Surgery for The Nasal Valve
Oren Friedman
INTRODUCTION
Nasal airway obstruction may result from a variety of etiologies including structural anatomical causes and nonanatomical physiologic causes. Nasal septal deformities and turbinate hypertrophy frequently lead to nasal obstruction and are therefore the most common targets of surgical intervention. When applied to the appropriate clinical setting, septoplasty and turbinate reduction alone may restore nasal airflow. However, some patients may not improve despite a straightened septum and shrunken turbinates. In these individuals, increased airflow resistance may result from a narrowed nasal valve angle or a weakened nasal sidewall that collapses under the dynamic forces of nasal inspiration. A detailed preoperative history and physical examination will frequently reveal nasal valve collapse to be a major contributor to nasal obstructive complaints. Recognition of nasal valve contributions preoperatively will help to guide the patient and surgeon through successful preoperative communication, establishment of expectations, and surgical outcomes. In recent years, surgery of the nasal valve has become an integral component in the management of nasal obstruction, frequently being the most important element in the surgical plan. The term “nasal valve collapse” does not refer to a single entity, and as such, surgical correction of the nasal valve does not refer to a single procedure. A variety of surgical approaches are available for each type of nasal valve collapse.
Definitions
Nasal valve collapse is a general term applied to nasal obstructive disorders associated with a narrowing of the area of the nasal valve and of the nasal vestibule. There is an internal and an external nasal valve on either side of the nose. The “internal nasal valve” is the narrowest portion of the nasal airway, and it is therefore the primary regulator of nasal airflow. The term “internal nasal valve” refers to the area bound by the nasal septum medially, the caudal edge of the upper lateral cartilage laterally, the floor of the nose inferiorly, and the head of the inferior turbinate inferolaterally (Fig. 23.1). The normal angle between the upper lateral cartilage and nasal septum is 10 to 15 degrees, and the cross-sectional area of this region is approximately 55 to 64 mm2. A smaller cross-sectional area in the internal nasal valve contributes to increased airway resistance and associated nasal airway obstruction.
Internal nasal valve collapse is categorized as static or dynamic. Static internal nasal valve collapse refers to a narrowing of the middle third of the nose at rest—that is, the angle between the upper lateral cartilage and nasal septum at rest, in the absence of negative inspiratory forces that could cause medialization of the upper lateral cartilage, is narrow. The upper lateral cartilage is displaced medially and positioned close to the nasal septum with a resultant reduction in internal nasal valve area. Static collapse often follows nasal trauma or rhinoplasty in which the loss of upper lateral cartilage support causes an indentation along the sidewall at rest. Static collapse of the internal nasal valve may also result from the tension nose deformity in which overgrowth of the septum leads to a tented nasal vault with a narrowed valve angle, a smaller nasal valve area, and greater airflow resistance.
Dynamic internal nasal valve collapse is a narrowing of the upper lateral cartilage and middle third of the nose that occurs only with active nasal inspiration through a valve that, at rest, appears of normal size. Dynamic
nasal valve collapse often results from an inherent weakness of the cartilaginous, muscular, and cutaneous nasal sidewalls. Thin, weak, detached, or absent upper lateral cartilages, paralysis of the nasal dilator muscles, or excessively thin skin cannot provide the necessary strength to the nasal sidewall to withstand the negative pressures created by inspiratory nasal airflow—the sidewalls collapse as the negative inspiratory pressure draws them inward. Previous rhinoplasty in which the upper lateral cartilages have been weakened or detached from the nasal septum may also contribute to structural weaknesses of the nasal sidewall that cannot withstand the negative inspiratory forces. In such cases, the patient may not have obvious findings suggestive of nasal valve collapse on inspection at rest, such as an inverted V deformity or a pinched middle third at rest, but when the patient is asked to inspire gently through the nose, there is a narrowing of the middle third that becomes obvious to the examining physician.
nasal valve collapse often results from an inherent weakness of the cartilaginous, muscular, and cutaneous nasal sidewalls. Thin, weak, detached, or absent upper lateral cartilages, paralysis of the nasal dilator muscles, or excessively thin skin cannot provide the necessary strength to the nasal sidewall to withstand the negative pressures created by inspiratory nasal airflow—the sidewalls collapse as the negative inspiratory pressure draws them inward. Previous rhinoplasty in which the upper lateral cartilages have been weakened or detached from the nasal septum may also contribute to structural weaknesses of the nasal sidewall that cannot withstand the negative inspiratory forces. In such cases, the patient may not have obvious findings suggestive of nasal valve collapse on inspection at rest, such as an inverted V deformity or a pinched middle third at rest, but when the patient is asked to inspire gently through the nose, there is a narrowing of the middle third that becomes obvious to the examining physician.
 FIGURE 23.1 Internal nasal valve. The area bound by the upper lateral cartilage, nasal septum, and the head of the inferior turbinate. |
The external nasal valve is located in the nasal vestibule, and it is an area bound by the alar rim and columella. As with the internal nasal valve, the external valve may either be narrowed at rest or it may have a floppy lateral component that narrows under the influence of negative pressure associated with nasal inspiration (Fig. 23.2). The external nasal valve is supported by the lower lateral cartilages and their overlying skin and
soft tissue covering. Static narrowing of this region (vestibular stenosis, alar rim collapse) may be seen following trauma, soft tissue triangle injury, reconstruction of nasal skin cancer defects, cleft lip repair, or alar base narrowing procedures; with significant caudal septal deformities; or secondary to a variety of other causes. It may also arise primarily as in the case of a tension type nasal deformity in which the vestibular aperture at the level of the nasal rim is narrowed. Dynamic collapse of the external nasal valve occurs when the valve appears normal at rest, but upon inspiration through the nose, there is collapse of the walls of the alar rim. Primary weakness of the lower lateral cartilages and cephalically malpositioned lower lateral cartilages are often found with dynamic external valve collapse—in both situations, the lower lateral cartilage and overlying soft tissue do not provide adequate support to the nasal rim.
soft tissue covering. Static narrowing of this region (vestibular stenosis, alar rim collapse) may be seen following trauma, soft tissue triangle injury, reconstruction of nasal skin cancer defects, cleft lip repair, or alar base narrowing procedures; with significant caudal septal deformities; or secondary to a variety of other causes. It may also arise primarily as in the case of a tension type nasal deformity in which the vestibular aperture at the level of the nasal rim is narrowed. Dynamic collapse of the external nasal valve occurs when the valve appears normal at rest, but upon inspiration through the nose, there is collapse of the walls of the alar rim. Primary weakness of the lower lateral cartilages and cephalically malpositioned lower lateral cartilages are often found with dynamic external valve collapse—in both situations, the lower lateral cartilage and overlying soft tissue do not provide adequate support to the nasal rim.
 FIGURE 23.2 Dynamic external nasal valve collapse. At rest, the nostrils appear patent (A), but with inspiration, the negative pressure closes the nasal vestibule, preventing proper airflow through the nostrils (B). |
HISTORY
As with most medical issues, the diagnosis of nasal valve collapse relies in large part on the basic patient history and physical examination. A complete history and physical examination, review of systems, and review of medications and allergies should be performed to insure that the patient is in generally good health and is a suitable candidate for surgery. Notation should be made of any anticoagulation therapy the patient may be on so that proper planning for surgery is facilitated. In the case of nasal obstruction associated with nasal valve collapse, the chief complaints most often highlighted by the patients include nasal obstruction, mouth breathing, dry mouth in the morning, daytime somnolence, exercise limitations, and snoring. Many clues in the history will lead the physician to search for common findings of nasal valve collapse on physical examination. Patients may report prior nasal surgery including septoplasty and turbinate reduction and have persistent nasal obstruction. Others may relate a history of nasal trauma or prior rhinoplasty that over time has led to worsened breathing. Some patients may have had allergy testing and treatments but continue to have complaints of nasal obstruction. One needs to clarify that the patient’s complaint of nasal obstruction is truly just that, and not actually nasal congestion, which may be associated with sinusitis or allergic/nonallergic rhinitis. In many cases, when asked what they do to relieve the symptoms of nasal obstruction, patients demonstrate to the physician that with lateral traction on the cheek or nasal sidewall, or with elevation of the nasal tip, they are able to improve nasal airflow. Some patients also report the use of nasal dilating devices at night or while exercising to help improve nasal airflow.
PHYSICAL EXAMINATION
Valuable information may be learned from the moment the patient interaction begins. Middle third narrowing at rest is seen from simple inspection of the external nose. Inverted-V deformity, a pinched middle third, and a disrupted brow-tip aesthetic line may be seen in patients with static collapse of the internal nasal valve. Similarly, while observing the patient breathing during the history taking portion of the interaction, the physician may note dynamic narrowing of the nasal sidewall, indicating a dynamic internal nasal valve collapse. Dynamic or static collapse of the lower third/ala may also be seen when one observes the lower third of the nose, indicating disorder of the external nasal valve. To appreciate dynamic nasal valve collapse and its effects on nasal breathing, it is often helpful to apply gentle lateral traction on the cheek adjacent to the nose (i.e., Cottle maneuver) in order to assess for improvements in nasal breathing with stiffening of the lateral nasal wall during inspiration. To pinpoint the precise location of collapse, it is helpful for the examiner to introduce a cotton-tip applicator or ear curette into the suspected areas and ask the patient to identify maximal improvements in nasal obstructive symptoms when the site of obstruction is supported. These sites are the targets of surgical intervention. Nasal endoscopy helps to identify areas not visible on anterior rhinoscopy such as posterior septal deflections, nasal polyps, concha bullosa, tumors, and various other pathologies that may contribute to the symptoms of nasal obstruction.
Once inspection is completed, palpation of the nose is performed. It is important to evaluate the strength of the nasal sidewall and nasal rim, the length of the nasal bones, and the integrity of the upper and lower lateral cartilages. Palpation may reveal flaccid cartilage, areas of absent or deformed cartilage, or regions of septal deviations that may be impinging on the nasal valve area, all of which will help to confirm the suspicion of nasal valve narrowing. The Cottle maneuver or cotton-tip applicator applied to these regions of cartilaginous deficiency will further confirm the precise location and severity of nasal valve collapse. Internal inspection of the anterior nasal cavity with and without the nasal speculum may reveal anatomical abnormalities consistent with nasal valve narrowing. Septal deformities in Cottle areas 1 or 2, hypertrophy of the head of the inferior turbinate, webbing or scarring in the nasal valve angle, concave upper or lower lateral cartilages, cephalic orientation of the lower lateral cartilage that leaves the rim of the nostril devoid of structural support, and a scroll region impingement on the nasal valve region may all be seen. Patients with an overprojected tension-type nasal deformity in which overgrowth of the nasal septum causes the angle between the upper lateral cartilage and the nasal septum to be excessively narrowed are also frequently found to have weak cartilaginous structures, with resultant static and dynamic collapse of both the internal and external nasal valves.
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