Nasal Airway Obstruction Symptoms & Treatment

[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 complaints. 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 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 symptom, 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.

[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.