Dr. Carlo Govoni – Ear, nose and throat specialist – Columbus Clinic Center
Our nose is an essential organ for breathing. In fact, if we breathe well through our nose, we can be sure that only air that has been appropriately purified, humidified and warmed reaches our lungs.
The nasal cavity is divided into two vertical parts by the nasal septum. The inside walls of the nose have three mounds: the lower, middle and upper turbinate bones (Figure 1), and it is these that do the most important work: humidifying, purifying and warming. So in order to work properly, the two nasal cavities must be the same size and the turbinate bones must have a normal structure.
The respiration of the lungs relies on good nasal respiration, and this is why the latter is so important. Many people, above all those who do not do regular exercise, think that they breathe well even though they have a deviated nasal septum or very enlarged turbinate bones. A good nasal respiration needs to be evaluated over a long period of time. While our organism adapts itself to many changes and anomalies during its development from infancy to maturity, this is not true for the elderly. In fact, it is in elderly subjects that we see that correct nasal respiration is fundamental in order to guarantee adequate pulmonary ventilation.
A normal nasal structure undergoes changes for many reasons. These are sometimes due to anomalies related to physical development, but more often they are due to trauma. During the course of a medical examination, the specialist will often diagnose a deviation of the septum and an increase in volume of the turbinate bones (or hypertrophy). One frequently found anomaly is hypertrophy of the lower turbinate bone that has developed to compensate for the deviation of the nasal septum (Figure 2). In this case, the nasal septum shifts to one side and the turbinate bone on the other side increases in volume, making it difficult for air to pass through the nose.
A visit to an ear, nose and throat specialist can verify if there are any problems with nasal respiration. At the Columbus Clinic Center, our specialists use rhinofibroscopy with fibre optical technology to carry out a complete evaluation. This equipment allows the medical team to actually see inside the nose, and obtain an overview of all the nasal and nasopharyngeal anatomy. A computed tomography (CT) scan is an important complementary examination that allows the specialist to analyse the nasal cavities and the paranasal sinuses.
The patient does not always report having any problems breathing, and this is found, above all, in people who breathe from only one nostril. The open nostril creates a situation of relative compensation. The patient gets used to this, and then thinks that he or she is breathing normally. Unfortunately, nasal respiration as a phenomenon is slightly more complex than this. We all have a “nasal cycle” in which air can enter easier in one nostril than the other. Later, this cycle is inverted. When respiration through the two nostrils is clearly asymmetrical, then the patient will go from periods in which he or she is breathing well to others in which slight breathing difficulties are experienced. This imbalance often requires correction because the nasal respiration as a whole is compromised.
Numerous pharmaceutical products have been made available on the market to cure these defects. These contain cortisones and act on the inflamed turbinate bones, but they are slow acting and not always efficacious. There are also fast action sprays with vasoconstrictors to reduce the blood flow in the turbinate bones. People who use them tend to use them frequently because the effect does not last long. The risk is that a continuous use of these sprays can lead to a real pathological situation: drug-induced hypertrophy of the turbinate bones. This is why ear, nose and throat specialists rarely prescribe vasoconstrictors.
If the problem is a deviation of the nasal septum, then pharmacological medication is not going to help and the only solution is surgery.
Various clinical profiles can be observed. There are examples of hypertrophy of the turbinate bones with the septum in axis and others with septum deviation with or without any hypertrophy of the turbinate bones. As always, more than one solution is possible and each case is evaluated individually.
Cases in which only hypertrophy of the turbinate bones is presented can be treated with a recently introduced technique that has changed the approach to this type of surgery: devascularisation with radiofrequency ablation (Figure 3). This can be carried out under local anaesthetic, the intervention lasts about 20 minutes, and does not require nasal plugging. This is considered a mini-invasive technique and consists of introducing an electrode (similar to a long needle) connected to a special device to reduce the volume of the turbinate bone. The surgeon can continue treatment for as long as needed (Figure 4). One of the main advantages of this technique is the fact that there is little bleeding, and it is suitable for use among adolescents and the elderly.
If the patient has a particularly pronounced deviation of the nasal septum then a more complex intervention, septoplasty, can be considered. Obviously, if besides the deviation of the nasal septum the patient presents hypertrophic turbinate bones, then the septoplasty and devascularisation will be carried out in one session. These cases require a general anaesthetic and a 2- or 3-day stay in the clinic.
A further surgical option is also available. Some people are not happy with the shape of their nose, and they often have not only alterations to the nasal septum and the nasal cavities, but a more complex situation. For some time now all these problems have been solved with a single operation: functional rhinoplasty. This corrects the dysmorphic nasal pyramid, straightens the nasal septum and can also reduce the volume of the turbinate bones. In other words, three interventions that can improve respiration are carried out in a single operation.
Since the nose is made up of bone and cartilage, surgery is the solution that immediately comes to mind to resolve any respiratory problems. Devascularisation of the turbinate bones, septoplasty and rhinoplasty are to be considered interventions to be carried out to improve an anatomical problem. These are not urgent operations but are therapeutical solutions to be carried out with the least risk to the patient. Such surgical procedures should be carried out when the patient is young or in maturity. It is useful to remember that a good air passage through the nose should be achieved as soon as possible, and this is even more important as the patient gets older. In fact, in the over 70s, the body responds slower and breathing air that is too cold or that is full of fine particles or other impurities can only worsen pulmonary ventilation. If cold air is not sufficiently warmed by the nose, then the patient can run the risk of tracheitis and bronchitis. Even those particles that are not filtered by the nose can reach the bronchial tree and stimulate the production of catarrh, and this will need to be continuously expelled through repeated coughing.
It is clear that interventions that can improve nasal respiration offer concrete advantages. They are useful in the short term to improve respiration, but they can also help people as they advance in age. Improving nasal respiration can, in some cases, have indirect advantages such as improving the sense of smell or reducing headaches. None of these considerations should be underestimated, but should be evaluated case by case in an effort to improve quality of life.
It is now well-known that good nasal respiration helps people sleep and enables them to get up in the morning feeling rested and refreshed, and this is important in getting through the day. Today, the medical community knows much more about sleep and snoring, and it has been seen that good oxygenation during the night is important in preventing pulmonary and cardiovascular disease.
All of the interventions described here, whether carried out under local anaesthetic or, even more importantly, under general anaesthetic, are available at the Columbus Clinic Center. Some techniques, and in particular, those using radiofrequency ablation, are not widely used, so these types of operations must be performed where the appropriate surgical facilities are available. Major surgery can also be performed under private health insurance.
All post-surgical follow up is carried out at the Columbus Clinic Center or, for those patients coming from outside Milan, also at the location where they were first examined.
I am sure that many of you, having read this, will have lots of questions to ask about your real ability to breathe well. An appointment with an ear, nose and throat specialist can help you to evaluate just how efficient your own breathing is. Even just looking inside your nose can help us understand whether you have a regular nasal structure or not. The specialist can carry out a specific exploratory examination that can provide a precise and objective picture of the situation. In some cases, it may be useful to carry out a CT scan, too, in order to get a good view of the paranasal sinuses.
Medicine has for many years now offered a wide range of solutions for those who have difficulties breathing, solutions which can only improve their quality of life.