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Piriform aperture enlargement for nasal obstruction

INTRODUCTION Surgical treatment of nasal obstruction attributed to nasal valve dysfunction is typically subdivided into interventions addressing the internal or external components of the nasal valve. Although carefully selected patients breathe more easily after nasal valve surgery, many fail to improve. We hypothesize that these patients may improve with surgery directed to correcting anatomic narrowing of the nasal airway at the piriform aperture. Data from numerous physiologic studies support the theory of a second, flow-limiting region in the nasal cavity besides the internal nasal valve, between 1.5 to 3 cm from the naris, in the coronal plane of the piriform aperture. This bony nasal valve is bounded by the nasal process of the maxilla laterally (principal component of the piriform aperture), head of the inferior turbinate concha inferiorly, and bony nasal septum medially (Fig. 1). It can be readily identified on physical examination as a lateral constriction just anterior to the inferior turbinate. If sufficiently narrow, the piriform aperture may cause a fixed obstruction and worsen dynamic airflow restriction secondary to turbinate hypertrophy. A narrowed piriform aperture may, therefore, serve as a secondary target for surgical intervention in select patients with nasal obstruction. We report our experience with piriform aperture enlargement (PAE) using the ultrasonic bone aspirator (UBA) (Stryker, Inc., Kalamazoo, MI).