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Nasal obstruction and its treatments

Nasal obstruction is caused by turbinates inflammation or other diseases that can swell turbinates or a deviated septum.

Nowadays, the first line of treatment to reduce nasal obstruction is by medication and if that doesn’t help, surgical procedures are considered. Here is a list of the common interventions:

Temporary medical treatments: nasal decongestant, antihistamine, allergy desensitization, nasal expander.
Permanent surgical interventions (from least invasive to most invasive): radiofrequency, septoplasty, bipolar probe, submucosal resection, turbinoplasty, turbinectomy.

The timeline of surgical interventions usually starts with bipolar probe or radiofrequency which are less invasive procedures under local anesthesia that can reduce the size of the turbinate. If these methods prove unsuccessful, other surgical procedures (submucosal resection, turbinoplasty, septoplasty, turbinectomy) are usually proposed. However, they are more invasive and often performed under general anesthesia. All surgical procedures on the turbinates hold a risk of causing ENS.
Let alone the risks of ENS, we know that cutting turbinates even partially is not the solution for nasal obstruction. Indeed the reduction of turbinate volume necessarily negatively affects their functions which are the following: sense of airflow, humidification, and heating of inhaled air, and adaptation of nasal resistance according to oxygen consumption. Burning them with laser or radiofrequency devices destroys the mucosa, and cutting with a scissor destroys everything. Even sub-mucosal reduction can affect nerves and damage the mucosa.

Luckily, another surgical procedure exists that has become increasingly common in recent years: it is called MSE (Maxillary Skeletal Expansion). In essence, this procedure expands the nasal cavity instead of cutting the turbinates. Think “pushing the walls of the room instead of removing the furniture”. We give an overview of this procedure in the present article.

Why do we have small nasal cavities along with underdeveloped jaws and airways?

Before we take a close look at the MSE procedure, let’s take a step back and understand the likely causes of our small nasal cavities.
In modern western societies, most of us suffer from craniofacial dystrophy. In a nutshell, this means elongated faces, deviated septums, small nasal cavities, narrow and high-arched palates, crooked teeth, small and recessed jaws… In the throat, the airway is small because our recessed jaws push the tongue backward. This is why sleep apnea is becoming increasingly prevalent.

The main causes of craniofacial dystrophy according to the book Jaws which comprises over 200 scientific references are:

For more details about this topic, we invite you to read this article in BioScience and this book.

Why is expanding the maxilla the solution?

Instead of cutting the lower turbinates to create space in the nasal cavity which disturbs the delicate physiology of the nose, another solution has become increasingly popular in recent years: maxillary expansion. The maxilla is the bone in the middle of the face, and maxillary expansion refers to the expansion of this bone through the palatal suture.

The hard palate which is a part of the maxillary bone serves as the base of the nasal passage. Consequently, by expanding the hard palate, the nasal passage gets wider. A wider nasal passage allows for more air to flow in the nose – no more obstruction! This avoids destroying mucosa with radiofrequency or cutting it off with scissors… In fact, expansion can even create some mucosa on the nasal floor.

The hard palate presents a suture that starts to fuse around puberty and becomes increasingly tight until about age 25 when it becomes tightly fused and hard to break apart. Therefore, the suture must be surgically cut prior to starting the expansion in adults. While this might sound just as invasive as turbinectomy, it is far from it because the turbinates play an essential role in breathing and nasal physiology, while the palate’s only role is structural – to be the roof of the mouth and the floor of the nasal cavity. With palate expansion, no tissue is cut off with scissors, a cut is made on the suture which can be done under local anesthesia and remains rather painless. Turbinectomy usually requires general anesthesia and multiple days or even weeks without being able to breathe through the nose because of nose plugs and crust build-up. Maxillary expansion on the other hand can require orthodontic treatment because as the palate expands, the teeth separate temporarily creating a diastema. In some cases, the diastema closes by itself without orthodontic treatment, but it depends on the type of expander used.

Methods for expanding the Maxilla

Some orthodontists have tried to split the suture without prior surgical assist, and while this can work on younger patients or on women who have a less tightly fused suture, it comes at the risk of failing to split the suture, pushing teeth out of the alveolar bone and asymmetric expansion. Therefore, in most cases, maxillary expansion takes place with a surgical assist.

Traditionally, expansion was done in conjunction with a Lefort 1 cut which is the cut of the maxillary bone above the roots of the teeth as shown in this slide from Dr Coppelson’s presentation. Please understand the Lefort 1 cut and the palatal suture cut are two different cut. The Lefort 1 is horizontal while the palatal suture is vertical.

However, the problem with MSE that combines the Lefort 1 cut is that expansion will not enlarge the nasal cavity, it will simply enlarge the dental arches to create a wider smile and more tongue space. To increase the width and therefore volume of the nasal cavity, there should be only a cut of the palatal suture, no Lefort 1 cut - this procedure is referred to as MARPE, and it is the one we suggest.

This decision tree shows a comprehensive overview of all the available types of expansion. It is explained in more detail in the video, but below is a short explanation of each procedure for your reference

Dentoalveolar: related to the alveolar bone in which rooted the teeth
SFOT: grafting bone in front of the root of the teeth to allow more teeth movement during
orthodontic treatment.
Orthodontic expanders: various types of usually acrylic expanders to widen the dental arches. It
might also widen the maxilla and therefore the nasal cavity in children. For this, see the work of
the “Orthotropics” community comprised of orthodontists like Dr Mike Mew and Dr Simon Wong.
Skeletal/Basal Bone: the bone most of the maxilla is composed of, that is not in contact with the teeth.
Traditional: related to the traditional methods of expanding the maxilla with a Lefort 1 cut.
Miniscrew-Assisted Rapid Palatal Expansion (MARPE): maxillary expansion with a prior cut
of the palatal suture. These are the procedures that we think are better.
Simple MARPE: MSE with a cut of the suture through the mouth
Corticopuncture: multiple holes in the suture to facilitate the split (risks of failure to split).
EASE: a cut of the suture through the nose or mouth. Created by Dr Kasey Lee.
MIND: a cut of the suture above the teeth as shown in the photo above. Created by Dr

In adults, MARPE is usually performed by a maxillofacial surgeon in conjunction with an orthodontist because it requires the surgical cutting of the maxillary suture, although some orthodontists perform the cut themselves under local anesthesia. This procedure is certainly more expensive than any other ENT intervention because it usually requires an orthodontic treatment (although not always). However, it can be partially or totally covered by insurance if you have sleep apnea or severe nasal obstruction which are often correlated. Unfortunately, many doctors are not aware of this procedure or think it’s too invasive and will prescribe classic ENT procedures as a first line of treatment. MSE is indeed a heavy treatment, but if you have the time and resources, we as ENS patients think that it is better to do MSE before any ENT procedure on your nose. If your nasal cavity has been properly expanded, you should not need turbinate reduction.

We hope this article has shed light on these practices and help you make the right decision for your health. Breathing is our most basic function, and everything else depends on it.

This article is co-written by Alexander CHALZ and Aurélien RUMIANO.
Main illustration by JawHacks, YouTube channel.


For decades, teams of researchers around the world have been trying to find ways to extend lifespan and slow aging. Recently billions of dollars are injected into the research and some wealthy people are trying to do all they can to slow their aging process.
Bryan Johnson is one of them, he spends 2 millions dollars per year and has a team of 30 doctors for  his health.
So what is the link with ENS? Some of the techniques and products developed for “anti-aging” can maybe help us with ENS symptoms.

Blueprint project website all of his program is detailed here.

Can skin health be transposed to mucosa health?

The answer is I don’t know but we can say that mucosa and skin are similar tissues. For skin Bryan are using different creams, light therapy, fat injection…

Nasal creams

Those vitamins and compounds are interesting, maybe using some nasal creams with all these ingredients can improve the health of the mucosa in the long run.

Light therapy

Bryan also uses light therapy on the skin with different wavelengths, duration etc… It seems pseudo-science but some studies suggest that it can help in many ways [3].
532 (green)  and 1064 nm (infrared) pulsed and around 650 nm (red) for 12 minutes two times a week. Some studies show that red light therapy (650nm) can improve mitochondrial function And so the tissue function.
It is not easy to do pulsed light therapy in the nasal cavity but non-pulsed red light therapy is feasible. I built a little device that can do that. I follow what power and lengthways were used the most and the less dangerous. I exclude the 800nm+ wavelength because it is an infrared ray and it heats the tissues. So I choose 670nm LEDs that have the power to obtain radiation of around 50mW/cm². For the exposition time, I’m using around 5 minutes which is a common duration used in studies.

Little red therapy device

Fat, PRP injections

In his video (at 28 min), we see that he had allograft (from donor) fat injection under the skin in order to rejuvenate it. But skin and turbinates are not comparable because fat is naturally present under the skin but not in the turbinate and in the nasal cavity in general. It is why fat injection seems to have a big absorption rate in the nasal cavity. But some persons can have improvement of their ENS symptoms with several fat injections.
He also uses PRP (platelet rich plasma) (at 43 min) for hair growth, it is used for over 10 years for ENS without great success. It can improve a bit if the turbinectomy was not too aggressive.

Conclusion and warning

I don't know if all these things can improve ENS symptoms, so be careful and do your own research.

Bleprint program video


  1. Topical niacinamide reduces yellowing, wrinkling, red blotchiness, and hyperpigmented spots in aging facial skin D. L. Bissett, K. Miyamoto, P. Sun, J. Li and C. A. Berge
  2. Low-level laser (light) therapy (LLLT) in skin: stimulating, healing, restoring Pinar Avci, MD, Asheesh Gupta, PhD, Magesh Sadasivam, MTech, Daniela Vecchio, PhD, Zeev Pam, MD Nadav Pam, MD and Michael R Hamblin, PhD
  3. Efficacy of a New Topical Nano-hyaluronic Acid in Humans S. Manjula Jegasothy, MD,a Valentina Zabolotniaia, MD,b and Stephan Bielfeldt, DIPL. BIO.-INGc

I designed a simplified 3d model of a nasal cavity (just one side) to test different scenarios such as adding an implant. You can see that I grouped the superior turbinate and the middle turbinate in order to simplify the model. I need a simple model because it is better to make future geometry change.

The model is simpler but it respects the cross-sectional area of my real nasal cavity, you can see my post about the cross-sectional area measurements that I have written here. Also as you can see it simulates a pretty large inferior turbinectomy and a total turbinectomy in the middle section area. For the flow I took 7.5l/min, it is the respiratory flow at rest. Here are the first results I get...

The airflow in the area of the absent inferior turbinate swirls and is very slow (less than 0.6m/s) unlike the airflow in the area of the middle turbinate (about 3m/s). This is not very surprising, it can be seen in quite a few CFD studies on empty nose syndrome. The speed values also match which means that my 3d model and the flow rate value taken are pretty accurate.

In the coronal section view, we can see that the velocity is higher between the middle turbinate and the septum but also in the zone at the bottom of the middle turbinate.

Now what I can say about these results is that too low airflow velocity greatly reduces sensations in the area of the absent inferior turbinate (inferior meatus). This is one of the big problems of the ENS.

In future articles, I will simulate an implant in the inferior meatus zone to see the change in airflow.

Go to https://www.prusa3d.com/, click on software and select your OS. Install the prusa slicer.
This software is a "slicer", it is used to prepare the 3d model to be 3d printed, to transform the STL file into a G-code readable for the 3d printer.
But in our case, we will just use this software to edit the 3d model. But of course, if you have a prusa 3d printer you will also use this software to 3d print the slices.
So open the .STL file that you have just saved with SLICER.
Click on file, then import STL/OBJ etc ...

Click on rotate and turn the model 90° to put it vertically.

Once it done click on cut and set the thickness you want, I set 10 mm.
Finally click on perform cut.

You will obtain that.

Now select the model and cut a slice again, organize the slices as you want but it is better to do it in the cut order.

Right click on each slices one by one and export as STL.

And that's it, now you have all the slices ready to be 3d printed where you want.
You can find a friend or a member of your familly which have a 3d printer or use an onlise service like shapeways or sculpteo for example.

An example of a 3d printed nasal cavity.

In this tutorial, I will explain how to turn your DICOM data pulled from your CT-SCAN into a 3d printable file.

Go to https://www.slicer.org/ download the software and install it.
Open it and click on import DICOM files, search the directory of your DICOM files and click on import.

Click on show DICOM database, click on your name and finally double click on the slices you are interested in, here sinus. The slices will load.

Now click on the scrolling menu and choose volume rendering.

Click on display ROI, white lines will appear.
You can click on the white dot next to Volume, your head will appear in 3d. But it is optional.

You also can select a preset, here I choose lung, like that you can see inside the nasal cavity.
Now crop the desired zone using the color dot.

When you are happy with your cropped zone click on the little magnifying glass, then write crop, click on crop volume and finally switch to module. After that click on the apply button. Wait a moment it can take a while.

Now return to the Volume rendering worshop and click on display ROI in order to hide white lines
Once it's done, click again on the little magnifying glass and write editor, then click on switch to module.
A little window will appear, click OK.

Click on the threshold effect button.

The slices will turn green, now you need to adjust the left cursor in order to paint all your soft tissues green.
I found that generally the good numbers are between -200 and -400 but it may depend on CT-SCAN.
Finally, click ok the apply button.
It's almost over, we've done the biggest part.

Now click on data in the menu.

Right-click on your "name files" cropped-label and click on Convert labelmap to segmentation mode.

A line tissue will appear, again right-click on it and Export visible segment to models.
Wait a moment, it can take a while, a line cropped-label-segmentation-models will appear and also your 3d model on the right window.

Click on file, then save or ctrl + s.
In the window, uncheck all boxes except tissue.
Click on Poly data (.vtk) and choose .STL.
Click on change directory for selected files and choose a directory you want to save the 3d model file.
Finally click on save and voila, well done !

This .STL file is a 3d file that can be used to 3d print the model directly, but as you can imagine it is not useful to 3d print the model in this state, we will see nothing. We need to see inside the nasal cavity.
That is why in the next tutorial I will explain how to cut the model into slices in order to see inside. The slices will be stackable.

The first one is hydrolized collagen, some studies tend to prove that it can improve skin health, hydration, thickness etc ... Exemple this study. Hydrolyzed collagen is a type of collagen with low molecular weight in order to be better absorbed by the body and reach the skin and other organs. So I ask myself if this product can help skin, maybe it can help the mucosa too because mucosa is made of collagen. So I took 5g/day for two months which is a dosage often seen in the studies. After one week I noticed some skin improvement, a little smoother, but no airflow sensation improvement. I cannot say if my mucosa was better after the two months or not but I can say that I feel no difference in sensation and hydration.

The second one is Hyaluronic Acid, yes the same thing that can be injected into our turbinates or lateral wall in order to regrow it temporarily. Oral HA supplementation seems to also improve skin health, hydration, thickness, reduce wrinkles etc ... Again, some studies tend to prove that, but there are small studies. The common dosage seems to be between 120 mg/day. I have not yet tried this product but maybe it is worth a try...

Collagen studies:

Hyaluronic acid studies:

I try to know how to rebuild the nasal cavity after an inferior turbinectomy, where to add volume in priority ?

Some ENTs think that the head of the turbinates is the most important because it is where it's easiest to add resistance. And they often think that nasal resistance is the most important parameter in the ENS.

In this study, Dr Nayak and others researchers/doctors prove that it is possible to reduce significantly the symptoms of ENS without adding resistance. He implanted cartilage in the inferior meatus (the place of the inferior turbinate) and they have seen with CFD that the airflow is better redistributed between middle meatus and inferior meatus.

This other study shows that without inferior turbinate the most part of the airflow is redirected in the middle turbinate compared to healthy subjects. And they found a correlation between peak wall shear stress in the inferior meatus and airflow feeling sensation. Peak wall shear stress is the quantity of friction of air on the mucosa.

Airflow distribution, source: Investigation of the abnormal nasal aerodynamics and trigeminal functions among empty nose syndrome patients

What we can say with all of this data? I think that it is useless and may be harmful to just add volume to the beginning of the nasal cavity ( head of turbinates) because that will increase wall shear stress just at the beginning of the nasal cavity and not all along. And that will not solve the redistribution airflow problem. Without adding volume all along the inferior meatus the airflow will stay in the middle meatus and the sensation will remain bad.

The solution is to rebuild the nasal cavity like before turbinectomy, with the same distribution of the volume. It can be with adding volume in the remaining inferior turbinate if it is possible or adding cartilage on the lateral wall. But you have understood it is very important to add volume not just at the beginning of the nasal cavity but all along like a healthy nose. In the graph below, we can see that a healthy nose has a stable cross-sectional area all along the nasal cavity, but of course, it is not the case with an inferior turbinectomy. The reconstruction of the nasal cavity must tend towards these values.

Source: Computational fluid dynamics and trigeminal sensory examinations of empty nose syndrome patients

In this post, I would like to see which place is the best for an implant in my left nasal cavity. On this side, there is a remaining inferior turbinate. So I would like to know if it is better to implant cartilage on a lateral wall or if an implant in the turbinate is a better thing to do.

We can see on the graph below that implant in the lateral wall (blue) doesn't increase the surface of the mucosa but it reduces the section of emptiness. On the contrary implant in the remaining turbinate increases a little bit the surface of the mucosa by 3,5% and reduce the emptiness too. Ok, 3,5% is not so much but maybe it can make the difference.

So it seems that increasing the volume of the remaining turbinate is a better solution than putting an implant in the lateral wall. However, I know that it is more difficult to do it and maybe more risky too.

Post turbinectomy
Post virtual lateral wall implant
Post virtual turbinate implant

In this post, I will try to find which implant shape is the best to get closer to the natural turbinate. Special thanks to Andrea Magelli to give me this idea.

Below it is my case of my right nasale cavity before turbinectomy (yellow), after turbinectomy (green), after my cartilage implant (blue), and after a virtual implant (red). We can see that the implant is placed on the lateral wall, it is often placed like that. On the graph below we can see that the implant reduces the emptiness, the value of the section in mm² is almost equal than before turbinectomy. So it seems good, but why many of us are not better after an implant like that ? One of the reasons is I think the quantity of the mucosa. In the second graph, you can see that the implant has not increased the surface of the mucosa, there is not more mucosa than before. In the graph I name that perimeter because it is a slide of the CT-SCAN so we are in a 2D view.

So the idea is to place several demi cylinders in order to increase the surface of the mucosa. Why demi cylinder?

It works the 4 demi cylinder increase the surface of the mucosa at about 7%, but we are still not at the same quantity than before turbinectomy.
I don't know if it is possible to implant cartilage like that, if the mucosa is enough elastic to follow the shape of the implants. And you what do you think about this, which shape can be better ?

Pre turbinectomy
Post turbinectomy
Post real implant
Post virtual implants