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The nasal valve is frequently a contributor or sole cause of nasal obstruction and must be clinically evaluated in any patient presenting with nasal obstruction.
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Understanding of nasal valve anatomy with critical assessment of the site of obstruction is essential to effective nasal valve management.
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Validated outcome measures, such as the Nasal Obstruction Symptom Evaluation score, are helpful for preoperative evaluation of the severity of obstruction and postoperative assessment of success.
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Management of the Nasal Valve
Section snippets
Key points
Anatomy
The nasal valve is an anatomically complex concept and is nonspecific in its original description. First suggested by Mink,10 the nasal valve was described as the region of maximal nasal resistance.10 It was later described by Bridger11 as the flow-limiting segment of the nasal airway located at the triangular aperture between the upper lateral cartilage (ULC) and septum. From the author’s perspective, the nasal valve is much more generic. In reality, the nasal valve encompasses the column of
Physiology
Normal airflow through the nasal valve depends on the Bernoulli principle and Poiseuille's law. The Bernoulli principle states that as the flow of air increases through a fixed space, the pressure in that space decreases. If the decrease in pressure overcomes the inherent rigidity of the flexible nasal sidewall, collapse can occur resulting in obstruction.11, 12 Clinically, the collapse of the nasal sidewall during inspiration is termed dynamic obstruction.
Pouseille’s law states that flow is
Terminology
The terminology regarding nasal valve management is varied, confusing, and in need of standardization. There are several terms in the literature that reference pathology of the nasal valve as well as its component structures, the internal and external nasal valves. Some of the terms in the literature referencing the valve include NVD,7 nasal valve collapse,8 nasal valve compromise (NVC),15 and nasal valve stenosis.17 Similar terms have been applied to both the internal and external valves.
The
Historical perspective
Traditionally, treatment of nasal obstruction centered on a septoplasty. The original submucous resection (SMR) consisted of removal of the deviated portion of the septum with preservation of a dorsal and caudal strut (L-strut). The SMR was made popular by Killian19 and Freer20 in early 1900s; however, this technique failed to address the dorsal or caudal portions of the septum. In 1948, Cottle and Loring21 advocated an incision at the mucocutaneous junction instead of the Killian incision as
Diagnosis
Diagnosis of NVD is based on history and physical examination. Subjective assessment should include onset, laterality, duration, exacerbating and alleviating factors, trauma, history of nasal surgery, and impact on daily life. A history of use of nasal splints, such as BreatheRight Strips (CNS Inc, Minneapolis, MN), and their effectiveness is helpful as it may provide an indication of surgical success. Physical examination should include inspection of the outward appearance, palpation, and
Objective outcome measures
Objective measures in nasal valve surgery serve 2 purposes. They are useful in the assessment of clinical outcomes determining whether surgery accomplished the goal of improving patient outcomes. Secondly, and perhaps most importantly, these measures would theoretically have diagnostic utility in predicting surgical success. Such measures would ideally be inexpensive, readily accessible, and easy to administer. Unfortunately, no such tool currently exists. Most objective measures are cumbersome
Subjective outcome measures
Perhaps more important than objective measures of the nasal valve is the subjective experience of obstruction and self-reported assessment of efficacy. Although subjective assessments are not helpful in the specific diagnosis of a nasal valve problem, they can be helpful in indicating the degree of impact on a patient’s quality of life. They also serve as an indicator of surgical success. The most commonly accepted patient-reported outcome measure in use is the NOSE scale. Initially developed
Controversy in technique selection
Long-term correction of NVD requires surgical intervention.15
Correction typically involves the use of various grafts or suture techniques to enlarge and/or support the nasal valve. Selection of the appropriate technique largely depends on the location and type of dysfunction (dynamic/static). Often, multiple techniques need to be used in the same surgical procedure.
Selection of the appropriate technique poses a significant challenge to the nasal valve surgeon. Most techniques have been shown to
Spreader grafts
Spreader grafts have been the workhorse technique for repairing the internal nasal valves and correcting abnormalities of the midvault. These grafts directly address static internal valve narrowing. Generally derived from septal cartilage, these grafts are secured to the dorsal septum increasing the angle and cross-sectional area of the internal nasal valve by lateral displacement of the ULC (Fig. 4). The grafts also have a cosmetic impact, often augmenting the concave side of the nasal dorsum
Autospreader grafts
A recently discovered alternative technique to the classic spreader grafts is the use of spreader flaps, or autospreader grafts. Autospreader grafts use the same principles, primarily impacting internal nasal narrowing. Contrary to spreader grafts, autospreader grafts involve infolding of the ULC to act as a spacer (Fig. 5). First described by Lerma53 in the late 1990s, the dorsal edge of the ULC is scored or left alone and infolded medially, occupying the space that a spreader graft would
Flaring sutures
The flaring suture is another method of primarily correcting internal NVC. The flaring suture is a horizontal mattress suture that extends from one ULC to the other over the nasal dorsum (Fig. 6). Once tightened, both ULCs are flared dorsally increasing the angle and cross-sectional area of the internal valve. This technique can impact both static narrowing and dynamic collapse. The suture widens the internal valve, whereas the suture tension resists sidewall collapse. The main advantage of
Alar batten grafts
Alar batten grafts are cartilaginous grafts typically composed of conchal cartilage that are placed in precise pockets along the point of maximal nasal sidewall collapse. The lateral aspect of the graft overlaps the piriform aperture in order to support the nasal sidewall and prevent dynamic collapse (Fig. 7). The location of graft placement should depend on preoperative evaluation of the site of the nasal sidewall collapse as determined by the modified Cottle maneuver.58 Typically this is deep
Lateral crural strut grafts
Lateral crural strut grafts are useful in cases of inherent weakness, concavity, or cephalic malposition of the lateral crura resulting in dynamic nasal sidewall collapse. These grafts are ideally fashioned from septal cartilage as thin and straight grafts. They may be placed as an overlay or underlay graft between the lateral crura and vestibular mucosa extending past the cephalic edge of the lateral crus (Fig. 8). It is important to place these grafts in a precisely dissected pocket, and the
Lateral crural turn-in grafts
Lateral crural turn-in grafts are a novel technique first described by Tellioglu and Cimen61 in 2007 and later Murakami and colleagues62 in 2009. This technique takes advantage of the excess cartilage along the cephalic lateral crura during a cephalic trim. Instead of discarding the cartilage, the cephalic cartilage is scored, infolded into a vestibular mucosal pocket, and secured with horizontal mattress sutures. The advantages of this technique are that it can improve nasal tip contour
Alar rim grafts
Alar rim grafts are useful when contour deformities and collapse of the alar rim exist. Alar rim collapse may result from congenital weakness or malposition or as a result of overzealous cephalic trimming of the LLC in prior surgery. In these cases, the alar rim lacks rigid support and is subject to static or dynamic collapse. The alar rim graft is a thin cartilage graft, 1 to 3 mm in thickness placed in a non-anatomic fashion spanning the alar rim margin (Fig. 9). The medial aspect of the
Lateral nasal sidewall suspension
Lateral nasal sidewall suspension involves placement of a permanent suture from the lateral alar cartilage to the bone of the infraorbital rim. As it was first described in the mid 1990s, the suture was placed using a combination of a small intranasal incision and an external incision on the medial lower eyelid or via transconjunctival incision.65 Disadvantages of this technique included risk of ectropion, external incisions, and unclear efficacy. A similar technique has been described through
Butterfly graft
The butterfly graft is a structurally supportive onlay graft harvested from the conchal cartilage of the ear (Fig. 10). The graft is carved into the shape of a wedge and positioned superficial to the anterior septal angle and caudal edge of the upper lateral cartilage. The caudal aspect of the graft is positioned deep to the cephalic margin of the lower lateral cartilage. Acting as an internal BreatheRight Strip (CNS Inc, Minneapolis MN), the graft provides an outward spring effect both
Summary
The nasal valve plays an important role in nasal airflow. It is important for the otolaryngologist to not only consider but also fully evaluate the nasal valve when seeing a patient with nasal obstruction. If not the primary cause of obstruction, it is often a contributing factor. If NVD is discovered, it should be addressed during surgical intervention to avoid a suboptimal outcome.
There is some controversy regarding the anatomy, terminology, evaluation, and management of the nasal valve. Both
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Disclosures: None of the authors have any commercial or financial conflicts of interest.