflow. Subclassification of the external nasal valve into alar and rim valves helps specify the site of obstruction when present and informs the choice of surgical intervention. Dynamic nasal valve obstruction, often characterized by inspiratory collapse of the nasal valve, must be distinguished from static obstruction, which refers to nasal valve stenosis. Accurate identification of the location and mechanism of nasal valve dysfunction is essential for effective management. Various surgical procedures target specific components of the nasal valve and can produce favorable functional outcomes. The selection of surgical procedures, whether individually or in combination, should be tailored to the characteristics of nasal valve dysfunction and the external nasal characteristics of the patient. Strict adherence to proper surgical techniques is imperative for achieving optimal treatment outcomes.

Management of Lateral Wall Insufficiency

Lateral wall insufficiency is a commonly encountered etiology of nasal obstruction, resulting from dynamic collapse at the level of the internal or external nasal valve. Various management strategies exist to strengthen the lateral wall or stent the nasal valves to relieve nasal obstruction, and range from noninvasive devices, minimally invasive implants, or surgical reconstructive techniques. Surgical options to address the nasal valves are selected based on each patient's anatomic findings, aesthetic and functional goals, and surgeon preference. This article describes the anatomy and physiology of the nasal sidewall and nasal valves and diagnosis of lateral wall insufficiency, and provides a framework for treatment options.

Gender Considerations in Rhinoplasty

SUMMARY

Precise nasofacial analysis ahead of rhinoplasty is imperative. Features common to the White masculine nose are reviewed in a stepwise fashion and contrasted with those of the White feminine nose. A solid understanding of the cisgender male, masculine nose enables the plastic surgeon to determine the changes required for a successful facial feminizing rhinoplasty as a part of facial gender confirmation surgery.

A Longitudinal Study of Improvement in Nasal Airway Obstruction after Secondary Cleft Rhinoplasty

BACKGROUND

Nasal airway obstruction is an increasingly recognized phenomenon in patients with cleft lip and/or palate and has the potential to significantly affect quality of life in this patient population. To date, the effect of secondary cleft rhinoplasty on cleft-related nasal airway obstruction has not been studied.

METHODS

Patients undergoing secondary cleft rhinoplasty at the Children's Hospital of Philadelphia from 2015 to 2021 were identified. Preoperative and postoperative Nasal Obstruction Symptom Evaluation scores were recorded. Alterations in scores were evaluated for variation depending on patient characteristics, operative maneuvers, and postoperative nasal stenting.

RESULTS

Nasal airway obstruction was present in mild to moderate severity in patients before secondary cleft rhinoplasty. Postoperatively, obstruction improved or resolved in the domains of nasal blockage/obstruction, trouble breathing through the nose, and ability to get enough air through the nose during exertion (P < 0.05). Overall composite Nasal Obstruction Symptom Evaluation scores improved (P < 0.05). Lateral crural strut grafting was associated with improvement in nasal blockage, whereas alar revision and tip sutures were associated with worsening in specific nasal symptoms. Patients who underwent nasal stenting were found to report less trouble breathing after surgery than patients who did not (P < 0.05).

CONCLUSIONS

Nasal airway obstruction is present in mild to moderate severity in patients with cleft lip and/or palate, and the subjective severity of obstruction is decreased by secondary cleft rhinoplasty. Specific operative maneuvers are associated with alterations in nasal airway obstructive symptoms, and nasal stenting is associated with an improvement in trouble breathing after secondary cleft rhinoplasty.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

One-Stage Repair of Alveolar Cleft and Nasal Deformities Using Grafts From Nasal Septum: Application of Vomer, Ethmoid, and Septal Cartilage

BACKGROUND

Patients with alveolar cleft unrepaired suffer from nasal deformities of different magnitude. Bone and cartilage grafts are harvested through several incisions. In this study, we present a method to simultaneously correct nasal deformities and repair alveolar cleft using grafts from the nasal septum.

PATIENTS AND METHODS

All 6 patients with unilateral cleft lip and palate have alveolar cleft unrepaired combined with nasal deformity. Computed tomography scans and 3-dimensional-printed models of vomer and ethmoid bone were used for the purpose of preoperative design and for assessing the magnitude of deformity. Grafts of bone and cartilage from deviated septum were harvested by septoplasty through which dorsum deviation was corrected. Bone grafts from vomer and ethmoid were then fixed to the prepared alveolar cleft to repair the defect and elevate the alar base. Septal cartilage was adjusted into different shapes of grafts and deformities of nasal tip, nostrils, and columella were then corrected by rhinoplasty to restore the symmetry of the nose.

RESULTS

Symmetry of nostrils was improved. The height of alar base on the cleft side was elevated to the level close to the noncleft side. Deviation of the septum, nasal dorsum, and columella was corrected. Projection of the nasal tip was adjusted to facial midline. Midface aesthetics was generally improved.

CONCLUSION

Application of septal grafts reduce the number of incisions. One-stage repair of alveolar cleft and nasal deformities, with the aid of digital design, improves the postoperative experience and the general outcome of the surgery.

Outcomes of Closed versus Open Rhinoplasty: A Systematic Review

Open and closed rhinoplasty are two main approaches to perform nasal modifications. According to current literature, there is no current consensus among plastic surgeons and otolaryngologists on which technique is preferred in terms of aesthetic result, complications, and patient satisfaction. This study uses published research to determine whether open or closed rhinoplasty leads to superior patient outcomes. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for systematic reviews were followed and a literature search was conducted in four databases based on our search strategy. Articles were then imported into COVIDENCE where they underwent primary screening and full-text review. Twenty articles were selected in this study after 243 articles were screened. There were 4 case series, 12 retrospective cohort studies, 1 prospective cohort study, 1 case–control, and 2 outcomes research. There were three cosmetic studies, eight functional studies, and nine studies that included both cosmetic and functional components. Sixteen studies utilized both open and closed rhinoplasty and four utilized open rhinoplasty. Both techniques demonstrated high patient and provider satisfaction and no advantage was found between techniques. Based on available studies, we cannot conclude if there is a preference between open or closed rhinoplasty in terms of which technique leads to better patient outcomes. Several studies determined that open rhinoplasty and closed rhinoplasty leads to comparative patient satisfaction. To make outcome reporting more reliable and uniform among studies, authors should look to utilize the Nasal Obstruction and Septoplasty Effectiveness scale and the Rhinoplasty Outcome Evaluation.

Functional Nasal Surgery

LEARNING OBJECTIVES

After studying this article, the participant should be able to: (1) understand the functional significance of nasal anatomy as it relates to rhinoplasty and perform a comprehensive functional nasal assessment. (2) Identify the anatomical level of obstruction based on the authors' algorithmic approach and understand the current evidence supporting operative techniques for correcting nasal airway obstruction from septal deformity, inferior turbinate hypertrophy, internal nasal valve collapse, external nasal valve collapse. (3) Understand the current evidence supporting operative techniques for correcting nasal airway obstruction from septal deformity, inferior turbinate hypertrophy, internal nasal valve collapse, and external nasal valve collapse. (4) Appreciate the objective assessment tools for functional nasal surgery from a clinical and research perspective.

SUMMARY

The intent of functional rhinoplasty is to improve nasal airflow (and the perception thereof) by surgically correcting the anatomical sources of obstruction in the nasal airway. Cosmetic and functional rhinoplasty are not mutually exclusive entities, and the techniques that address one area, inevitably may affect the another. The rate of functional problems after cosmetic rhinoplasty range from 15 to 68 percent with nasal airway obstruction found to be the most common indication for secondary surgery. The objective of this CME article is to provide readers with an understanding of the (1) functional components of nasal anatomy, (2) clinical functional assessment, and (3) the current evidence supporting corrective maneuvers for each component.

Preoperative Evaluation of the Rhinoplasty Patient

Requiring both high-level technical skills and artistic sense, rhinoplasty continues to be one of the most challenging procedures in plastic surgery despite its popularity. A thorough preoperative consultation of the rhinoplasty patient forms the foundation of a successful case. During the consultation, the physician should obtain a detailed medical and nasal history, understand the patient's areas of concern, conduct a nasal analysis, and evaluate the patient's candidacy for surgery. This article reviews the key functional, esthetic, and psychosocial considerations that should be taken into account during a preoperative consultation for a rhinoplasty patient.

Septal Reconstruction with Folded Porous Polythylene Implants: An Alternative Technique for the Correction of Severe Saddle Nose Deformities in Asian Populations

BACKGROUND

Congenital or secondary deficiency in septal cartilage leads to an unpleasant cosmetic appearance and compromised function as well. Rhinoplasty maneuvers such as spreader graft and septal extension graft with autologous tissue have been exhibited to correct the deformities. However, the relatively severe donor site morbidity stands as a main concern for both surgeons and patients.

METHODS

From January of 2014 to April of 2018, 52 patients presenting septal deformities underwent rhinoplasty with our modified technique. A piece of Medpor (8438) was tailored, folded and then placed as a combination of spreader and septal extension graft. The surgical outcomes were evaluated both objectively and subjectively.

RESULTS

All the patients were followed up for 12 to 24 months postoperatively. The ratio of tip projection and the nasal length exhibited significant improvement in all our patients. Nasal obstruction subjectively mended among the 24 patients who had airway obstruction complaint preoperatively. Only 2 patients had severe adverse events and the implants were removed instantly.

CONCLUSIONS

With our modified technique, Medpor proved to be an effective and reliable material for the reconstruction of septal cartilage, which provides us an alternative way to achieve extended spreader and septal extension graft with one single implant in the correction of saddle nose.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Deviated nose: Physiological and pathological changes of the nasal cavity

Deviated nose is highly challenging in rhinoplasty since the surgeon should consider both aesthetic and functional aspects of the nose. Deviated nose correction is surgically complex, and a thorough understanding of the mechanical and physiological changes of intranasal structures, including the septum and turbinates, is necessary for functional improvement.

The Role of the Depressor Nasi Septi Muscle in Nasal Air Flow

Background

Musculus depressor septi nasi and its tendon, the dermocartilaginous ligament, play an important role in external nasal valve and nasal respiration. If the ligament is cut during septorhinoplasty operations, nasal functions of the nose and facial expressions are affected. Therefore, the aim of this study was to investigate the role of M. depressor septi nasi in nasal respiration at open rhinoplasty operations using rhinomanometry and electromyography.

Methods

The study included 29 patients who had only external nasal deformity (nasal hump deformity). All patients underwent open rhinoplasty. The dermocartilaginous ligament of the patients in the study group (DCL + group) was repaired but not in the control group (DCL − group). Rhinomanometry and electromyography were applied to all patients preoperatively and postoperatively.

Results

In the DCL − group, right and left nasal airflow values were significantly lower in post-op (562.92 cm³/s and 548.57 cm³/s), whereas right, left, and total nasal resistances were significantly lower in pre-op (0.28 Pa/cm³/s, 0.22 Pa/cm³/s, and 0.11 Pa/cm³/s). Statistically significant differences were not found between rhinomanometric measurements in pre-op and post-op values of the DCL + group. Post-op right, left and mean values of M. depressor septi nasi amplitude in the DCL + group (2.05 mV, 2.0 mV, 2.02 mV) were significantly higher than those in the DCL − group (1.52 mV, 1.61 mV, 1.57 mV).

Conclusion

Repair of the dermocartilaginous ligament during open rhinoplasty operations enhances nasal respiratory functions by expanding the external nasal valve through M. depressor septi nasi and allows the nose to participate in mimic movements.

Level of Evidence IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Electronic supplementary material

The online version of this article (10.1007/s00266-020-01693-3) contains supplementary material, which is available to authorized users.

Nasal Obstruction and Rhinoplasty: A Focused Literature Review

BACKGROUND

There is a significant variation in the assessment, treatment, and outcomes of nasal airway obstruction and management in the published literature. This study aimed to: (1) define key components of the nasal airway, (2) identify frequent causes of nasal obstruction, and (3) review existing treatment methods.

METHODS

A systematic review of the literature was performed, and 135 studies were included via the following criteria: English, human subjects, and a primary endpoint of nasal airway improvement. Exclusion criteria were: abstract only, no airway data, pediatric patients, cleft rhinoplasty, sleep apnea, isolated traumatic nasal reconstruction, and cadaveric-only or animal studies.

RESULTS

The relevant obstructive sites include the ENV, septum, inferior turbinates, INV, and nasal bones. Addressing the alar rim alone may be insufficient, and inspection of the lateral wall and crura may be indicated. Correction of septal deviation involves attention to the bony base. Mucosal sparing treatment of inferior turbinates improves outcomes. INVs are a major source of nasal obstruction, and treatment includes spreader grafts. The bony nasal vault can contribute to nasal obstruction, including due to surgical osteotomies.

CONCLUSIONS

Anatomic causes of airway obstruction include the alar rims and lateral nasal walls, deviated nasal septum, inferior turbinate hypertrophy, decreased INV angle, and narrowed nasal bones. Treatments include graft placement; septoplasty; mucosal sparing turbinectomy; and lateral wall support. Pitfalls include failing to address the bony septum, over-resection of inferior turbinates, and narrowing of the nasal vault. Appreciation of airway management during rhinoplasty will improve functional outcomes.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Decision-Making in Middle Vault Reconstruction following Dorsal Hump Reduction in Primary Rhinoplasty

BACKGROUND

Dorsal hump reduction during open rhinoplasty disrupts the continuity between the upper lateral cartilages and the dorsal septum. Options to reconstitute the midvault include primary closure of the upper lateral cartilages to the dorsal aspect of the septum, placement of spreader grafts, and creation of spreader flaps. The authors sought to clarify from highly experienced rhinoplasty surgeons their decision-making rationale for midvault reconstruction, distilling down the group consensus into algorithmic guidelines.

METHODS

A panel of internationally recognized rhinoplasty surgeons participated in a two-part organized communication method. An introductory summit consisted of open discussions on various topics in midvault reconstruction. The summit transcription was analyzed by thematic content analysis to develop a survey encompassing clinical scenarios for primary rhinoplasty, which was then individually administered to each panelist. Data gathered from both parts were used to generate technical guidelines and a decision-making algorithm.

RESULTS

The panelists identified the following anatomical features as pertinent to their selection of midvault reconstruction method: size of the dorsal hump reduction, width of the midvault relative to the upper vault, presence of dorsal angulation, and presence of nasal obstructive symptoms. Individual panelist preference was gathered from the 24-scenario survey divided into either cosmetic or functional rhinoplasty cases.

CONCLUSIONS

Management of the midvault after dorsal hump reduction is important to establish proper aesthetic relationships and to provide functional integrity of the internal valve. Our authors present an algorithmic approach to decision-making based on the systematic analysis practiced by senior rhinoplasty surgeons.

Use of anatomically-accurate 3-dimensional nasal airway models of adult human subjects in a novel methodology to identify and evaluate the internal nasal valve

The optimal method for radiographic evaluation of the internal nasal valve (INV) has not been established. The objective of this study was to develop a method to assess the cross-sectional area and the angle of the INV using anatomically-accurate 3D digital nasal airway models. Axial CT images of the paranasal sinuses of twenty adult subjects with healthy nasal airways (50% female and 50% age ≥ 50) were used to create the models. Patients with significant radiographic evidence of sinonasal disease were excluded. A primary cutting plane that passed through the edge of the nasal bone, upper lateral cartilage, and the head of the inferior turbinate was defined in coronal view. This primary coronal cutting plane was then rotated in 5° increments anteriorly while ensuring the anatomic criteria for the INV were still met. The cutting plane resulting in the minimum INV area was identified as the optimal cutting plane and the total cross-sectional area of INV in this plane,198.79 ± 54.57 mm², was significantly less than the areas obtained using the existing methods for radiographic evaluation of the INV. The angle between the optimal cutting plane and nasal dorsum was 75.00 ± 10.26°, and the corresponding INV angle was 10.77 ± 6.02°.

The Relation Between the Lower Lateral Cartilages and the Function of the External Nasal Valve

INTRODUCTION

The position of the lower lateral cartilages (LLC) is closely related to the function of the external nasal valve (ENV). When there is a cephalic malposition of these cartilages, the nasal alae have inadequate support, which leads to ENV insufficiency during deep inspiration.

METHODS

Retrospective study with 60 patients evaluated: the positioning of the LLC and the occurrence of ENV insufficiency; the effectiveness of structuring the medial and lateral walls of the ENV; and the frequency of the grafts used for structuring it.

RESULTS

Of the 60 operated cases, 37 patients (62%) had ENV insufficiency, in 23 cases there was cephalic malposition of the LLC, and in the latter group 17 patients (74%) presented this insufficiency. A structured ENV was effective in the treatment of this insufficiency (p = 0.001). A lateral crural strut graft was performed in 24 cases (40%) of 60 patients operated. The alar contour graft was performed from 2013 to 2015 in 4 patients (22%) of 18 cases operated, and between 2016 and 2018 it was performed in 29 patients (69%) out of 42 cases. The columellar strut was routinely used from 2013 to mid-2016 in 33 cases (100%), and after that period until the present day the tongue-in-groove technique was performed in 11 cases (41%) and in the remaining 16 cases (59%) the caudal septal extension graft was performed.

CONCLUSION

Cephalic malposition of the LLC is an important red flag of ENV insufficiency. This insufficiency should be treated by structuring the walls of the ENV.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Use of Roof-Shaped Costochondral Cartilage for Correction of Saddle Nose Deformity

BACKGROUND

Cartilage grafts are routinely used in secondary and posttraumatic rhinoplasty. However, in most cases, there are weak areas in the nasal bones and upper lateral cartilages. The purpose of this study was to seek a solution for the keystone area and dorsum of the nose in revision and posttraumatic rhinoplasty cases, and reconstruction of saddle nose deformity including upper lateral cartilage with a roof-shaped graft.

METHODS

A retrospective review of reconstructive rhinoplasties performed for saddle nose deformities was conducted. A part of the costochondral graft was carved and thinned (roof graft) for reconstruction of the keystone area and upper lateral cartilages, and another portion was used for making a neoseptal (reconstructed septum) graft and strut graft. The roof graft was capped onto the neoseptal graft with sutures, and this cartilage framework was adapted with fitting the cranial edge of the neoseptal cartilage between the nasal bones. Finally, the strut graft was fixed to the cartilage framework.

RESULTS

A significant improvement in nasal shape and overall appearance was achieved in all cases, and 71.42 percent of patients recovered from nasal obstruction. No gross absorption, graft exposure, or recurrence of deformities was observed.

CONCLUSIONS

Surgical correction of a saddle-shaped nose should be an acceptable and uncomplicated technique, and the cosmetic result should be totally acceptable. There are many management options for a saddle-shaped nose. Use of roof grafts (shrunk gull-wing grafts) with neoseptal and strut grafts enables simulation of the internal nasal valve and results in a natural nasal position.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Creation of Experimental Human Nose Model With Lyophilized and Decellularized Bovine Cartilage Xenograft

The nose anatomy is a functional and aesthetically important organ because of its three-dimensional structure, visible location in the face region, and its connection with the respiratory tract. Aesthetic and reconstructive nasal surgery requires correction of deformations in cartilage and bone structures as well as preservation of the natural connections between all subunits. The minimal mistake made can result in functional or aesthetically bad results. In this study, the authors aimed to create an experimental nose model that help aesthetic and reconstructive nose surgery operations.

Correction of deviated nose

Deviated nose deformities have always been a surgical challenge, and it is essential to achieve both functional and esthetic improvements. Various techniques have evolved over time to correct deviated noses but no one method applies in all cases. Successful correction requires a complete understanding of the various surgical techniques and concepts, including the three-dimensional nasal structure and the time-related changes to surgically-treated noses.

Effect of Spreader Graft on Nasal Functions in Septorhinoplasty Surgery

OBJECTIVE

The authors aimed to investigate the effect of spreader grafts on nasal function in septorhinoplasty (SRP).

METHODS

A prospective randomized double-blind study was conducted. Thirty patients who underwent SRP operation between October 2011 and January 2013 were divided into 2 equal groups randomly. Fifteen patients underwent SRP surgery without spreader graft technique (Group I) and 15 patients underwent SRP surgery with spreader grafts (Group II). Preoperative and postoperative evaluation included visual analog score (VAS) and acoustic rhinometry test.

RESULTS

Visual analog scores and acoustic rhinometry measurements of Group I and Group II patients were compared. Statistically significant difference was found for VAS scores of both the sides of the nasal cavity (both before and after topical decongestion) (P < 0.05), except for the VAS on the right side of the nasal cavity before decongestion (P > 0.05). On acoustic rhinometry test the difference was statistically significant for minimal cross-sectional area (MCA) and volumetric values (VOL)-MCA1, MCA2, VOL1, VOL2 values on the left side of the nasal cavity (both before and after topical decongestion) (P < 0.05) but not on the right side of the nasal cavity (P > 0.05).

CONCLUSIONS

Performing spreader graft technique in SRP surgery can prevent the narrowing of the internal nasal valve area after surgery and maintain adequate airway for respiration.

The Nasal Valve: A Review of the Anatomy, Imaging, and Physiology

Background

The nasal valve region has remained difficult to define in clinical practice in part because of lack of integration between physiological data and anatomic-surgical findings.

Methods

In this review, we summarize the anatomic, physiological, and imaging data regarding this complex area of airflow regulation.

Results

There is no singular resistive focus or singular valve structure to explain all of the reported findings.

Conclusion

We conclude that there is a nasal valve region that begins approximately at the limen nasi and continues for several millimeters within the nasal cavum beyond the piriform aperture. Intranasal pressure measurements reflect distributed resistance across this nasal valve region. The geometry and anatomic constitution of the nasal valve region change greatly from its entrance to its distal aspect. To refer consistently to the component portions of the nasal valve region, we suggest the terms cartilaginous valve segment and bony valve segment for use in reporting future studies.

In Vitro Assessment of Spray Deposition Patterns in a Pediatric (12 Year-Old) Nasal Cavity Model

PURPOSE

Nasal sprays available for the treatment of cold and allergy symptoms currently use identical formulations and devices for adults as well as for children. Due to the obvious differences between the nasal airway dimensions of a child and those of an adult, the performance of nasal sprays in children was evaluated.

METHODS

Deposition patterns of nasal sprays administered to children were tested using a nasal cast based on MRI images obtained from a 12 year old child's nasal cavity. Test formulations emitting a range of spray patterns were investigated by actuating the device into the pediatric nasal cast under controlled conditions.

RESULTS

The results showed that the nasal sprays impacted in the anterior region of the 12 year old child's nasal cavity, and only limited spray entered the turbinate region - the effect site for most topical drugs and the primary absorptive region for systemically absorbed drugs.

CONCLUSION

Differences in deposition patterns following the administration of nasal sprays to adults and children may lead to differences in efficacy between these populations. Greater anterior deposition in children may result in decreased effectiveness, greater anterior dosage form loss, and the increased potential for patient non-compliance.

Assessment of Functional Rhinoplasty with Spreader Grafting Using Acoustic Rhinomanometry and Validated Outcome Measurements

BACKGROUND

Rhinoplasty is 1 of the most common aesthetic and reconstructive plastic surgical procedures performed within the United States. Yet, data on functional reconstructive open and closed rhinoplasty procedures with or without spreader graft placement are not definitive as only a few studies have examined both validated measurable objective and subjective outcomes of spreader grafting during rhinoplasty. The aim of this study was to utilize previously validated measures to assess objective, functional outcomes in patients who underwent open and closed rhinoplasty with spreader grafting.

METHODS

We performed a retrospective review of consecutive rhinoplasty patients. Patients with internal nasal valve insufficiency who underwent an open and closed approach rhinoplasty between 2007 and 2016 were studied. The Cottle test and Nasal Obstruction Symptom Evaluation survey was used to assess nasal obstruction. Patient-reported symptoms were recorded. Acoustic rhinometry was performed pre- and postoperatively. Average minimal cross-sectional area of the nose was measured.

RESULTS

One hundred seventy-eight patients were reviewed over a period of 8 years. Thirty-eight patients were included in this study. Of those, 30 patients underwent closed rhinoplasty and 8 open rhinoplasty. Mean age was 36.9 ± 18.4 years. The average cross-sectional area in closed and open rhinoplasty patients increased significantly (P = 0.019). There was a functional improvement in all presented cases using the Nasal Obstruction Symptom Evaluation scale evaluation.

CONCLUSIONS

Closed rhinoplasty with spreader grafting may play a significant role in the treatment of nasal valve collapse. A closed approach rhinoplasty including spreader grafting is a viable option in select cases with objective and validated functional improvement.

Nasal valve evaluation in the Mexican-Hispanic (mestizo) nose

BACKGROUND

Our aim in this study was to determine the angle of the internal nasal valve in Mexican patients with the "mestizo nose" feature and without nasal obstructive symptoms. The work was prospective, comparative, and observational in nature and included patients >14 years of age who were seen in the Otolaryngology Department at the Los Angeles Lomas Hospital between April and May 2016.

METHODS

The angle of the internal nasal valve was measured in 30 patients without obstructive symptoms. Endoscopic examination was performed with a 0° endoscope framed with tape at a 13-mm distance from the endoscope's tip, and digital photographs of the internal nasal valve were taken. The measurement of the angle of the internal nasal valve was made in sexagesimal degrees using Golden Ratio v3.1 (2012) software. Statistical analysis was performed using Excel v15.13.3.

RESULTS

The angles of the internal nasal valve of the patients were (mean ± standard deviation) 24.07 ± 4.8° for the right nasal cavity and 25.07 ± 5.0° for the left nasal cavity, wider than the angle reported in the normal Caucasian nose established in the literature.

CONCLUSIONS

According to our results, the Mexican-Hispanic mestizo nose has a wider angle in the internal nasal valve than that considered normal in the literature (10°-15°). We believe it is necessary to undertake a second study and add an airflow resistance measurement with a rhinomanometry procedure so we can compare the results with those in the Caucasian population.

The Use of Spreader Grafts in Revision Septoplasty

INTRODUCTION

Persistent nasal obstruction at internal nasal valve was a common problem seen after septoplasty and submucous resection, the 2 methods used for surgical treatment for deviation of nasal septum during the first half of twentieth century. The authors performed cartilage-grafting technique and retrospectively analyzed the patients after 12 months with Nasal Obstruction and Septoplasty Effectiveness scale to emphasize persistent nasal obstruction.

METHODS

In this study, 115 (65 male, 50 female) patients operated between 2008 and 2013 who underwent revision septoplasty and complaints were evaluated with Nasal Obstruction and Septoplasty Effectiveness scale. The surgical technique was used in 32 (27.8%) of the patients "open" and in 83 (72.2%) "closed" approach. Wilcoxon sign test is used for the statistical analysis. Postoperative values were statistically significant compared with preoperative ones (P <0.05).

DISCUSSION

Septoplasty and submucous resection described by Cottle and Killian are similar techniques, but a septoplasty often includes less cartilage resection and septal cartilage modification or placement of a cartilage graft instead of resection. Most important disadvantage of these techniques is to be deficient in the correction of the caudal and/or dorsal deviations. In authors' experience these classical septoplasty techniques are not suitable for columellar and dorsal deviations and especially in revision surgery an internal nasal valve correction with cartilage grafts is a necessary alternative technique.

Evidence-Based Medicine: Current Practices in Rhinoplasty

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Perform aesthetic and functional nasal analysis to guide septorhinoplasty. 2. Recognize common complications associated with rhinoplasty. 3. Select appropriate septorhinoplasty techniques to refine nasal aesthetics and treat nasal airway obstruction. 4. Identify factors leading to poor patient satisfaction following rhinoplasty.

SUMMARY

Septorhinoplasty is among the most technically challenging procedures in the realm of plastic and reconstructive surgery. Moreover, it is a constantly evolving topic with extensive background literature. Surgeons must be comfortable with the traditional knowledge base and the current practices in the field. This article reviews the latest thinking on patient selection, functional indications, aesthetic analysis, and operative techniques in septorhinoplasty, with an emphasis on key cartilage grafting and tip suture techniques.

Outcomes of septorhinoplasty: a new approach comparing functional and aesthetic results

The aim of this study was to compare objective and subjective functional results of septorhinoplasty with subjective aesthetic results. A prospective study was performed including global and subgroup analyses (primary versus secondary septorhinoplasty). Three instruments were used to evaluate pre- and postoperative results: rhinomanometry for the objective functional analysis, the Nasal Symptom Obstruction Evaluation (NOSE) scale for the subjective functional analysis, and the Rhinoplasty Outcome Evaluation (ROE) scale for the subjective aesthetic analysis. A septorhinoplasty was performed in all cases. Thirty-five patients were included (22 female), of whom 74% underwent primary septorhinoplasty. The correlation between rhinomanometry, NOSE and ROE scores was analysed. Mean resistance of the two nasal cavities was 4.9 (standard deviation (SD) 8.35) sPa/ml before surgery and 0.8 (SD 0.7) sPa/ml after surgery. NOSE and ROE scores were, respectively, 72.5/100 (SD 21.7) and 7.5/24 (SD 11.3) before surgery and 22/100 (SD 20.6) and 18/24 (SD 17.3) after surgery. Patients complaining of postoperative nasal obstruction had a worse aesthetic evaluation. Correction of the functional disease appears to be as important as aesthetic correction. This study comparing functional and aesthetic results after septorhinoplasty could provide a basis for future studies.

Primary Open Rhinoplasty

Rhinoplasty is perhaps the most complex cosmetic surgery procedure performed today. It is characterized by an intricate interplay between form and function, with patient satisfaction being dependent not only on improvement of nasal appearance but also resolution of preexisting airway symptoms. The prerequisite for successful execution of this challenging procedure is a thorough understanding of nasal anatomy and physiology. Hence, a thorough preoperative evaluation is at least as important and the surgical skill in performing the operation. Establishing an accurate diagnosis through a comprehensive nasal analysis is obligatory. As to the surgical approach, much has been written about the advantages and disadvantages of closed vs open rhinoplasty. The more commonly chosen open approach has numerous advantages, including improved visualization without distortion, thus, enabling precise diagnosis and correction of deformities. While the surgical treatment of existing nasal deformities is tailored to the needs of the individual patient, the authors have noted a total of 10 essential components to form the foundation for successful technical execution of rhinoplasty. These include: (1) septoturbinotomy; (2) opening the nose; (3) humpectomy/spreader flaps; (4) tip-plasty; (5) supratip-plasty; (6) columellar strut; (7) dorsal augmentation; (8) nasal base reduction; (9) osteotomies; and (10) rim grafts. Postoperative, a variety of problems, such as edema, may be successfully addressed without surgical intervention. Diligent postoperative management is critical in ensuring a positive patient experience. Finally, a comprehensive understanding of possible postoperative complications, such as bleeding, ecchymosis, edema, and persistent or new iatrogenic deformity is mandatory prior to offering rhinoplasty to patients.

The Crooked Nose

Correction of a crooked nose is one of the most common requests from patients presenting for rhinoplasty. Both esthetic and functional issues are typically present in patients with this deformity. Rhinoplasty for the crooked nose is particularly challenging because multiple nasal structures, both external and internal, are commonly involved. A major septal deformity is almost always a component of severely deviated noses. The crooked nose results from extrinsic and intrinsic forces that produce distortion of the nasal structures and nasal deviation. The open approach is particularly useful and is the focus of this article.

A Practical Approach to Rhinoplasty

Rhinoplasty continues to be one of the most commonly performed aesthetic surgical procedures. Over the past 25 years, the open approach has increased in popularity and is the focus of this article. The principles for successful rhinoplasty include comprehensive clinical analysis and defining rhinoplasty goals, preoperative consultation and planning, precise operative execution, postoperative management, and critical analysis of one's results. Systematic nasal analysis is critical to establish the goals of surgery. Techniques to address the nasal dorsum, nasal airway, tip complex, alar rims, and bony vault that provide consistent results are discussed.

Photographic Measurements Partially Correlate to Nasal Function and Appearance among Adult Cleft Patients

Background:

Unilateral cleft lip and palate (UCLP) affects nasal function and appearance. There is a lack of objective measurements to evaluate these features. This study analyzes whether objective measurements on photographs correlate with nasal function and/or appearance among adults treated for UCLP.

Methods:

All patients with UCLP born from 1960 to 1987 treated at the Uppsala University Hospital were invited (n = 109). Participation rate was 68% (n = 74); mean follow-up was 35 years. An age-matched control group (n = 61) underwent the same tests. Nostril area, nasal tip deviation angle, and width of the nostril were measured on photographs and were compared with functional tests and with appearance as assessed by self-assessment questionnaire, professional panel, or laymen panel.

Results:

The photographically measured nostril area correlated with nasal volume (acoustic rhinometry) among UCLP patients, both cleft side and noncleft side, and controls (0.331, P = 0.005; 0.338, P = 0.004; and 0.420, P < 0.001, respectively). For the patients’ noncleft side and controls, the area correlated inversely with airflow resistance at inspiration (noncleft side: −0.245, P = 0.043; controls: −0.226, P = 0.013). Laymen assessment of nasal appearance correlated with width ratio of the patients (0.27, P = 0.022) and with nasal tip deviation angle and area ratio of the controls (0.26, P = 0.041, and 0.31, P = 0.015, respectively).

Conclusions:

Photographic measurements correlate partially with both functional tests of the nose and panel ratings of appearance. No correlation was found with self-assessment of appearance. Evaluation of photographs needs to be combined with patient-reported outcome measures to be a valuable endpoint of nasal appearance.

Anatomy of the upper lateral cartilage along the lateral pyriform aperture

BACKGROUND

The upper lateral cartilages underlie the nasal bones cephalically, and articulate with the nasal septum medially. The authors studied the histologic and anatomical relationships between the lateral aspect of the upper lateral cartilages and the frontal process of the maxilla.

METHODS

Six cadaver noses were dissected by open rhinoplasty to expose the upper lateral cartilages bilaterally. Subperiosteal dissection was performed over the medial maxillae and nasal bones to expose the perimeter of the pyriform aperture. Twelve sides were analyzed anatomically. Three cadavers were used to create six tissue specimens for histologic analysis, by resecting the tissue of the upper lateral cartilage-maxillary bone articulation en bloc.

RESULTS

Grossly in all specimens, the upper lateral cartilage articulated with the frontal process of the maxilla laterally, lying deep to the coronal plane of the maxillary bone. In four histologic specimens, the upper lateral cartilage was found to underlie the frontal process of the maxilla laterally, displaying an overlapping relationship. In the other two histologic specimens, the upper lateral cartilage ended medial to the maxilla. In all specimens, the ends of the upper lateral cartilage and maxilla articulated by way of a pyriform ligament.

CONCLUSIONS

The upper lateral cartilage articulates laterally with the frontal process of the maxilla by means of the pyriform ligament, with a variable amount of overlap between the upper lateral cartilage and maxilla. Relationships among the upper lateral cartilage, maxilla, and pyriform ligament affect the configuration of the lateral internal nasal valve area, and should be considered when planning internal nasal valve reconstruction.

The accordion suture technique: A modified rhinoplasty spreader flap

In rhinoplasties, a spreader flap is a widely used alternative to dorsal reconstruction with spreader grafts; however, it has a limited ability to provide sufficient nasal dorsal width. The upper lateral cartilage (ULC) thickness is four times thinner than a spreader graft. This report presents an accordion suture technique for the ULC that involves simple sutures which fix each ULC (3 times folded) to the septum. We performed this technique in 64 primary rhinoplasties, and the patients were followed up for approximately 18 months. The patients completed a questionnaire 12 months postoperatively, and reported marked satisfaction with the aesthetics and function. Furthermore, rhinomanometric analysis showed that nasal airway resistance (NAR) decreased significantly in the postoperative period.

Upper lateral strut graft: a technique to improve the internal nasal valve

BACKGROUND

Internal nasal valve (INV) collapse can contribute significantly to nasal obstruction and may be caused by upper lateral cartilage (ULC) collapse medially or laterally. Surgical techniques addressing INV collapse have focused more on treating the narrowed INV angle, with less consideration of the lateral INV area. This article describes a technique to improve INV patency both medially and laterally. This study analyzes the changes in minimal cross-sectional area (MCA) at the INV after graft placement and determines whether these changes are significantly different for normal versus narrow INVs.

METHODS

Noses of six fixed cadavers were dissected by open rhinoplasty to release the ULCs from the septum. Upper lateral strut grafts were placed through subperichondrial pockets along the ULC undersurfaces and out over the piriform apertures into subperiosteal pockets. Grafts were secured to the dorsal septum. Acoustic rhinometry and nasal endoscopy were used to classify INVs before graft placement as narrow or normal and to assess changes at the INV after graft placement.

RESULTS

Mean pregraft MCA was 0.58 cm(2). Mean MCA percent increase after graft placement was 22%. By INV type, percent increases were 51% for narrow INVs and 1% for normal INVs. Mean increases in MCA after graft placement were statistically significant for the entire group and for narrow INVs, with increases of 0.10 cm(2) (p = 0.03) and 0.22 cm(2) (p = 0.004), respectively.

CONCLUSION

The upper lateral strut graft improved patency of cadaveric INVs, with statistically significant increases in the MCA most notable when placed for narrow INVs.

Comparison of the effects of columellar strut and septal extension grafts for tip support in rhinoplasty

BACKGROUND

The purpose of this study was to compare the effects of columellar strut and septal extension grafts for reconstruction of caudal nasal supportive structures on the long-term stability of nasal projection and rotation.

METHODS

A comparison was done on the differences between the early- and long-term results of the ratios of nasal projection to nasal length and columella labial angle values in 36 patients who were operated on by the same surgeon using columellar or septal extension grafts.

RESULTS

Both grafts had the effect of increasing nasal projection, and this effect was found to be stable over time. Some increased values of nasal projection obtained in the early postoperative period were lost over time. Although no significant difference was found between the groups, clinical and numerical observations showed that the values decreased less in the group that received septal extension grafts.

CONCLUSION

The tip position was more stable in cases with septal extension grafts than in those with columellar strut grafts.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The use of short spreader grafts in rhinoplasty for patients with thick nasal skin

BACKGROUND

Thick nasal skin presents a challenge in rhinoplasty. Conventional spreader grafts in patients with thick nasal skin may result in an undesirable widening of the lower half of the nose where the nasal skin is thick. The use of short spreader grafts was evaluated in patients with thick nasal skin.

METHODS

For this study, 32 patients underwent closed rhinoplasty in which short spreader grafts were used. The spreader graft was 1 to 2 cm long and extended only to the transition of thin and thick nasal skin. The patients were followed for more than 1 year postoperatively.

RESULTS

Aesthetic improvement was observed in all the patients. Nasal airway patency was improved or maintained in 94 % of the patients.

CONCLUSIONS

Short spreader grafts effectively restore or maintain the internal nasal valve area after dorsal hump reduction while allowing for more aggressive narrowing of the lower part of the nose where nasal skin is thick.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[CT rhinometry : a correlation of rhinomanometry and multiplanar computer tomography of the nasal cavity]

BACKGROUND

Otorhinolaryngologists require new diagnostic methods to give further insight into the physiology of nasal breathing. The functional aspects of radiological data in the field of ENT have rarely been examined. This study compares computed tomography (CT) scan area measurements of the paranasal sinuses with physiological data from rhinomanometry.

PATIENTS AND METHODS

In a retrospective study, paranasal CT scans from 36 patients were analysed for volume, width and hydraulic diameter of the five key regions of the nasal cavity (CT rhinometry) and compared to the active anterior rhinomanometric (RMM) results representing the gold standard in nasal flow description.

RESULTS

The highest correlation between the rhinomanometric results and CT rhinometry was found at the internal ostium, followed by the diffuser region. The structures important for regulating nasal flow could thus be identified in the CT area data.

CONCLUSION

CT rhinometry revealed structures important for nasal breathing, in addition to providing anatomical and topographical data. CT rhinometry measured volumes, width and hydraulic diameters of the nasal cavity correlated with measurements of transnasal flow.

Assessment of nasal patency after rhinoplasty through the Glatzel mirror

Introduction: Objective evaluation of nasal function is a constant challenge for plastic surgeons, otolaryngologists, and allergists. The modified Glatzel mirror can evaluate nasal expiratory flow; however, there is little information on this method and its use in the measurement of nasal patency after surgical procedures.

Objective: To compare, in a prospective study, the functional results before and after cosmetic rhinoplasty and evaluate the use of the Glatzel mirror as an objective method to assess nasal patency.

Methods: To achieve this objective, we analyzed the functional results of surgery through a subjective questionnaire and objective evaluation through a modified Glatzel mirror, and evaluated the correlation between the 2 methods. Twenty patients (14 women and 6 men) underwent aesthetic rhinoplasty using spreader grafts. Pre- and postoperative evaluation (90–120 days) included a respiratory quality score (subjective) and modified Glatzel mirror test (objective). Subsequently, the Spearman test was used to compare the pre- and postoperative subjective and objective data.

Results: The subjective evaluation demonstrated a statistical difference between pre- and postoperative scores (8 ± 2 and 9.4 ± 0.7, P ≤ 0.001). There was no statistical difference in mean nasal patency by modified Glatzel mirror. No statistically significant correlation was observed when comparing the modified Glatzel mirror values with the subjective scores reported by patients pre- or postoperatively.

Conclusion: The Glatzel method lacks sensitivity in detecting patient-reported improvements in breathing following rhinoplasty. This suggests that the method is a poor assessment tool to detect small, post-surgical changes in the nasal airways.

Nasal patency after open rhinoplasty with spreader grafts

BACKGROUND

Spreader grafts have been used in cosmetic rhinoplasty, but little information is available about the objective results of treatment. This study sought to determine subjective and objective functional results of open cosmetic rhinoplasty with spreader grafts.

METHODS

Twenty patients (14 women, six men; mean age, 31 ± 6 years) had open cosmetic rhinoplasty. Surgery included dissection of the upper lateral cartilages, from the septum, and placement of spreader grafts, symmetrically, along the dorsal edge of the septal cartilage. Preoperative and postoperative evaluation included breathing quality score, acoustic rhinometry and a modified Glatzel mirror test.

RESULTS

Evaluation after surgery (range, 5-18 months) showed significant improvement of breathing quality (before surgery, 8; after surgery, 9.4; P ≤ 0.001) and a mean minimal cross-sectional area of the left side (before surgery, 0.6 cm(2); after surgery, 0.9 cm(2); P ≤ 0.01). There was no significant change of the mean minimal cross-sectional area of the right side (acoustic rhinometry) or nasal patency (modified Glatzel mirror test) between preoperative and postoperative evaluation. Complications included postoperative synechiae in two patients and septal granuloma in one patient.

CONCLUSIONS

Open structure rhinoplasty using spreader grafts is effective in reconstructing the internal nasal valve and preserving or improving nasal patency.

LEVEL OF EVIDENCE

IV (case series with preoperative and postoperative testing).

Rhinoplasty

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Discuss desired preoperative aesthetic and functional assessment of the postsurgical nose with rhinoplasty patients. 2. Identify factors that have the potential to affect procedural outcomes. 3. Develop an operative plan to address aesthetic goals while preserving/improving nasal airway function. 4. Recognize and manage complications following rhinoplasty.

SUMMARY

Rhinoplasty is one of the most commonly performed aesthetic surgical procedures in plastic surgery. Over the past 20 years, the trend has shifted away from ablative techniques involving reduction or division of the osseocartilaginous framework to conserving native anatomy with cartilage-sparing suture techniques and augmentation of deficient areas to correct contour deformities and restore structural support. Accurate preoperative systematic nasal analysis and evaluation of the nasal airway, along with identification of both the patient's expectations and the surgeon's goals, form the foundation for success. Intraoperatively, adequate anatomical exposure of the nasal deformity; preservation and restoration of the normal anatomy; correction of the deformity using incremental control, maintenance, and restoration of the nasal airway; and recognition of the dynamic interplays among the composite of maneuvers are required. During postoperative recovery, care and reassurance combined with an ability to recognize and manage complications lead to successful outcomes following rhinoplasty.

Nasal strips for evaluating and classifying valvular nasal obstruction

BACKGROUND

A normal-appearing upper lateral cartilage (ULC) or lower lateral cartilage (LLC) may be functionally abnormal. The Cottle sign estimates obstruction but not its exact location. A test is needed that evaluates the ULC and LLC separately.

METHODS

The study included 30 patients with airway obstruction symptoms and signs referable only to the nasal valves. They received a Cottle test and a Breathe-Rite nasal strip to the middle third of the nose and again to the lower third (the rims). The patients were asked whether the strip made their inspiration better, worse, or no different and classified as BR 0 (no airway obstruction due to ULC/LLC dysfunction), BR I (improvement with the strip on the ULC), BR II (improvement with the strip on the LLC), or BR III (improvement with strips on both the ULC and the LLC, independently). All the patients underwent surgery involving spreader grafts, lateral crural struts, suture techniques, and the like. Correlations were sought between the BR classification, Cottle sign, and physical integrity of the ULC/LLC.

RESULTS

A total of 12 patients required internal valve correction, whereas 8 required external valve correction, and 10 required correction of both. The Cottle test was nonspecific because most patients in all the groups exhibited a positive Cottle. However, the BR classification was specific, correlating with functional outcomes for 27 of the 30 patients. The McNemar test showed a significant correlation (Χ(2) = 9.09091; P = 0.00257) between physical finding and BR score.

CONCLUSIONS

Inspiratory nasal function (related to ULC/LLC cartilages) is easily classified using nasal strips. The BR test is more specific and powerful than the Cottle test.

Contemporary techniques in inferior turbinate reduction: survey results of the American Society for Aesthetic Plastic Surgery

BACKGROUND

Nasal airway obstruction is a frequently-encountered problem, often secondary to inferior turbinate hypertrophy. Medical treatment can be beneficial but is inadequate for many individuals. For these refractory cases, surgical intervention plays a key role in management.

OBJECTIVE

The authors evaluate the current trends in surgical management of inferior turbinate hypertrophy and review the senior author's (SS) preferred technique.

METHODS

A questionnaire was devised and sent to members of the American Society for Aesthetic Plastic Surgery (ASAPS) to determine their preferred methods for assessment and treatment of inferior turbinate hypertrophy.

RESULTS

One hundred and twenty-seven physicians responded to the survey, with 85% of surveys completed fully. Of the responses, 117 (92%) respondents were trained solely in plastic surgery and 108 (86.4%) were in private practice. Roughly 81.6% of respondents employ a clinical exam alone to evaluate for airway issues. The most commonly-preferred techniques to treat inferior turbinate hypertrophy were a limited turbinate excision (61.9%) and turbinate outfracture (35.2%).

CONCLUSIONS

Based on the results of this study, it appears that limited turbinate excision and turbinate outfracture are the most commonly-used techniques in private practice by plastic surgeons. Newer techniques such as radiofrequency coblation have yet to become prevalent in terms of application, despite their current prevalence within the medical literature. The optimal method of management for inferior turbinate reduction should take into consideration the surgeon's skill and preference, access to surgical instruments, mode of anesthesia, and the current literature.

Diagnosis of nasal airway obstruction

Nasal airway obstruction is the source of significant patient discomfort and financial burden; hence, otolaryngologists encounter this symptom on an almost daily basis. This article provides a thorough yet concise summary of common and more specialized techniques that are instrumental in diagnosing nasal obstruction. The article begins with a brief overview of significant nasal anatomy and physiology. Ultimately, the main focus is on exploring the role of nasal endoscopy, radiographic imaging, acoustic rhinomanometry and other diagnostic tests that assist in the diagnosis of nasal airway obstruction.