Skip to main content

Impact of rapid palatal expansion on the internal nasal valve and obstructive nasal symptoms in children



The aim of this study is to evaluate the impact of rapid palatal expansion (RPE) on the nasal airway subjectively by utilizing patient-reported outcome measures (PROM) and objectively by evaluating validated internal nasal valve (INV) measurements obtained from cone beam computed tomography (CBCT) in pediatrics.

Materials and methods

In this retrospective cohort study, subjects who underwent RPE from March to December 2018 with cone beam CT and Nasal Obstruction Symptom Evaluation (NOSE) scores were included. Exclusion criteria included craniofacial deformity, allergies, asthma, recent nasal trauma, or surgery. INV measurements (angle and cross-sectional area), diastema, midpalatal suture opening, and NOSE scores were evaluated.


Fifty-one subjects met the inclusion criteria with a mean age of 10.1 ± 2.6. Pre-expansion mean NOSE score was 32.55 (moderate) while post-expansion was 13.92 (mild). Mean NOSE score improved significantly by an average of 18.63 following post-expansion (P < 0.0001). The patients’ right and left INV angles increased significantly by a mean of 2.42° and 2.65° respectively (P < 0.0001). Right and left INV cross-sectional areas increased significantly by an average of 14.35 mm2 (P < 0.0001) and 14.17 mm2 (P < 0.0001) respectively. An average expansion of the diastema and the suture was 1.60 mm and 3.05 mm respectively (P < 0.0001), with an average of 6.29 mm of expansion. We found the amount of diastema expansion to correlate with change in NOSE score (R = − 0.32, P = 0.022). Age and diastema showed a negative correlation (R = − 0.44, P = 0.0019), while INV angle and diastema showed a statistically significant positive correlation (R = 0.28, P = 0.048).


RPE showed improvement in both NOSE scores and objective measures of the INV. This may show the possibility of considering RPE in managing resistant pediatric nasal airways. Future studies should include collaboration with pediatric otolaryngologists, with the inclusion of pediatric patients with persistent nasal obstruction.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6


  1. Hsu DW, Suh JD (2018) Anatomy and physiology of nasal obstruction. Otolaryngol Clin N Am 51:853–865.

    Article  Google Scholar 

  2. Schuman TA, Senior BA (2018) Treatment paradigm for nasal airway obstruction. Otolaryngol Clin N Am 51:873–882.

    Article  Google Scholar 

  3. Awad MI, Kacker A (2018) Nasal obstruction considerations in sleep apnea. Otolaryngol Clin N Am 51:1003–1009.

    Article  Google Scholar 

  4. Miman MC, Deliktaş H, Özturan O, Toplu Y, Akarçay M (2006) Internal nasal valve: revisited with objective facts. Otolaryngol Head Neck Surg.

  5. Bloom JD, Sridharan S, Hagiwara M, Babba JS, White WM, Constantinides M (2012) Reformatted computed tomography to assess the internal nasal valve and association with physical examination. Arch Facial Plast Surg.

  6. Pirelli P, Saponara M, Guilleminault C (2012) Rapid maxillary expansion before and after adenotonsillectomy in children with obstructive sleep apnea Forcierte Gaumennahterweiterung vor und nach Adenotonsillektomie bei Kindern mit obstruktiver Schlafapnoe, Somnologie - Schlafforsch. Und Schlafmedizin.

  7. Villa MP, Rizolli A, Miano S, Malagola C (2011) Efficacy of rapid maxillary expansion in children with obstructive sleep apnea syndrome: 36 months of follow-up. Sleep Breath.

  8. Lotfi V, Ghoneima A, Lagravere M, Kula K, Stewart K (2018) Three-dimensional evaluation of airway volume changes in two expansion activation protocols. Int Orthod 16:144–157.

    Article  PubMed  Google Scholar 

  9. Christie KF, Boucher N, Chung CH (2010) Effects of bonded rapid palatal expansion on the transverse dimensions of the maxilla: a cone-beam computed tomography study. Am J Orthod Dentofac Orthop.

  10. El H, Palomo JM (2014) Three-dimensional evaluation of upper airway following rapid maxillary expansion A CBCT study. Angle Orthod.

  11. Oliveira De Felippe NL, Da Silveira AC, Viana G, Kusnoto B, Smith B, Evans CA (2008) Relationship between rapid maxillary expansion and nasal cavity size and airway resistance: short- and long-term effects. Am J Orthod Dentofac Orthop.

  12. Stewart MG, Witsell DL, Smith TL, Weaver EM, Yueh B, Hannley MT (2004) Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) Scale. Otolaryngol Head Neck Surg.

  13. Camacho M, Zaghi S, Certal V, Abdullatif J, Means C, Acevedo J, Liu S, Brietzke SE, Kushida CA, Capasso R (2015) Inferior turbinate classification system, grades 1 to 4: development and validation study. Laryngoscope.

  14. Poetker DM, Rhee JS, Mocan BO, Michel MA (2004) Computed tomography technique for evaluation of the nasal valve. Arch Facial Plast Surg.

  15. Abdelwahab M, Yoon A, Okland T, Poomkonsarn S, Gouveia C, Liu SY-C (2019) Impact of distraction osteogenesis maxillary expansion on the internal nasal valve in obstructive sleep apnea. Otolaryngol Neck Surg 019459981984280:362–367.

    Article  Google Scholar 

  16. Abdelwahab MA, Neves CA, Patel PN, Most SP (2020) Impact of dorsal preservation rhinoplasty versus dorsal hump resection on the internal nasal valve : a quantitative radiological study. Aesthet Plast Surg.

  17. Lipan MJ, Most SP (2013) Development of a severity classification system for subjective nasal obstruction. JAMA Facial Plast Surg.

  18. Cicchetti DV, Nelson LD (1994) Re-examining threats to the reliability and validity of putative brain-behavior relationships: new guidelines for assessing the effect of patients lost to follow-up. J Clin Exp Neuropsychol 16:339–343.

    CAS  Article  PubMed  Google Scholar 

  19. Koo TK, Li MY (2016) A guideline of selecting and reporting intraclass correlation coefficients for reliability research. J Chiropr Med.

  20. Vaezeafshar R, Moubayed SP, Most SP (2018) Repair of lateral wall insufficiency. JAMA Facial Plast Surg.

  21. Samra S, Steitz JT, Hajnas N, Toriumi DM (2018) Surgical management of nasal valve collapse. Otolaryngol Clin N Am 51:929–944.

    Article  Google Scholar 

  22. Abdelwahab M, Most S (2020) The miniature lateral crural strut graft: efficacy of a novel technique in tip plasty. Laryngoscope.

  23. Smith MM, Ishman SL (2018) Pediatric nasal obstruction. Otolaryngol Clin N Am 51:971–985.

    Article  Google Scholar 

  24. Most SP, Rudy SF (2017) Septoplasty: basic and advanced techniques. Facial Plast Surg Clin North Am 25:161–169.

    Article  PubMed  Google Scholar 

  25. Funamura JL, Sykes JM (2014) Pediatric septorhinoplasty. Facial Plast Surg Clin North Am.

  26. Baccetti T, Mucedero M, Leonardi M, Cozza P (2009) Interceptive treatment of palatal impaction of maxillary canines with rapid maxillary expansion: a randomized clinical trial. Am J Orthod Dentofac Orthop.

  27. Baccetti T, Franchi L, Cameron CG, McNamara JA (2001) Treatment timing for rapid maxillary expansion. Angle Orthod.<0343:TTFRME>2.0.CO;2

  28. Haralambidis A, Ari-Demirkaya A, Acar A, Küçükkeleş N, Ateş M, Özkaya S (2009) Morphologic changes of the nasal cavity induced by rapid maxillary expansion: a study on 3-dimensional computed tomography models. Am J Orthod Dentofac Orthop.

  29. Kim SY, Park YC, Lee KJ, Lintermann A, Han SS, Yu HS, Choi YJ (2018) Assessment of changes in the nasal airway after nonsurgical miniscrew-assisted rapid maxillary expansion in young adults. Angle Orthod.

  30. Rohra AK, Demko CA, Hans MG, Rosen C, Palomo JM (2018) Sleep disordered breathing in children seeking orthodontic care. Am J Orthod Dentofac Orthop.

  31. Williams R, Patel V, Chen YF, Tangbumrungtham N, Thamboo A, Most SP, Nayak JV, Liu SYC (2019) The upper airway nasal complex: structural contribution to persistent nasal obstruction. Otolaryngol - Head Neck Surg (United States).

  32. Din H, Bundogji N, Leuin SC (2019) Psychometric evaluation of the nasal obstruction symptom evaluation scale for pediatric patients. Otolaryngol - Head Neck Surg (United States).

  33. Çakmak Ö, Coşkun M, Çelik H, Büyüklü F, Özlüoǧlu LN (2003) Value of acoustic rhinometry for measuring nasal valve area. Laryngoscope.

  34. De Felice F, Di Carlo G, Saccucci M, Tombolini V, Polimeni A (2019) Dental cone beam computed tomography in children: clinical effectiveness and cancer risk due to radiation exposure. Oncology.

  35. Ng BA, Ramsey RG, Corey JP (1999) The distribution of nasal erectile mucosa as visualized by magnetic resonance imaging. Ear, Nose Throat J.

  36. Cole P, Haight JSJ, Cooper PW, Kassel EE (1983) A computed tomographic study of nasal mucosa: effects of vasoactive substances. J Otolaryngol 12(1):58–60

  37. Saunders MW, Jones NS, Kabala J, Lowe J (1995) An anatomical, histological and magnetic resonance imaging study of the nasal septum. Clin Otolaryngol Allied Sci 20:434–438.

    CAS  Article  PubMed  Google Scholar 

  38. Wexler D, Braverman I, Amar M (2006) Histology of the nasal septal swell body (septal turbinate). Otolaryngol Head Neck Surg.

  39. Bishara SE, Staley RN (1987) Maxillary expansion: clinical implications. Am J Orthod Dentofac Orthop.

Download references


The authors would like to thank Dr. Myung Shim Sim for her valuable statistical assistance.

Author information

Authors and Affiliations



All authors have seen and approved the manuscript.

Corresponding author

Correspondence to Daniela Silva.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This retrospective study was approved by University of California, Los Angeles Institutional Review Board (IRB#18-001326).

Informed consent

Informed consent was obtained from all individual participants included in the study.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Yoon, A., Abdelwahab, M., Liu, S. et al. Impact of rapid palatal expansion on the internal nasal valve and obstructive nasal symptoms in children. Sleep Breath 25, 1019–1027 (2021).

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI:


  • Rapid palatal expansion
  • Internal nasal valve
  • Midpalatal suture
  • Nasal obstruction in children
  • Rapid maxillary expander
  • Nasal breathing