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Nasal Airway Obstruction Treatment & Symptoms

Author Julia Casazza covers Nasal Airway Obstruction Treatment & Symptoms on BackTable ENT

Julia Casazza • Apr 24, 2024 • 35 hits

Nasal airway obstruction is a common condition in which nasal anatomy compromises airflow into the nose. Patients with nasal airway obstruction symptoms report difficulty engaging in vigorous activities, dysphagia, ear fullness, and sleep problems. Otolaryngologist Dr. Nora Perkins recently joined the BackTable ENT team to share her expertise on this condition. Through a combination of nasal airway obstruction treatment including medical and procedural management, she helps patients breathe (and live) better.

This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.

The BackTable ENT Brief

• Nasal airway obstruction is defined as the reduced passage of air through the nose due to structural blockage.

• Nasal airway obstruction can present with difficulty breathing through the nose, or, less obviously, with dysphagia, difficulty sleeping, and/or ear pressure/stuffiness.

• Nasal airway obstruction treatment options include medical or procedural management. Medical management includes sinus rinses (with saline and steroids), Breathe Right strips, and treatment of comorbid allergies.

• Rhinoplasty is the most effective treatment for a narrowed external nasal valve.

• Patients with narrowed internal nasal valves, prominent septal swell bodies, or enlarged inferior turbinates are good candidates for radiofrequency ablation (RFA) of excess nasal tissue.

Nasal Airway Obstruction Treatment & Symptoms

Table of Contents

(1) Nasal Airway Obstruction Symptoms

(2) Medical Management of Nasal Airway Obstruction

(3) Identifying Areas for Intervention Using the Physical Exam

Nasal Airway Obstruction Symptoms

Nasal airway obstruction symptoms are reported as difficulty breathing, ear pressure/stuffiness, dysphagia, and challenges sleeping. Patients whose predominant symptom is obstructed nasal breathing are the easiest to diagnose. These patients often try less invasive measures (including Breathe Right strips, sinus cones, and nasal sprays) before requesting procedural management. Patients whose nasal congestion manifests as other symptoms might not realize that nasal anatomy is the cause of their problem. Sometimes, these patients with less obvious presentations have seen other physicians and heard that there’s nothing that can be done to fix their problem. Regardless of their initial presentation, Dr. Perkins recommends tracking subjective improvement over time using the Nasal Obstruction and Septoplasty Effectiveness Scale (NOSE) [1] and the Total Nasal Symptom Score (TNSS) [2].

[Dr. Nora Perkins]
I'm going to group them as two large groups of patients. There's the patients who self-select. They come in because they cannot breathe through their nose. Sometimes they've actually done the research and they say, "Hey, I read about this and I want this procedure." For nasal airway obstruction, I would say they might have hit on the right thing. You can kind of have some self-selection, especially if they've tried Breathe Right strips, they've tried sinus cones, they've been on nasal sprays in the past.

They've sort of done all of the initial steps. That group of patients is nice because they've done some of the work. They have an idea of what they want. They know what their goals are. You're at least halfway down the road.

The other patients who come in might have other nasal airway obstruction symptoms. They may have ear pressure or congestion. They might have swallowing symptoms or throat symptoms or sleep symptoms. They have these non-nasal symptoms, but during the evaluation, it becomes apparent that the nose is part of this problem. That's usually a little bit of a longer path because obviously, we have to rule out the throat or address if they have reflux or address if they have post-nasal drainage or whatever their issues are.

I do think if you stay with those patients, if you listen to them, and if you're willing to consider the nose as part of what could be causing some of those symptoms, you can definitely identify those patients. They're very receptive to the idea of the nose, especially once you've gone through that whole process of evaluating the larynx and the ears and whatnot. They're excited that somebody is giving them a potential nasal airway obstruction treatment option because I'm sure you have all seen patients who've seen other ear, nose, and throat doctors, primary doctors, and said, "There's nothing wrong with you."

I find that just a really frustrating response. I think it's actually a little lazy on our part. There's one thing to be reassuring when you have an anxious patient who says, "I'm just nervous that I have a tumor or something." Reassuring them that they don't have that is great. For the patient who says, "My ear just feels funny. It is plugged. It is congested," and you can identify they have a septal deviation. They have huge turbinates. They have some things that might actually contribute to some of that symptomatology.

I think patients appreciate you evaluating it, considering it, not diminishing their symptoms or telling them that they don't have these symptoms. Then if you can actually do something to help the nasal airway obstruction symptoms, that's-- even if you can't, but if you listen and don't make them feel like they're being crazy, I know that's a silly thing to say, but it happens so often and being dismissive is just not something that I want.

Listen to the Full Podcast

Nasal Airway Management: Evolving Practices in Diagnosis and Treatment with Dr. Nora Perkins on the BackTable ENT Podcast)
Ep 158 Nasal Airway Management: Evolving Practices in Diagnosis and Treatment with Dr. Nora Perkins
00:00 / 01:04

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Medical Management of Nasal Airway Obstruction

Many patients with nasal airway obstruction do not require a procedure for symptomatic relief. Medical management of nasal congestion emphasizes reducing inflammation and treating comorbid allergies. All patients should start saline/budesonide sinus irrigations. Breathe Right strips are a helpful adjunct; patients who improve with these typically have symptoms due to lateral nasal wall collapse. Intranasal antihistamines can provide immediate relief for those with comorbid allergies. Immunotherapy drastically reduces allergic symptoms but takes over a year to reach maximum efficacy.

[Dr. Nora Perkins]
I'm a pretty big proponent of sinus irrigations. I like adding budesonide to them, especially for patients who may have tried nasal sprays over the counter and maybe didn't necessarily have success. I think the administration of the medication is just much more thorough and sometimes patients do a lot better with an irrigated steroid.

Nasal antihistamines certainly would be reasonable if they have other allergy symptoms, allergy testing, but that tends to be where I'll go for medical management. One thing that I think I have personally changed in my practice, I like to start conservative and take a stepwise approach, but I definitely like the patient to also weigh in on that.

If I have somebody with allergy and they're doing medications, they're using their saline rinses, their steroids, whatnot, if they're thinking of starting allergy immunotherapy as part of their treatment, but they also have some nasal airway obstructive symptoms, I will tend to offer them intervention earlier because immunotherapy is incredibly successful, but it's like getting braces. It's going to be a few years. We're going to have this relationship for a while and I'm optimistic that you're going to find significant benefit, but it's going to take a little bit of time.

If we can also give you some immediate symptom relief, I think that's something that in my practice, I'm trying to offer a little earlier rather than, "I'll see you in a year. Let's see how these weekly shots have gone," because that's a really big time investment for patients. It's asking them to do a lot and maybe not see dramatic symptom changes for a number of months.



[Dr. Gopi Shah]
Do you try Breathe Right strips or cones? What are your thoughts on that for the patients that haven't tried them?

[Dr. Nora Perkins]
I think they're a really great option to identify patients with lateral nasal wall, either dynamic collapse or fixed obstruction there. I think it's funny when patients are hesitant to use them. Because you can use them at night, use them at home. I'm not asking you to walk to the grocery store or to go to school events or anything like that, but just try them because if those give you some benefit, I think that's a very good predictor that you will do well with a nasal valve procedure.

Identifying Areas for Intervention Using the Physical Exam

Physical exam findings predict effective management strategies for nasal airway obstruction. Before decongesting, Dr. Perkins examines the external nasal valve, internal nasal valve, and inferior turbinates. Patients with narrow external nasal valves likely require rhinoplasty, whereas patients with narrowed internal nasal valves, large inferior turbinates, or prominent septal swell bodies benefit from radiofrequency ablation (RFA). To further assess whether RFA is an appropriate option, Dr. Perkins performs the modified Cottle maneuver before and after decongesting; in her experience, better breathing after decongestion predicts a positive response to turbinate reduction. Finally, she finishes with a flexible scope.

[Dr. Gopi Shah]
Moving on to what's in your nasal obstruction toolbox? What kind of options or interventions are you thinking about when these patients are at that point where it's like, "Okay, let's do something more definitive."?

[Dr. Nora Perkins]
Yes. I think it depends a little bit. From an exam standpoint, I'm going to just look at their nose. I usually ask people to sort of tilt their head back a little bit and just look at essentially the nostril, the external nasal valve. If it's an incredibly narrow external valve and they take a sniff and the whole nostril collapses, I'm not sure that I'm the best person to address that. They probably need to see a facial plastic surgeon and have a little bit of a more extensive rhinoplasty procedure, which I don't do rhinoplasty, but if their external nasal valve is pretty reasonable, I'll start to examine the internal nasal valve.

Is there just a compromise there? Is it just incredibly narrow or is there a dynamic collapse with normal breathing or deep inspiration? Once we've sort of addressed, is it the turbinates? Do they have a huge septal deviation? My personal treatment options for an in-office procedure, I think the radiofrequency treatments of the nasal valve are very simple and very effective for patients with either fixed or dynamic internal nasal valve collapse.

They're simple in that you're directly treating the areas collapsing. It isn't something where you have to try to imagine, how is this going to support that area? Is it placed in the actual area that I want it to be placed to offer that support? You directly see it. Under your endoscopic visualization or using a headlight and nasal speculum, you can see where you're treating and you do get some immediate visual response to what you've done. You can see that you've treated that area and you can adjust your treatment as needed to allow for some improvement.

That's one option. I use radiofrequency to treat the inferior turbinates for turbinate hypertrophy. I am a believer/treater of the septal swell bodies. I think that was something that we had all seen where you see the superior deviation on both sides and wonder how is that possible that they have this deviation on both sides or you get the CAT scan that shows it and you're like, "How am I going to address this?" Because it causes a lot of obstruction and it's in an area that otherwise would be hard to meet and a septoplasty probably isn't really going to do anything for it.

Podcast Contributors

Dr. Nora Perkins discusses Nasal Airway Management: Evolving Practices in Diagnosis and Treatment on the BackTable 158 Podcast

Dr. Nora Perkins

Dr. Nora Perkins is an otolaryngologyst with Albany ENT & Allergy Services in New York.

Dr. Ashley Agan discusses Nasal Airway Management: Evolving Practices in Diagnosis and Treatment on the BackTable 158 Podcast

Dr. Ashley Agan

Dr. Ashley Agan is an otolaryngologist in Dallas, TX.

Dr. Gopi Shah discusses Nasal Airway Management: Evolving Practices in Diagnosis and Treatment on the BackTable 158 Podcast

Dr. Gopi Shah

Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.

Cite This Podcast

BackTable, LLC (Producer). (2024, February 13). Ep. 158 – Nasal Airway Management: Evolving Practices in Diagnosis and Treatment [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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