The Upper Airway Nasal Complex: Structural Contribution to Persistent Nasal Obstruction

Abstract

Objective To determine the contribution of the nasal floor and hard palate morphology to nasal obstruction for nonresponders to prior intranasal surgery. Study Design Retrospective case-control study. Setting Tertiary academic center. Methods Institutional review board–approved, retrospective institutional database analysis was obtained of a cohort of 575 patients who presented with nasal obstruction over a 21-year period. Of the patients, 89 met inclusion criteria: 52 were placed into the experimental group, defined as having persistent nasal obstruction following endoscopic sinus surgery (ESS), septoplasty, nasal valve repair, and/or turbinoplasty using validated subjective questionnaires, and 37 were placed into the control group, defined as having resolution of subjective nasal obstruction. Computed tomography imaging was presented to 3 blinded experts, who measured numerous nasal airway and hard palate morphology parameters, including anterior nasal floor width, anterior maxillary angle, maxilla width, anterior nasal floor width, and palatal vault height. Standard demographic information, comorbidities, perioperative 22-item Sinonasal Outcome Test (SNOT-22), and follow-up time were also assessed. Wilcox rank sum analysis or t test was performed where appropriate. Results Follow-up ranged from 2 to 36 months following surgical intervention. Several skeletal characteristics within the upper airway were significantly associated with persistent nasal obstruction, including acute maxillary angle ( P = .035), narrow maxillary width ( P = .006), and high arched palate ( P = .004). Conclusion Persistent nasal obstruction may be seen in patients with narrow, high arched hard palate despite prior nasal surgical intervention and may benefit from additional skeletal remodeling procedures such as maxillary expansion.

Causative Factors for Complications in Transpalatal Advancement

“…Surgeons contemplating TPA on patients with high-arched hard palates should do so with caution and consider altering the approach to a propeller rather than gothic arch incision, as well as forewarning their patients of the increased risk of developing a fistula. 132 (0.48) 0 (0.57) Gastroesophageal reflux (8) 1 (0.67) 0 (1.00) Inflammatory nasal disease (20) 4 (0.54) 1 (1.00) High-arched palate (13) 5 (0.28) 4 (0.0016) Current smoker (10) 2 (1.00) 0 (1.00) Previous palate surgery (8) 2 (1.00) 0 (1.00) OSA severity (mild vs. moderate vs. severe) P = .29 P = .71…”

“…Currently there is no objective clinical criteria or measurable anatomical landmarks to identify a patient who has a high-arched palate. Radiological computed tomography measurements of narrower maxillary width have correlated a higher-arched palate to persisting nasal obstruction following soft tissue surgery, 13 but the difference was 1 mm, making it very hard to identify in the clinical setting and its relevance to TPA surgery is unknown. The degree of arching that becomes clinically relevant for OSA, nasal obstruction, and TPA surgery has yet to be properly explored.…”

Anatomy and Pathophysiology of Upper Airway Obstructive Sleep Apnoea: Review of the Current Literature

“…In addition, mouth breathing narrows the pharyngeal lumen, reduces retroglossal diameter due to further posterior displacement of the tongue, increases soft palate length, and oscillates redundant pharyngeal tissues [17,18,[24][25][26]. Furthermore, prolonged mouth breathing may lead to facial changes which can lead to a narrow nasal floor and deviated nasal septum [27].…”

Surgical Algorithm for Obstructive Sleep Apnea: An Update

“…Expansion of the adult nasal floor is useful for OSA patients who present with narrow and high-arch maxilla [15]. Patients with this phenotype tend struggle with both nasal obstruction and lack of intraoral volume for the tongue during sleep.…”

“…1 ). This is the classic adenoid facies associated with chronic mouth breathing [ 13 - 15 ]. The internal nasal valve (INV), the most restrictive part for nasal airflow, is a target for intervention.…”