ORIGINAL ARTICLE
Nasal airway obstruction: Prevalence
and anatomic contributors
David W. Clark, MD; Anthony G. Del Signore, MD, PharmD; Roheen Raithatha, MD;
Brent A. Senior, MD
Abstract
Surgical treatments for nasal airway obstruction
(NAO) are commonly offered as part of otolaryngology
practice. Anatomic causes include septal deviation, in-
ferior turbinate hypertrophy, and nasal valve collapse
(NVC). This study was performed to determine the
prevalence of anatomic contributors to NAO. A total
of 1,906 patients with sinonasal complaints were sur-
veyed by 50 otolaryngologists in varying U.S. geograph-
ic regions. Patients were first evaluated using the Nasal
Obstruction Symptom Evaluation (NOSE) instrument
to assess the NAO symptoms and their severity. Phy-
sicians then examined patients for the presence of the
three anatomic contributors. Presence of septal devia-
tion and turbinate hypertrophy was assessed through
an internal nasal exam with direct or endoscopic vi-
sualization based on the physician’s standard method-
ology for diagnosis. Presence of NVC was determined
by the modified Cottle maneuver. Among all patients
surveyed, prevalence was 67% for NVC, 76% for septal
deviation, and 72% for inferior turbinate hypertrophy.
We found that 64% of the patients (n = 1,211) had
severe/extreme NOSE scores (≥55), representing the
most likely nasal obstruction candidates for interven-
tion. In these patients, the prevalence of NVC, septal
deviation, and inferior turbinate hypertrophy was 73,
80, and 77%, respectively. Eighty-two percent of the 236
patients with severe/extreme NOSE scores who report-
ed prior septoplasty and/or inferior turbinate reduction
From the Department of Otolaryngology–Head and Neck Surgery,
Baylor Scott & White Health, and Texas A&M Health Science Center
College of Medicine, Temple, Texas (Dr. Clark); the Department of
Otolaryngology–Head and Neck Surgery, Mount Sinai Beth Israel,
New York, N.Y. (Dr. Del Signore); ENT & Allergy Associates, New
York, N.Y. (Dr. Raithatha); and the Department of Otolaryngology–
Head and Neck Surgery, University of North Carolina at Chapel
Hill, Chapel Hill, N.C. (Dr. Senior).
Corresponding author: Brent A. Senior, MD, Department of
Otolaryngology–Head and Neck Surgery, University of North
Carolina at Chapel Hill, 170 Manning Dr., Campus Box #7070,
Chapel Hill, NC 27599. Email: bsenior@med.unc.edu
Financial support: This study was supported with funding by Spirox,
Inc., Redwood City, Calif. Dr. Clark., Dr. Del Signore, and Dr.
Senior are consultants for Spirox, Inc.
Volume 97, Number 6
had NVC. Our study revealed a comparable prevalence
of all three anatomic contributors across all patients
and the subset with severe/extreme NOSE scores, high-
lighting the importance of evaluating the lateral nasal
wall as a component of NAO treatment strategy.
Introduction
Nasal airway obstruction (NAO) is a common present-
ing symptom in otolaryngology practices and has been
described as a source of significant patient discomfort
and financial burden.1,2 Diagnosis of nasal obstruction
includes symptom assessment via the Nasal Obstruc-
tion Symptom Evaluation (NOSE) instrument1 and
physical exam of the nasal valve, including lateral nasal
wall, septum, and inferior turbinates.
Etiologies of nasal obstruction consist of inflamma-
tory and anatomic contributors.3 Anatomic causes in-
clude inferior turbinate hypertrophy, septal deviation,
and nasal valve dysfunction.4 Nasal valve dysfunction
can have static and dynamic components, where
dynamic nasal valve dysfunction (hereby defined as
nasal valve collapse [NVC]) is caused by lateral wall
insufficiency. Many patients have more than one
anatomic cause for their nasal obstruction; however,
the prevalence of these anatomic causes has not been
reported. A survey of patients complaining of nasal
obstruction was conducted to establish the prevalence
of these anatomic causes.
Patients and methods
Patients’ identifying information was not collected;
therefore, Institutional Review Board approval was not
sought for this survey.
Fifty physicians, including general otolaryngologists,
rhinologists, and facial plastic surgeons in various U.S.
geographic regions surveyed patients with symptoms
of nasal obstruction and/or sinonasal complaints. Data
collected included (1) the severity of nasal obstruction,
(2) anatomic contributors to nasal obstruction, and (3)
history of nasal surgery.
The NOSE instrument was used to assess the severity
of nasal obstruction, using five questions, each scored
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 CLARK, DEL SIGNORE, RAITHATHA, SENIOR

on a scale of 0 to 4.1 The total NOSE score was converted hypertrophy. Most patients with NVC and inferior
to a 100-point scale, which defines nasal obstruction turbinate hypertrophy had bilateral contribution (84
severity using a classification system: mild (5 to 25), and 60%, respectively).
moderate (30 to 50), severe (55 to 75), or extreme (80 Among all patients, septoplasty and/or turbinate
to 100).5 The patient group with severe or extreme reduction procedure history was available for 331
scores was of interest as these patients are potential patients. Seventy-one percent (n = 236) of these
candidates for intervention. patients presented with severe/extreme nasal ob-
Three components of the nasal valve anatomy, struction. The prevalence of NVC in these patients
including the lateral nasal wall, septum, and inferior was 82% (table 2). Eleven patients reported previous
turbinates, were evaluated by physicians during office lateral nasal wall surgery. Other surgeries reported
visits. The evaluation included an internal nasal exam included functional endoscopic sinus surgery and
with direct or endoscopic visualization, based on the cosmetic rhinoplasty; these were not analyzed as they
physician’s standard methodology for diagnosis, and are not intended to address anatomic contributors
a modified Cottle maneuver. The modified Cottle to nasal obstruction.
maneuver (intranasal stabiliza-
tion of the lateral nasal wall) was Table 1. Prevalence of anatomic contributors in overall cohort of patients
performed to gently support the with nasal obstruction and those with severe/extreme obstruction
lateral nasal wall cartilage on each
side of the nose while the patient Anatomic contributor All patients Severe/ extreme
combination prevalence, % (n) N = 1,906 n = 1,211
was asked to inspire. A modified
6,7

Cottle maneuver was considered Nasal valve collapse

positive if the patient reported
NVC only 6% (121) 6% (72)
improvement in breathing.
NVC + septal deviation 13% (252) 14% (166)
Results NVC + inferior turbinate hypertrophy 7% (138) 7% (85)
A total of 1,906 patients were NVC + septal deviation + inferior turbinate 40% (762) 46% (558)
surveyed by 50 physicians from hypertrophy
nine U.S. states (Calif., Fla., Ga., Total NVC 67% (1,273) 73% (881)
Ill., In., N.C., N.Y., Pa., and Tex-
as). Based on the NOSE scores,
most (63%) patients had severe Septal deviation
(37%) or extreme (26%) nasal Septal deviation only 5% (102) 2% (28)
obstruction, 24% reported mod- Septal deviation + inferior turbinate
erate nasal obstruction, and 11% 18% (337) 18% (213)
hypertrophy
had mild nasal obstruction. A NVC + septal deviation 13% (252) 14% (166)
small number of patients (2%)
NVC + septal deviation + turbinate 40% (762) 46% (558)
were asymptomatic. hypertrophy
Most patients had multiple
Total septal deviation 76% (1,453) 80% (965)
anatomic contributors (table 1).
Among all patients, the prev-
alence was 67% for NVC, 76% Inferior turbinate hypertrophy
for septal deviation, and 72% for Inferior turbinate hypertrophy only 7% (131) 6% (72)
inferior turbinate hypertrophy. Inferior turbinate hypertrophy + septal 18% (337) 18% (213)
The prevalence in the subgroup deviation
of patients with severe/extreme
NVC + inferior turbinate hypertrophy 7% (138) 7% (85)
nasal obstruction for NVC, septal
deviation, and inferior turbinate NVC + septal deviation + inferior turbinate 40% (762) 46% (558)
hypertrophy
hypertrophy was 73, 80, and 77%,
respectively. Among the patients Total inferior turbinate hypertrophy 72% (1,368) 77% (927)
considered to be symptomatic (se-
vere/extreme nasal obstruction, Asymptomatic 3% (63) 1% (17)
n = 1,211), 46% presented with
NVC, 51% had septal deviation,
Key: NVC = nasal valve collapse.
and 49% had inferior turbinate

174 www.entjournal.com ENT-Ear, Nose & Throat Journal June 2018

 NASAL AIRWAY OBSTRUCTION: PREVALENCE AND ANATOMIC CONTRIBUTORS
Table 2. Prevalence of NVC among patients with severe/extreme nasal obstruction who reported prior
septoplasty and/or inferior turbinate reduction
Septoplasty and inferior
turbinate reduction
(n = 157)
Anatomic contributors*
NVC 82% (128)
Septal deviation 52% (82)
Inferior turbinate hypertrophy 46% (73)
*Anatomic contributors are not mutually exclusive.
Discussion
To the best of our knowledge, this is the largest as-
sessment of the prevalence of anatomic contributors
to nasal obstruction that has been conducted. The re-
sults showed that NVC (73%) was as common as sep-
tal deviation (80%) and inferior turbinate hypertrophy
(77%) in patients with severe/extreme nasal obstruction.
Furthermore, in a subset of patients with severe/extreme
nasal obstruction despite prior septoplasty and/or inferi-
or turbinate reduction, NVC prevalence was high (82%),
suggesting that missed or untreated NVC may be associ-
ated with symptom persistence.
Nasal obstruction is associated with a reduction
in quality of life and is a common surgically treated
problem.8,9 Identification of anatomic contributor(s)
is critical for selection of an appropriate treatment
strategy. The finding that septal deviation, inferior tur-
binate hypertrophy, and NVC are common anatomic
contributors to nasal obstruction is consistent with the
frequency of septoplasty and inferior turbinate reduc-
tion procedures performed by otolaryngologists.10,11
Unfortunately, surgery is associated with dimin-
ished satisfaction and persistent nasal obstruction
over time.12,13 Furthermore, a fraction of the patients
with NAO who were ideal candidates for septoplasty
did not achieve significant improvement after the
procedure.1,14 Although these results show that NVC
is an equally prevalent anatomic contributor, analysis
of commercial payer and Medicare fee-for-service data
indicates that its surgical correction is less frequent
than septoplasty and inferior turbinate reduction. A
potential explanation for this divergence in treatment
is infrequent screening for NVC.
Most patients with nasal obstruction have multiple
anatomic contributors, and diagnoses of septal devia-
tion and inferior turbinate hypertrophy are commonly
achieved; however, surgical techniques to address
these anatomic contributors do not directly address
weakness in the lateral nasal wall.15 The NVC clinical
consensus statement published in 2010 concluded that
Volume 97, Number 6
Septoplasty Inferior turbinate
only reduction only
(n = 54) (n = 25)
83% (45) 80% (20)
52% (28) 72% (18)
72% (39) 48% (12)
NVC is a distinct etiology for nasal obstruction and
that the validity of the modified Cottle maneuver for
identifying NVC suggests suitability for inclusion in
examinations.6
Previous reports of patients who underwent revision
septoplasty and who suffered from persistent nasal
obstruction after their primary septoplasty showed
that NVC was highly prevalent and frequently re-
quired correction during the revision surgery.16 This
finding, coupled with high prevalence rates in patients
with severe/extreme nasal obstruction, suggests that
more routine diagnosis of NVC may inform optimal
treatment for patients.
Treatment options for NVC include invasive car-
tilaginous grafts, such as batten grafts and lateral
crural strut grafts, and less invasive options, such as
absorbable nasal implants. Temporary, noninvasive
options include nasal strips and dilators. This survey
did not examine the outcomes of the treatment options.
This survey showed that the prevalence of NVC was
as common as the prevalence of septal deviation and
inferior turbinate hypertrophy in patients with nasal
obstruction. Therefore, assessment of all anatomic
contributors, including NVC, is critical to ensure
adequate symptom reduction.
Acknowledgments
The authors thank the following physicians for par-
ticipating in this survey: Ford Albritton, MD (Texas);
Steven Bomeli, MD (Ga.); Russell Briggs, MD (Tex-
as); Robert Butler, MD (Texas); Jeffrey Campbell, MD
(N.C.); Ajaz Chaudhry, MD (Ga.); David Clark, MD
(Texas); Michael Cohen, MD (N.Y.); William Cohen,
DO (Calif.); Chris Dehan, MD (Texas); Anthony Del
Signore, MD (N.Y.); Jeff Feinfield, MD (Calif.); Alexis
Furze, MD (Calif.); David Godin, MD (N.Y.); Barba-
ra Goheen, MD (N.C.); Alexander Goldin, MD (Ill.);
Douglas Holmes, MD (N.C.); Raymond Howard, MD
(Ga.); Thomas Hung, MD (Texas); Bennie Jarvis, MD
www.entjournal.com 175
 CLARK, DEL SIGNORE, RAITHATHA, SENIOR

(N.C.); Richard Jones, MD (N.C.); Paul Juengel, MD

(N.C.); Alex Kim, MD (Ill.); Daniel Kurtzman, MD
(Ill.); Charles Lano, MD (Texas); Michael Layland, MD
(Ill.); Gregory Levitin, MD (N.Y.); Frederic Levy, MD
(N.C.); Lisa Liberatore, MD (N.Y.); Douglas Liepert,
MD (In.); Neal Lofchy, MD (Ill.); Ram Madasu, MD
(Fla.); Neelesh Mehendale, MD (Texas); Rob Nason,
MD (Texas); Anand Ponnappan, MD (Ill.); Roheen
Raithatha, MD (N.Y.); Suresh Raja, MD (Fla.); Angelo
Reppucci, MD (N.Y.); Waldemar Riefkohl, MD (N.C.);
Aaron Rogers, MD (Ga.); Cooper Scurry, MD (N.C.);
Luke Shellenberger, MD (Texas); Farhad Sigari, MD
(Calif.); Richard Thrasher III, MD (Texas) Satish Va-
dapalli, MD (Calif.); Glenn Waldman, MD (Calif.);
Richard Weinstock, DO (Fla.); Allison Wyll, MD (Tex-
as); David Yen, MD (Pa.); Jay Youngerman, MD (N.Y.).

References
1. Stewart MG, Smith TL, Weaver EM, et al. Outcomes after nasal
septoplasty: Results from the Nasal Obstruction Septoplasty
Effectiveness (NOSE) study. Otolaryngol Head Neck Surg
2004;130(3):283-90.
2. Chandra RK, Patadia MO, Raviv J. Diagnosis of nasal airway
obstruction. Otolaryngol Clin North Am 2009;42(2):207-25.
3. Moche JA, Palmer O. Surgical management of nasal obstruction.
Oral Maxillofac Surg Clin North Am 2012;24(2):229-37.
4. Barrett DM, Casanueva FJ, Cook TA. Management of the nasal
valve. Facial Plast Surg Clin North Am 2016;24(3):219-34.
5. Lipan MJ, Most SP. Development of a severity classification
system for subjective nasal obstruction. JAMA Facial Plast Surg
2013;15(5):358-61.
6. Rhee JS, Weaver EM, Park SS, et al. Clinical consensus statement:
Diagnosis and management of nasal valve compromise.
Otolaryngol Head Neck Surg 2010;143(1):48-59.
7. Fung E, Hong P, Moore C, Taylor SM. The effectiveness of
modified cottle maneuver in predicting outcomes in functional
rhinoplasty. Plast Surg Int 2014;2014:618313.
8. Rhee JS, Book DT, Burzynski M, Smith TL. Quality of life
assessment in nasal airway obstruction. Laryngoscope
2003;113(7):1118-22.
9. Bhattacharyya N. Ambulatory sinus and nasal surgery in the
United States: Demographics and perioperative outcomes.
Laryngoscope 2010;120(3):635-8.
10. Manoukian PD, Wyatt JR, Leopold DA, Bass EB. Recent trends
in utilization of procedures in otolaryngology–head and neck
surgery. Laryngoscope 1997;107(4):472-7.
11. Brunworth J, Holmes J, Sindwani R. Inferior turbinate
hypertrophy: Review and graduated approach to surgical
management. Am J Rhinol Allergy 2013;27(5):411-15.
12. Illum P. Septoplasty and compensatory inferior turbinate
hypertrophy: Long-term results after randomized turbinoplasty.
Eur Arch Otorhinolaryngol 1997;254 Suppl 1:S89-92.
13. Roblin DG, Eccles R. What, if any, is the value of septal surgery?
Clin Otolaryngol Allied Sci 2002;27(2):77-80.
14. Siegel NS, Gliklich RE, Taghizadeh F, Chang Y. Outcomes of
septoplasty. Otolaryngol Head Neck Surg 2000;122(2):228-32.
15. Matthias C. Surgery of the nasal septum and turbinates. GMS
Curr Top Otorhinolaryngol Head Neck Surg 2007;6:Doc10.
16. Becker SS, Dobratz EJ, Stowell N, et al. Revision septoplasty:
Review of sources of persistent nasal obstruction. Am J Rhinol
2008;22(4):440-4.

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