1

Introduction

Difficulty breathing through the nose is one of the most frequent complaints presented to an otolaryngologist. Nasal septal deviation and turbinate hypertrophy are easily identified as areas of anatomic obstruction. One area that can be overlooked as an etiology for obstruction is an incompetent nasal valve. Nasal valve obstruction can markedly reduce airflow through the anterior nostril. This reduction in flow can contribute to snoring. Patients perceive snoring as an inconvenience and may not realize that this can be a symptom of obstructive sleep apnea. People who snore also admit to excessive daytime sleepiness and fatigue. Mostly, patients with nasal valve collapse are concerned about an inability to breathe through the nose.

Incompetence of the nasal valve, either internal or external, may arise from several factors. Congenital weakness of the nasal sidewalls may allow for easier collapse. As age progresses, nasal ptosis and sagging of the sidewalls can occur. This can contribute to nasal obstruction. An anatomically narrow nasal valve may contribute to nasal valve collapse, which can be congenital or present years after cosmetic rhinoplasty surgery.

Anything that increases the resistance of nasal airflow can be markedly perceived as obstruction by the patient. During rhinoplasty, specifically hump reduction, the internal nasal valve can be interrupted. Interruption of the attachment of the septum to the upper lateral cartilages allows for collapse of the weakened cartilage. The interrupted support for the upper lateral cartilage can cause it to fall toward the dorsal septal edge, narrowing the internal nasal valve. The external nasal valve can be weakened by overzealous resection of the lower lateral cartilage. Scar tissue formation can also contribute to weakening of the remaining alar cartilage. A weakened alar sidewall with less support can easily collapse and obstruct the anterior nostril.

The internal valve is the area in which the septum articulates with the lower border of the upper lateral cartilage ( Fig. 23.1A ). The angle of this area is normally 10 to 15 degrees. Minimal reduction in this angle can substantially restrict nasal airflow. The external nasal valve is an area composed of the alar or lower lateral cartilage with its associated cutaneous support as a mobile alar wall ( Fig. 23.1B ). It is bordered superiorly by the caudal edge of the upper lateral cartilages, inferiorly by the nasal floor, and posteriorly by the inferior turbinate. Laterally, it is supported by the pyriform aperture of the maxilla and fibrofatty tissue of the ala.

(A) Internal nasal valve. (B) External nasal valve.

In consideration of surgical approaches to correct nasal obstruction, all possible causes must be entertained. Correction of septal deviation alone may not alleviate nasal obstruction. Valvular effects may equal or surpass a deviation of the septum as the cause of airflow restriction. In a study by Constantain and Clardy, it was shown that septoplasty in addition to internal and external valve reconstruction offered the best relief in nasal obstruction. This combined approach offered significantly improved airflow in comparison to septoplasty alone.

2

History and Examination

A useful tool for eliciting the history of nasal obstruction and its significance on quality of life is the Nasal Obstruction Symptom Evaluation (NOSE) survey developed by Stewart et al. Patients often report constant nasal obstruction despite attempts at medical management. In the absence of rhinitis, medical management does not improve obstruction caused by constricted anatomy.

Examination before and after the application of topical vasoconstrictors can allow the effects of turbinate hyperplasia to be evaluated. The use of a standard nasal speculum spreads the valve open and can allow a narrowed valve to go undetected. An otoscope is a useful tool to evaluate internal valve collapse, as it does not splay open the area of concern. Some advocate the use of a Q-tip or cerumen spoon to elevate the sidewall of the nose 1 to 2 mm. If the patient reports improved breathing with this conservative maneuver, valve restriction is contributing to the patient’s obstruction. It is important to evaluate the competence of both the internal and the external nasal valves, as concurrent correction is often required to alleviate the symptoms of nasal obstruction.

A clinical consensus statement was compiled in 2010 to review the diagnosis and management of nasal valve compromise. The panel concluded that nasal valve collapse is best diagnosed by history and examination. Radiographic imaging is not helpful in making the diagnosis. Nasal steroid medication in the absence of rhinitis is not useful as it does not address the anatomic obstruction. Surgical correction of the source of obstruction is the treatment of choice.

3

Techniques and Surgical Approaches

This is by no means a complete review of all of the techniques that are available to surgically address incompetent valves. However, it will serve as a guideline of the most commonly accepted techniques. More recently, several companies have purported implants in lieu of homologous cartilage for nasal valve reconstruction. These may serve well in a patient with poor donor cartilage. Limitations to these implants are often cost driven.

General anesthesia is typically applied in surgical preparation for nasal valve reconstruction surgery. The patient is placed supine on the surgical table in a reverse Trendelenburg position. The patient is prepped and draped in a normal sterile fashion. Baby shampoo can be used as a prep agent for the face. Lidocaine is used, and the injection site depends on the surgical approach and technique applied.