Zoumalan RA, Constantinides M. Subjective and Objective Improvement in Breathing After Rhinoplasty. Arch Facial Plast Surg. 2012;14(6):423-428. doi:10.1001/archfacial.2012.665
Author Affiliations: Department of Otolaryngology–Head and Neck Surgery, Cedars Sinai Medical Center, Beverly Hills, California (Dr Zoumalan); and Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology–Head and Neck Surgery, New York University School of Medicine, New York (Dr Constantinides).
Objective To determine whether rhinoplasty improves subjective and objective nasal patency.
Design Retrospective study including subjective breathing scores and acoustic rhinometry before and 6 to 9 months after septorhinoplasty among a cohort of 31 patients. We used a paired t test to analyze the difference between preoperative and postoperative values.
Setting Academic medical center.
Patients Patients undergoing septorhinoplasty with potassium titanyl phosphate laser turbinate reduction at a single institution.
Results The mean subjective breathing scores improved significantly, with an overall improvement of 38%. The overall mean volume increased and the overall resistance decreased, but the changes were significant only on the right side. The minimal cross-sectional area (MCA) did not change, but the distance of the MCA of the nasal cavity moved anteriorly by 0.23 cm on the left side. The patients were stratified into subsets based on other procedures undergone, including spreader grafts and alar batten grafts, and on the absence of osteotomies. These groups had similar results. In patients with severe obstruction, all measured values improved more than any other subgroup, including the MCA, which improved significantly by an average of 55%. Patients with normal preoperative MCA values did not experience any significant changes except for an anterior shift in MCA.
Conclusions Septorhinoplasty increases nasal volume, decreases nasal resistance, and advances the MCA anteriorly. These changes coexist with subjective improvements in nasal patency, which suggests that this new anatomic configuration creates a positive outcome on nasal airflow. Spreader grafts do not increase the MCA significantly. Patients with preoperative severe obstruction have the best overall improvement, whether measured subjectively or objectively.
Functional rhinoplasty uses a combination of aesthetic principles and knowledge of causes and remedies of nasal obstruction to improve a patient's nose cosmetically and to optimize nasal airflow. In addition to the various procedures used to improve the cosmetic outcomes, today's functional rhinoplasty frequently includes septoplasty and turbinate reduction. Cartilage grafts, such as spreader and alar batten grafts, are often used to decrease nasal obstruction/valve collapse and to improve the aesthetic appearance of the nose.
Each nose is different and requires a holistic evaluation. This preoperative assessment includes subjective and objective measurements. For one us (M.C.), the subjective evaluation includes recording patients' perceptions of nasal airflow with and without modified Cottle maneuvers. Modified Cottle maneuvers are performed with a cerumen curette placed intranasally to support the upper and lower lateral cartilages individually. These maneuvers are used to determine the existence of collapse of the internal or external nasal valves.1 This evaluation is repeated 6 months postoperatively to assess functional outcomes.
The objective evaluation involves the use of acoustic rhinometry. More than 2 decades ago, acoustic rhinometry was first introduced by Hilberg et al2 as a noninvasive objective determination of the cross-sectional area of the nasal cavity. Acoustic rhinometry uses acoustic reflections to measure the cross-sectional area as a function of the distance from the nostril. The effect of septorhinoplasty on nasal patency has been studied using acoustic rhinometry with varied results. In a study by Grymer,3 reduction rhinoplasty for cosmetic reasons was shown to decrease the minimal cross-sectional area (MCA; at the nasal valve) significantly by 22% to 25%; the MCA at the pyriform aperture decreased by 11% after osteotomies. Guyuron4 argued that nasal osteotomies do not affect the airway in most instances. However, in anatomic cadaveric studies using acoustic rhinometry, Grymer and colleagues5 demonstrated that, in general, low and high lateral osteotomies decrease the anterior dimensions of the nose. The total MCA decreased by 12%, and the cross-sectional area at the pyriform aperture decreased by 15% postoperatively. Schlosser and Park6 used acoustic rhinometry on cadavers to demonstrate that spreader grafts, flaring sutures, and batten grafts all independently improve cadaveric MCAs, with the combination of spreader grafts and flaring sutures having the greatest impact.
Useful objective data on the overall effect of septorhinoplasty on nasal obstruction are difficult to collect because each operation includes different combinations of, for example, grafts, turbinoplasty, sinus surgery, and struts. Such data would be useful to inform patients how their overall nasal breathing would be affected by septorhinoplasty, for better or for worse. In addition, in an age when third-party insurers increasingly require objective data to justify authorization for reimbursement, an objective evaluation would prove helpful. An attempt to gather data on individual parts of septorhinoplasty, such as osteotomies, is helpful in this determination. However, the complex nature of rhinoplasty limits the ability to analyze the effect of a specific maneuver.
In this study, we focused on the objective and subjective analysis of septorhinoplasty in consecutive patients. The patients in this study underwent a multitude of procedures as part of septorhinoplasty. Thus, we focused on the cumulative effect of all these procedures and then tried to analyze the effects of the different individual maneuvers used.
We performed a retrospective study of 31 consecutive patients (22 women and 9 men) who requested septorhinoplasty for cosmetic and functional reasons. Ages ranged from 18 to 57 (mean, 36) years. All operations were performed by one of us (M.C.).
All 31 patients underwent acoustic rhinometry before and after decongesting during the week before the operation and then during a follow-up visit 6 to 9 months later. We used an acoustic reflection pharyngometer (Eccovision; Hood Laboratories). A single experienced technician performed all acoustic rhinometry measurements. Measurements were repeated to ensure precision. Preoperative and postoperative values measured included the MCA (in centimeters squared) and the distance of the MCA from the nasal sill (in centimeters). The volume of nasal cavity (in milliliters) and nasal resistance (in centimeters of water per liter per minute) were derived by the pharyngometer's calculation. For purposes of analysis, the results reflect postdecongestion values to negate the effects of congestion due to various factors, including the nasal cycle, seasonal allergies, and changes in ambient temperature, which have all been shown to affect acoustic rhinometry results.7
During the preoperative and postoperative visits, 23 of the 31 patients underwent an extensive subjective analysis of nasal patency with modified Cottle maneuvers to analyze the internal and external nasal valves. For each maneuver, patients reported a score on a scale of 1 (totally obstructed) to 10 (excellent, unobstructed breathing).
All 31 patients in the study underwent septoplasty. All but 5 patients underwent turbinoplasty using a potassium titanyl phosphate (KTP) laser. The KTP laser turbinoplasty consisted of 6 W of continuous power delivered through a flexible light carrier passing through a dual-channel suction cannula with a suction port. Each inferior turbinate was treated by vaporizing 2 channels along the length of the turbinate, leaving intact bridges of mucosa between channels to facilitate reepithelialization. When treated this way, inferior turbinates were routinely not out-fractured.
Twenty-two patients underwent bilateral low lateral internal osteotomies; 2, bilateral medial internal osteotomies. Six patients did not receive osteotomies. Eighteen patients had placement of dome-binding sutures. Six patients underwent concomitant bilateral functional endoscopic sinus surgery.
In all but 2 patients, the source of all grafts was septal cartilage. The other 2 patients had conchal cartilage grafts. Four patients had bilateral and 9 had unilateral spreader grafts. Of patients who underwent alar batten grafts, 14 grafts were bilateral and 6 were unilateral. Twenty-two patients received columellar strut grafts. Three patients received a graft fashioned from diced cartilage wrapped with absorbable cellulose-based material (Surgicel; Ethicon, Inc) or irradiated cadaveric dermis for dorsal augmentation. Three patients received nasal tip grafts. Two patients underwent bilateral upper lateral cartilage reductions, and 2 underwent bilateral cephalic trim. Five patients had vertical lobule divisions with reconstruction of the intact strip by overlapping the cut cartilages and suture fixation.
A paired t test was used to analyze the preoperative and postoperative differences in the subjective breathing scores and the objective acoustic rhinometry measurements.
After cosmetic/functional septorhinoplasty, the overall subjective breathing score significantly improved by 2.27 points (38% improvement) compared with the preoperative value (P = .01) (Table 1). This value was correlated with subjective improvement on the right and left sides by 60% and 51%, respectively (P = .02 and P = .005, respectively). In the evaluation using modified Cottle maneuvers, all patients significantly improved as well.
When obtaining the mean postdecongestion acoustic rhinometry values of all 31 patients, we found statistically significant anterior shifts in the distance of the MCA from the nasal sill postoperatively (Table 2). On the right side, the MCA moved 0.30 cm anteriorly; on the left side, 0.19 cm anteriorly. Compared with preoperative values for all 31 patients, the mean difference in overall volume of the nasal cavity measured by acoustic rhinometry increased bilaterally but only reached significance on the right side, where there was a 43% increase in nasal volume (P = .049). Similarly, the resistance decreased bilaterally but only reached significance on the right side, where there was a 19% decrease in resistance postoperatively (P = .02). The mean MCA of the 31 patients did not change significantly on either side.
When the groups were stratified into subsets by specific procedures, similar results were obtained. In the 14 patients who received bilateral batten grafts, a similar shift in MCA distance occurred anteriorly, but this shift was significant on the left side only, with a 0.23-cm anterior shift (P = .01) (Table 3). Significant changes in resistance (30% decrease) and volume (29% increase) also occurred on the right side. Once again, the change in MCA value did not reach significance.
Among the 13 patients who received left spreader grafts, a 0.42-cm anterior shift in MCA distance occurred (P = .04) but without a significant change in the resistance, volume, or MCA (Table 4). Among the 4 patients with right spreader grafts, we found no significant change in any of the values (volume, resistance, MCA, or MCA distance). Patients without osteotomies had a significantly increased MCA and volume on the right side only, but the differences did not reach statistical significance in any other measured category (Table 5). Patients who underwent functional endoscopic sinus surgery did not have a statistically significant change in any measured value except shift in MCA distance anteriorly on 1 side (Table 6).
In the 7 sides (each side of patients' noses evaluated independently) of unilateral obstruction, defined by an abnormally low MCA (<0.30 cm2), postoperative MCA increased significantly by an average of 55% (P = .048) (Table 7). This subset alone showed a significant improvement in all measurements (volume, resistance, MCA location, and MCA). All measured values in this subset had the largest percentage of change/improvement compared with any other subset. The percentage change in all values was also greater than the overall mean values for all 31 patients.
In the 28 sides (each side of patients' noses evaluated independently) with mild obstruction (MCA, 0.30-0.50 cm2), the volume increased and the MCA shifted anteriorly (Table 7). However, the changes in these values (24% and 22%, respectively) were less than those of the groups with severe obstruction. Resistance and MCA values did not change significantly. In the 27 sides with normal MCA values (>0.50 cm2), the only value with significant change was an anterior shift in MCA (Table 7).
All 31 patients in the study had significant subjective improvements in breathing after functional septorhinoplasty with KTP laser turbinoplasty. When patients' functional breathing was evaluated with acoustic rhinometry, resistance decreased and volume increased in all patients, but the differences only reached statistical significance on the right side.
The MCA at the internal nasal valve is bounded by the septum, the caudal edge of the upper lateral cartilage, the anterior portion of the inferior turbinate, and the pyriform floor. We expected that, after septoplasty and reduction of the inferior turbinates, the MCA would change significantly. However, the MCA improved significantly only in patients who had a very low MCA on one side preoperatively (ie, in those with unilateral severe obstruction).
One subset that should have had an increase in MCA postoperatively was the group in which spreader grafts were placed. In this group, the MCA did not change significantly. However, the MCA moved anteriorly in most subsets and in the overall group. Furthermore, the combination of low lateral continuous osteotomies, septoplasty, and inferior turbinate reduction shifted the MCA (internal nasal valve) anteriorly but did not change it unless a patient had significant preoperative obstruction. In the group with significant preoperative obstruction, the MCA increased, contradicting the findings of the earlier study by Grymer.3
The significance of this anterior shift in MCA position is unclear. This shift may be an incidental finding without any clinical relevance, and it may correspond to a shift of the internal valve toward the sill. Another possibility may be that we widen the cross-sectional area of the internal valve to a degree that the area with the smallest cross-sectional area becomes the area just anterior to the internal nasal valve. A third possibility is related to a change in the shape of the inferior turbinate head. Laser turbinoplasty flattens the rounded head of the inferior turbinate. The MCA may have initially been at this bulbous area. As the bulbous inferior turbinate head is flattened, the MCA is found at the anterior aspect of the inferior turbinate. Furthermore, many patients have septal spurs at the area of the internal valve that are routinely removed during septoplasty. This procedure may have also affected the location of the MCA. As for the difference in the results of the right vs left sides of the nose, it remains unclear why this exists. The surgeon who performed this procedure is right-handed, and a difference in the treatment of each side may be the reason.
In patients with severe obstruction, septorhinoplasty provides the greatest improvement in nasal patency. These patients constituted the only subset with significant improvement in all objective measurements. This information is consistent with a previous study by Constantinides et al8 that demonstrated that patients with severe obstruction derive the greatest benefit from this procedure. In patients with mild obstruction, the volume of their nasal cavities increased but did not objectively improve as much as in patients with severe obstruction. In patients with normal preoperative MCA values, their nasal patency did not change with surgery. Our values indicate a gradation of benefit that depends on preoperative MCA values in which those of lower initial MCA values benefit the most from septorhinoplasty.
The combination of the increase in nasal cavity volume, the decrease in overall resistance, and the shift in MCA forward creates entirely new boundaries for airflow in patients after septorhinoplasty. In our analysis, we find significant subjective improvement overall in those patients who have this new geometry. The MCA may serve as a rate-limiting factor, but decreases in overall resistance and increases in nasal volume may give the patient an overall improvement in nasal patency.
In the subsets of patients undergoing procedures in addition to septoplasty and KTP laser turbinate reductions, we would expect some to improve their objective acoustic rhinometry values further. For example, spreader grafts have been shown in previous studies to improve cadaveric MCAs.6 We would expect this subset of patients to have an even greater increase in nasal volume than other subjects. However, these values were similar to those of other patients. This finding calls into question the actual effects that spreader grafts have on MCA and the internal nasal valve. Based on our analysis, spreader grafts may not have as great a clinical impact as previously thought.
Septorhinoplasty increases nasal volume and decreases nasal resistance. In addition, it advances the MCA anteriorly. These changes coexist with subjective improvements in nasal patency, which suggests that this new anatomic configuration after septorhinoplasty and inferior turbinoplasty creates a positive outcome on nasal airflow. Spreader grafts do not increase the MCA significantly. Patients with preoperative severe obstruction have the best overall improvement, whether measurements are subjective or objective.
Correspondence: Richard A. Zoumalan, MD, Department of Otolaryngology–Head and Neck Surgery, Cedars Sinai Medical Center, 9401 Wilshire Blvd, Ste 1105, Beverly Hills, CA 90212 (DrZ@BHfaceMD.com).
Accepted for Publication: April 23, 2012.
Published Online: September 10, 2012. doi:10.1001/archfacial.2012.665
Author Contributions:Study concept and design: Zoumalan and Constantinides. Acquisition of data: Zoumalan and Constantinides. Analysis and interpretation of data: Zoumalan and Constantinides. Drafting of the manuscript: Zoumalan. Critical revision of the manuscript for important intellectual content: Zoumalan and Constantinides. Statistical analysis: Zoumalan. Administrative, technical, and material support: Zoumalan and Constantinides. Study supervision: Constantinides.
Financial Disclosure: None reported.