THE RELATIVE IMPORTANCE OF SEPTAL AND NASAL VALVULAR SURGERY IN CORRECTING AIRWAY-OBSTRUCTION IN PRIMARY AND SECONDARY RHINOPLASTY

Despite the apparent association of nasal airway obstruction with sept al deviation and/or inferior turbinate hypertrophy, increasing clinica l evidence suggests that incompetence of the internal or external nasa l valves may also affect airflow. But how much? What is the relative i mportance of the valves and septum in causing nasal airway obstruction ? One-hundred and sixty consecutive patients (88 primary rhinoplasty, 72 secondary rhinoplasty) without turbinate hypertrophy or septal perf oration and operated on for correctable nasal airway obstruction were evaluated prospectively by anterior active mask rhinomanometry preoper atively and from 1 to 43 months (mean 8.4 months) postoperatively afte r 1% phenylephrine decongestion to eliminate mucosal factors. Patients were stratified according to the site(s) of preoperative obstruction at the internal valves, the external valves, the septum, or any combin ation of the three. Geometric mean nasal airflow was calculated from i ndependent measurements of each nasal airway. Surgical treatment consi sted of submucous septal resection, internal valvular reconstruction w ith dorsal or spreader grafts, and external valvular reconstruction wi th cartilage or bone grafts; inferior turbinectomy was not performed. All procedures were performed endonasally. In the entire 160 patient s tudy group, septal and/or valvular surgery corrected the airway in 152 patients (95 percent); 8 patients had partial residual obstruction. O ur data support the prior rhinologic data in showing only a modest (an d statistically insignificant, p < 0.4, n = 25) improvement in (geomet ric) mean nasal airflow following septal surgery alone. However, exter nal valvular reconstruction alone increased airflow 2.6 times over pre operative values (n = 10). Internal valvular reconstruction alone by d orsal grafts (n = 17) or spreader grafts (n = 29) increased nasal airf low 2.0 times; spreader grafts and dorsal grafts were equally effectiv e in supporting the internal valves. The largest improvement in postop erative airflow was seen in the patients with septal plus internal and external valvular incompetence (n = 21), in which flow increased 4.9 times over preoperative values (p < 0.0003). Patients in whom valvular incompetence alone was corrected experienced as much relative improve ment as patients in whom valvular plus septal obstruction was correcte d. Finally, valvular reconstruction in 54 secondary rhinoplasty patien ts who had previously undergone septoplasty corrected the airway obstr uction in 49 patients (91 percent). Notably, 110 of 160 patients (69 p ercent) had a lateralized preoperative obstruction; however, the septu m was deviated toward the clinically obstructed side in only 51 of the se patients (46 percent); in the other 54 percent, the subjectively ob structed side was contralateral to the side toward which the septum wa s deviated. Nasal valvular function should be assessed in all preopera tive rhinoplasty patients with airway obstruction; in many individuals , valvular effects may equal or surpass septal deviation as the primar y cause of nasal airflow obstruction.