Introduction
The nasal valve is one of the most important areas that should be addressed when evaluating a patient for nasal obstruction. When it is not assessed properly and only the septum is treated, patients may experience persistent obstruction (1). In fact, nasal valve pathology is the cause of persistent nasal obstruction after septoplasty in 95% of cases (2). This is one of the reasons why the consensus statement of 2010 from the American Academy of Otolaryngology – Head and Neck Surgery concluded that the nasal valve compromise should be treated surgically in order to improve nasal airflow (3). The main complaint of patients with this pathology is difficulty in breathing through their nose.
Causes of nasal valve obstruction may be mucosal or structural (2). Mucosal causes can be due to allergic rhinitis, chronic rhinitis and rhinosinusitis, amongst others. Structural causes may be posttraumatic, idiopathic or iatrogenic (2). Collapse in the nasal valve can be static or dynamic. Dynamic nasal valve collapse is usually secondary to lack of structural support of the nasal valve (1).
Nasal Valve Classification
The site of valve collapse can be divided according to the localization of the lateral nasal wall collapse (1) in internal nasal valve collapse and external nasal valve collapse.
Internal Nasal Valve Colapse
The internal nasal valve is the area that is bounded by the caudal margin of the upper lateral cartilage laterally, the nasal septum medially, and the floor of the nose inferiorly. If the head of the inferior turbinate is enlarged, it can affect this area as it is located inferiorly to the upper lateral cartilage. The normal angle of the nasal valve is 10 to 15 degrees.
Internal nasal valve collapse is common in patients that underwent reductive rhinoplasty (1), older patients with weakened cartilages and certain phenotypes with weak nasal cartilages (Asian, Mestizo, African American).
Patients with internal nasal valve collapse typically have a “pinched” appearance or medial collapse of the supra-alar region (1).
The diagnosis is made by identifying the medialization of the upper lateral cartilage towards the septum on inspiration through the nose (dynamic collapse). This usually improves with the Cottle maneuver, where the surgeon or the patient lateralizes the cheek with improved nasal breathing or with the modified Cottle maneuver where the surgeon lateralizes the upper lateral cartilage inside the nose with an instrument.
Treatment for correcting the internal nasal valve consist in repositioning the upper lateral cartilages or adding support to the lateral wall of the nose (1).
External Nasal Valve Collapse
The external nasal valve is the area of the nostril margin where the nasal cavity begins. It is bounded by the nasal vestibule, caudal septum and medial crura of the alar cartilages medially, the nasal sill inferiorly and the alar rim laterally. It is usually seen on moderate to deep inspiration where the nostril margin medializes against the columella.
External nasal valve collapse is common in patients with narrow noses, over projecting nasal tip and thin alar sidewalls. Other causes are aging and facial paralysis. These patients usually do not have undergone surgery (1).
The diagnosis is made by observing the alar rim in inspiration and observing medialization of the nostril.
Controversies
Even though the classification of nasal valve pathology in internal and external may seem simple, sometimes the classical classification of nasal valve anatomy and collapse is not enough as some authors have shown that the main place of sidewall collapse is the inter valve area (Ballert and Park, 4) and others (Most, 5) describe 2 zones of collapse: zone 2 at the scroll region and 1 and the classically external nasal valve.
Surgical Techniques
Many surgical techniques have been developed to correct nasal valve pathology according to the place of maximum collapse. In 1984, Sheen described the use of spreader grafts to correct the internal nasal valve by widening the nasal middle vault after reduction rhinoplasty (6). It was noted that the spreader graft increased the angle of the internal nasal valve as it displaced laterally the upper lateral cartilage (6).
Other options that target specifically the internal valve are auto spreaders flaps and flaring sutures (2). Nevertheless, there are some techniques that can impact both the internal and external nasal valve depending on the location of grafts in the lateral sidewall such as alar batten grafts, alar struts and alar rim grafts. (2)
Treatment for correcting the external nasal valve may comprise deprojecting the over projected nose to change the shape of the nostrils, realigning the lateral crura to a caudal orientation (with or without the aid of lateral crura strut graft) and adding structural grafts to the alar lobule to provide support (1).
In our experience with mestizo noses we find that the most useful techniques for correction of nasal valve collapse in patients that haven’t undergone rhinoplasty are spreader grafts and batten grafts. Though it is important to recognize that other techniques are also valuable in the treatment of patients with lateral nasal wall collapse, we find that techniques like auto spreader flaps, lateral crura turn in flap, lateral crura strut grafts, and flaring sutures are more convenient in the prevention of nasal valve obstruction postoperatively in patients undergoing rhinoplasty.
Options of grafts and flaps to correct nasal valve collapse can be seen in table 1.
Spreader grafts
Spreader grafts aid to correct the nasal mid vault by widening it. They are helpful for both dynamic and static nasal valve collapse. They are a very useful tool in functional surgery as they widen the nasal dorsum, but this is also a disadvantage of them when one does not want that result. They have a cosmetic impact as they help to re design the eyebrow to tip line.
Spreader grafts are strip like grafts made preferably of septal cartilage that are secured to the dorsal edge of the septum. They can be inserted either via endonasal or through an external approach.
Positioning spreader grafts through an endonasal approach
If the procedure is done endonasally, a transfixion incision exposing the anterior nasal angle is done and extended 1 cm beyond, cartilage is harvested, then a localized 5 mm wide mucoperichondrial pocket is developed corresponding to the dorsal edge of the septum and the graft is inserted and secured with a mattress suture against the contralateral graft and the septum.
Positioning spreader grafts through an external approach
When inserted via an open approach, cartilage is harvested from the septum, the graft is designed and septolateral separation is done. The graft is then secured to the dorsal edge of the septum and secured with a matress suture against the contralateral graft and the septum.
Batten grafts
Batten grafts are curvilinear cartilage grafts that are placed in a precise pocket at the point of maximal lateral wall collapse (1). They may create a slight fullness at the site of insertion.
They are versatile grafts that can be used to correct either internal or externa nasal valve collapse depending of the area of insertion of the graft.
Spreader grafts can be used in conjunction to increase a narrow middle third for internal collapse, but spreader grafts do not correct external nasal valve medialization.
Batten grafts can be inserted endonasally or via external rhinoplasty. If there is septal cartilage to be used it makes a good graft or the cavum or cymba concha of the ear can be used (1). Once the cartilage is harvested it is shaped to an ovoid shape of 10 to 15 mm in length and 4 to 8 mm in width. This shape must ensure that the graft can be positioned from the piriform aperture to the junction of the middle and lateral third of the lateral crura to ensure that it will resist the negative inspiratory forces that produce the collapse.
The ideal site of positioning of the graft is the point of the lateral wall where the collapse is the greatest. For internal nasal valve collapse this is usually between the caudal border of the upper lateral cartilage and the cephalic border of the inferior lateral cartilage at the scroll area.
For external nasal valve collapse this is between the caudal border of the lateral third of the inferior lateral cartilage and the alar rim.
Batten grafts. According to the desired effect the position can be altered. If positioned more cephalic on the scroll area the internal nasal valve is managed. If positioned more caudally, inferior to the lower lateral cartilage, the external nasal valve is strengthen.
Positioning batten grafts through an endonasal approach
The first step in this approach is to identify the point of maximum collapse with an awake patient and mark the area of lateral nasal wall where the graft will be positioned. A small incision of 6 to 8 mm is created intranasally in an inter-cartilaginous fashion that corresponds to the point of supra alar pinching. After this, a precise pocket is created with blunt scissors in the premarked area making sure that it extends to the piriform aperture superficially to the lower lateral cartilage. Once the pocket is created, the graft is inserted keeping in mind that the concave surface of the cartilage graft is facing laterally. A simple suture with 4-0 gut through and through may be used to fix the graft, though if the pocket is precise there is no need to fix it. The inter-cartilaginous incision is then closed with an absorbable suture.
Positioning batten grafts through an open approach
Again, the first step is to identify the point of maximum collapse with an awake patient and mark the area of lateral nasal wall where the graft will be positioned. Once the external approach is started, the initial dissection of the lower lateral cartilage should be kept until the junction of the middle and lateral thirds of the lateral crura (1). The point of maximum collapse previously marked is assessed and a subcutaneous pocket is created superficially to the lateral crura with blunt scissors that corresponds to the pre marked area. The graft is positioned inside this pocket that should also extend toward the piriform aperture and are sutured to the lateral third of the lateral crura to prevent migration.
Porous polyethylene grafts
When septal cartilage or auricular cartilage are not appropriate or present, an option to create batten or spreader grafts are porous polyethylene (Medpor) implants. The implant is designed in the same fashion as the autologous graft would be and positioned in the desired pocket.
An advantage of Medpor implants is that they can be reshaped after surgery. In the case of batten implant, one can give them a more concave repositioning if desired to increase support on the nasal valve. The disadvantage is that the produce more fullness, they can get infected or they can extrude.
Conclusion
Nasal valve collapse whether dynamic or static is an important pathology that should be recognize in every patient that is undergoing septoplasty o rhinoplasty surgery. Failure to recognize malfunction of the nasal valve may result in patients with persistent nasal obstruction after septoplasty and rhinoplasty, and patients with the novo nasal obstruction after rhinoplasty.
In rhinoplasty patients, we must assess as surgeons if our patients are at risk of nasal valve collapse or would be if reductive techniques are needed. If this is the case, preventive measures during surgery must be taken to avoid this condition after rhinoplasty.
It is very important to be aware of all the available techniques to correct nasal valve collapse and to learn how to execute them to offer our patients more and better tools to address nasal obstruction. Though our preference for patients with nasal valve collapse that do not have previous surgery and do not want rhinoplasty are batten and spreader grafts, these and other techniques are valid in patients that have iatrogenic nasal valve pathology or are at risk of it when undergoing rhinoplasty.
Table 1
|
Valve impacted | |
|
Internal |
External |
| Spreader | Alar batten grafts |
| Laring sutures | Lateral crura strut graft |
| Alar batten grafts | Lateral crura turn in |
| Lateral nasal wall suspension | Alar rim graft |
| Butterlfy graft | Butterfly graft |
|
Type of collapse | |
|
Static |
Dynamic |
| Spreader grafts | Flaring sutures |
| Autospreader flaps | Alar batten graft |
| Flaring sutures | Lateral nasal wall suspension |
| Lateral nasal wal suspension | Lateral crura strut graft |
| Lateral crura strut graft | Lateral crura turn in flap |
| Lateral crura turn in flap | Alar rim graft |
| Ala rim graft | Butterfly graft |
| Butterfly graft |
References
- Toriumi DM, Josen J, Weinberger M, et al. Use of alar batten grafts for correction of nasal valve collapse.Arch Otolaryngol Head Neck Surg. 1997;123:802–808.
- Barrett D, Casanueva F, Cook T. Management of the nasal valve. Facial Plast Surg Clin North Am2016;24(3):219–234
- Rhee JS, Weaver EM, Park SS, et al. Clinical consensus statement: diagnosis and management of nasal valve compromise. Otolaryngol Head Neck Surg 010; 143:48–59
- Ballert JA, Park SS. Functional rhinoplasty: treatment of the dysfunctional nasal sidewall. Facial Plast Surg 2006;22(1):49–54.
- Lee MK, Most SP. Evidence-based medicine: rhinoplasty.Facial Plast Surg Clin North Am 2015;23(3):303–12.
- Sheen JH. Spreader graft: a method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plast Reconstr Surg 1984;73(2):230–9.