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 septal deviation and/or inferior turbinate hypertrophy, increasing clinical evidence suggests that incompetence of the internal or external nasal valves may also affect airflow. But how much? What is the relative importance 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 perforation and operated on for correctable nasal airway obstruction were evaluated prospectively by anterior active mask rhinomanometry preoperatively and from 1 to 43 months (mean 8.4 months) postoperatively after 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 combination of the three. Geometric mean nasal airflow was calculated from independent measurements of each nasal airway. Surgical treatment consisted of submucous septal resection, internal valvular reconstruction with dorsal or spreader grafts, and external valvular reconstruction with cartilage or bone grafts; inferior turbinectomy was not performed. All procedures were performed endonasally. In the entire 160 patient study group, septal and/or valvular surgery corrected the airway in 152 patients (95 percent); 8 patients had partial residual obstruction. Our data support the prior rhinologic data in showing only a modest (and statistically insignificant, p < 0.4, n = 25) improvement in (geometric) mean nasal airflow following septal surgery alone. However, external valvular reconstruction alone increased airflow 2.6 times over preoperative values (n = 10). Internal valvular reconstruction alone by dorsal grafts (n = 17) or spreader grafts (n = 29) increased nasal airflow 2.0 times; spreader grafts and dorsal grafts were equally effective in supporting the internal valves. The largest improvement in postoperative 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 improvement as patients in whom valvular plus septal obstruction was corrected. Finally, valvular reconstruction in 54 secondary rhinoplasty patients who had previously undergone septoplasty corrected the airway obstruction in 49 patients (91 percent). Notably, 110 of 160 patients (69 percent) had a lateralized preoperative obstruction; however, the septum was deviated toward the clinically obstructed side in only 51 of these patients (46 percent); in the other 54 percent, the subjectively obstructed side was contralateral to the side toward which the septum was deviated. Nasal valvular function should be assessed in all preoperative rhinoplasty patients with airway obstruction; in many individuals, valvular effects may equal or surpass septal deviation as the primary cause of nasal airflow obstruction.