Anatomic Obstruction

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Anatomic Obstruction

Rhinology
Author Credentials 

Duc A. Tien, MD
David B. Keschner, MD, JD
Rohit Garg, MD, MBA
Department of Head and Neck Surgery
Kaiser Permanente southern California
Orange County, California

Module Summary

Nasal obstruction is an extremely common presenting symptom to the otolaryngologist. A comprehensive understanding of nasal/sinus embryology and anatomy will aid in proper diagnosis. Patient evaluation and workup always begins with a complete and thorough history and physical examination. Nasal endoscopy as well as diagnostic imaging aid in confirmation of the disease process and selection of appropriate treatment options. Treatment modalities include both medical and surgical options.

Module Learning Objectives 
  1. Explain the embryology and anatomy of sinonasal cavity.
  2. Describe the pathogenesis of nasal obstruction.
  3. Recognize the symptoms and signs associated with nasal obstruction.
  4. Discuss adjunctive tests and imaging to diagnose nasal obstruction.
  5. Cite medical and surgical management options for nasal obstruction.

Embryology

Learning Objectives 
  1. Understand how embryogenesis can contribute to various types of nasal obstruction.
  2. Be familiar with the development of the nasal septum.
  3. Understand the formation of the choanae.
  4. Understand the development of the sinus anatomy and turbinates.
References 
  1. Kennedy D, Hwang P. Sinonasal Development and Anatomy. In Rhinology: diseases of the nose, sinuses, and skull base. New York: Thieme; 2012:1-20.
  2. Flint et al. Congenital Malformations of the Nose. In Cummings otolaryngology head & neck surgery. 5th edition. 2010:2686-2696.

Anatomy

Learning Objectives 

Describe the anatomy of the nasal valve, nasal septum, sinus, and nasopharynx.

References 
  1. Kennedy D, Hwang P. Sinonasal Development and Anatomy. In Rhinology: diseases of the nose, sinuses, and skull base. New York: Thieme; 2012:1-20.
  2. Lang J. Clinical anatomy of the nose, nasal cavity and paranasal sinuses. New York: Thieme; 1989:31-40, 46-50, 56-85.

Pathogenesis

Learning Objectives 

Understand the various etiologies of nasal obstruction, such as anatomic abnormalities, inflammatory disorders, and neoplasms.

References 
  1. Kennedy, Hwang. Rhinology: diseases of the nose, sinuses, and skull base. New York: Thieme; 2012:171-181, 126-140.
  2. Flint et al. Cummings otolaryngology head & neck surgery. 5th edition. 2010:596-617, 657-661, 703-708.

Basic Science

Learning Objectives 

Understand normal physiology of the nose.

References 
  1. Kennedy, Hwang. Rhinology: diseases of the nose, sinuses, and skull base. New York: Thieme; 2012:21-31.
  2. Flint et al. Cummings otolaryngology head & neck surgery. 5th edition. 2010:640-656.

Incidence

Learning Objectives 

Understand the incidence of the following anatomic and pathophysiologic factors in the general population:

  1. Deviated septum
  2. Concha bullosa
  3. Polyposis
  4. Allergic rhinitis
  5. Non-allergic rhinitis
References 
  1. Kimmelman CP. The problem of nasal obstruction. Otolaryngol Clin North Am. 1989;22:253-64.
  2. Hirsch AG, Stewart WF, Sundaresan AS, et al. Nasal and sinus symptoms and chronic rhinosinusitis in a population-based sample. Allergy Eur J Allergy Clin Immunol. 2016;72(274):274-281.

Patient Evaluation

Learning Objectives 
  1. Know the pertinent symptoms and signs in the evaluation of nasal obstruction.
  2. Understand adjunctive tests that may be helpful in the evaluation of the patient with nasal obstruction.
References 
  1. Keeler J, Most SP. Measuring Nasal Obstruction. Facial Plast Surg Clin North Am. 2016;24(3):315-322.
  2. May M, Mester SJ, Levine HL. Office evaluation of nasosinus disorders: patient selection for endoscopic sinus surgery. In: “Endoscopic sinus surgery. New York: Thieme; 1993:60-90.

Measurement of Functional Status

Learning Objectives 

Although not necessary for the routine evaluation of nasal obstruction, various studies to objectively measure nasal function may be employed in specific circumstances or for research purposes:

  • Rhinomanometry
  • Ciliary flow testing
References 
  1. Kennedy D, Hwang P. Sinonasal Development and Anatomy. In Rhinology: diseases of the nose, sinuses, and skull base. New York: Thieme; 2012:69-81.
  2. Flint et al. Cummings otolaryngology head & neck surgery. 5th edition. 2010:640-656.
  3. Gryner LF, Illum P, Hilberg O. Septoplasty and compensatory inferior turbinate hypertrophy: a randomized study evaluated by acoustic rhinomanometry. J Laryngol Otol. 1993;107:413-7.
  4. Jalowayski AA, Yuh YS, Koziol JA, et al. Surgery for nasal obstruction - evaluation by rhinomanometry. Laryngoscope. 1983;93:341-5.
  5. Reber M, Rahm F, Monnier P. The role of acoustic rhinomanometry in the pre- and postoperative evaluation of surgery for nasal obstruction. Rhinology. 1998;36:184-7.

Imaging

Learning Objectives 

Understand the role of diagnostic imaging in evaluating nasal obstruction.

References 
  1. Kennedy D, Hwang P. Sinonasal Development and Anatomy. In Rhinology: diseases of the nose, sinuses, and skull base. New York: Thieme; 2012:32-56.
  2. Flint et al. Cummings otolaryngology head & neck surgery. 5th edition. 2010:662-681.

Pharmacology

Learning Objectives 

Know the mechanism and potential side effects of the following pharmacologic agents (and their role in treating nasal obstruction of varying causes):

  1. Decongestants
  2. Topical steroid sprays
  3. Systemic steroids
  4. Anti-histamines
  5. Anti-cholinergic sprays
References 
  1. Kennedy D, Hwang P. Medical Therapies for Rhinosinusitis: Anti-Inflammatory. In Rhinology: diseases of the nose, sinuses, and skull base. New York: Thieme; 2012:229-238.
  2. Flint et al. Medical Management of Nasosinus Infectious and Inflammatory Disease. In Cummings otolaryngology head & neck surgery. 5th edition. 2010:728-738.
  3. Bernstein DI, Schwartz G, Bernstein JA. Allergic Rhinitis: Mechanisms and Treatment. Immunol Allergy Clin North Am. 2016;36(2):261-278.
  4. Lieberman PL, Smith P. Nonallergic Rhinitis: Treatment. Immunol Allergy Clin North Am. 2016;36(2):305-319.

Surgical Therapies

Learning Objectives 

Know the surgical indications and techniques for management of nasal obstruction such as:

  1. Open vs endonasal approaches for nasal valve surgery (functional rhinoplasty)
  2. Endonasal vs endoscopic septoplasty
  3. Various techniques of inferior turbinoplasty (Surgery of the Inferior, Middle, and Superior Turbinates)
  4. Functional endoscopic sinus surgery
References 
  1. Barrett DM, Casanueva FJ, Cook TA. Management of the Nasal Valve. Facial Plast Surg Clin North Am. 2016;24(3):219-234.
  2. Acevedo JL, Camacho M, Brietzke SE. Radiofrequency Ablation Turbinoplasty versus Microdebrider-Assisted Turbinoplasty: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg. 2015.
  3. Brunworth J, Holmes J, Sindwani R. Inferior turbinate hypertrophy: Review and graduated approach to surgical management. Am J Rhinol Allergy. 2013;27(5):411-415.
  4. Kennedy D, Hwang P. Chapter 25: Functional Endoscopic Sinus Surgery: Concepts, Surgical Indications, and Techniques. In Rhinology: diseases of the nose, sinuses, and skull base. New York: Thieme; 2012:306-335.
  5. Kennedy D, Hwang P. Chapter 34: Surgery of the Septum and Turbinates. In Rhinology: diseases of the nose, sinuses, and skull base. New York: Thieme; 2012:457-466.
  6. Thamboo A, Patel ZM. Office Procedures in Refractory Chronic Rhinosinusitis. Otolaryngol Clin North Am. 2017 Feb;50(1):113-128.
  7. http://www.american-rhinologic.org/videos (Surgical dissection videos on the ARS website, for members. ARS membership is FREE for residents.)

Complications

Learning Objectives 

Understand the potential sequelae of nasal obstruction, such as:

  1. Sleep apnea
  2. Rhinitis
  3. Sinusitis
  4. Hyposmia/ anosmia
  5. Epiphora
  6. Epistaxis
References 
  1. Kennedy D, Hwang P. Chapter 21: Complications of rhinosinusitis. In Rhinology: diseases of the nose, sinuses, and skull base. New York: Thieme; 2012:261-270.
  2. Thompson A, Sardana N, Craig TJ. Sleep impairment and daytime sleepiness in patients with allergic rhinitis: The role of congestion and inflammation. Ann Allergy, Asthma Immunol. 2013;111(6):446-451.

Review

Review Questions 
  1. List the most common causes of nasal obstruction. What are associated presenting symptoms of each?
  2. How do you typically evaluate a patient with nasal obstruction?
  3. What are common medical therapies for nasal obstruction?
  4. Discuss surgical management of nasal obstruction including indications, benefits, and risks.
Resources 

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  1. Annual Meeting Webcasts (AMW):