Correction of nasal obstruction due to nasal valve collapse

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Chapter 21 Correction of nasal obstruction due to nasal valve collapse

Maria T. Messina-Doucet

1 INTRODUCTION

Airway obstruction or 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. A patient who complains of snoring is indicating that something more serious may be occurring. Snoring can present as a symptom of obstructive sleep apnea. Many people who snore also admit to excessive daytime sleepiness and fatigue.1

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 towards 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. 21.1A). The angle of this area is normally 10° to 15°. 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. 21.1B). 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.2

image image

Fig. 21.1 A, Internal 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 obstruction. Valvular effects may equal or surpass a deviation of the septum as the cause of airflow obstruction. In an excellent study by Constantain 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.3

2 EXAMINATION

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 dose 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 1–2 mm. If the patient reports improved breathing with this conservative maneuver, valve restriction is contributing to the patient’s obstruction.4 It is important to evaluate the competence of both the internal and the external nasal valves as concurrent correction is often required in order to alleviate the symptoms of nasal obstruction.

3 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.

3.1 INTERNAL NASAL VALVE

The spreader graft as described by Sheen in 19845 has been the most common approach to correct internal nasal valve collapse. Several adaptations to this technique have been reported in the literature.6–9 Each offers a varying twist of the standard that may accommodate specific circumstances pertaining to individual patients. An open approach is preferable as it allows superior visualization of anatomy.

3.1.1 TECHNIQUES FOR INTERNAL VALVE REPAIR

Spreader graft

1. For an open approach: an 11 blade is used to make an inverted V transcolumellar incision. Marginal incisions are made in the nasal vestibule of each nostril. Soft tissue is elevated off the medial crus of the lower lateral cartilages with care taken not to disrupt this delicate cartilage. A converse scissors is used to create a subperi-osteal plane that allows for a clean dissection. Tissue is elevated following each lower lateral cartilage laterally. By exposing the cartilages in this way, multiple problem areas can be corrected through the same approach.
2. Dissection then follows at the septal edge and mucoperi-osteal flaps are elevated from both sides of the septum. If septal cartilage is available this is the graft material of choice as it is in the same operative field. Otherwise, auricular cartilage can be harvested. Leaving a 1 cm strut to both the caudal septal edge as well as to the dorsal aspect of the septum, septal cartilage is harvested. The cartilage is then carved with either a 15 blade or a 64 beaver blade into two grafts 15 mm in length and 2–3 mm in thickness.
3. The grafts are placed on either side of the septum as high as possible. Try to place the grafts at the same height as the septum so that they sit flush at the nasal dorsum. The use of a 25-gauge 1 inch straight needle helps to hold the grafts in place on each side of the septum while preparing to place sutures. At the caudal edge of the graft, a 5.0 absorbable suture (Vicryl) is placed through the spreader graft, the septum, and the other spreader graft in a mattress fashion (Fig. 21.2). Approximately 1 cm posterior another suture is placed from the upper lateral cartilage, through the spreader graft, septum spreader graft, and upper lateral cartilage in a mattress fashion (Fig. 21.2).
image

Fig. 21.2 Spreader graft.

The advantage of this technique is that it causes little nasal deformity. It can widen the dorsum but this trade-off is usually acceptable as the function of the nose is improved as the obstruction may be alleviated.

Cartilage spanning graft

Occasionally, spreader grafts alone are not sufficient especially in a patient with weak septal cartilages. Even if auricular cartilage is used for spreader grafts sometimes the septum is very thin and another option must be considered. Cartilage placed over the area of internal valve collapse can provide structural support and prevent collapse of the internal nasal valve.

Technique

1. Prior to anesthesia, the area on the external nose that corresponds to the internal nasal valve is observed. A Q-tip is used to view the internal valve area and a surgical marking pen is used to mark the surface of the skin on the lateral nose that sits above this weak area.
2. An open approach, as described above, is then used to expose the area of the septum and the upper lateral cartilage. Cartilage is harvested and a 64 beaver blade is used to configure a graft that is circular in fashion and large enough to cover the defect as determined by preoperative markings. Tapering the edges improves cosmetic camouflage and makes the graft less visible postoperatively.
3. The graft is placed spanning the upper lateral cartilage and the lower lateral cartilage, lateral to the septum (Fig. 21.3). The graft is sutured percutaneously with a 4.0 PDS in order to coapt tissues, prevent graft migration, and prevent the accumulation of fluid between the graft and the skin (Fig. 21.3). The PDS is removed in 7 days.
image

Fig. 21.3 Cartilage spanning graft.

This technique is advantageous in elderly patients with thin septal cartilages. It can also be used in patients with thick skin. The disadvantage of this method is that the tip is made to appear wider, and may not be acceptable to a cosmetic rhinoplasty patient or patients with thin skin.

Splay conchal graft1,10,11

1. The open technique is initiated as described above.
2. Conchal cartilage is harvested by making a postauricular incision. The perichondrium is left intact on the posterior surface. The entire concha is harvested.
3. A 15 blade is used to sculpt the graft to fit over the anatomic deformity that extends laterally to cover both internal nasal valve areas. The area of deformity usually sits between the septum and upper lateral cartilage on both sides, and cephalic to the lower lateral cartilage. The size of the graft ranges from 0.9 to 1.2 cm in length, by 2.2 to 2.5 cm in width.1 The edges of the concealed graft are beveled.
4. The graft is placed on the nasal dorsum, over the upper lateral cartilages, with the concave side facing down and the periosteal covered side facing up. A 5.0 Vicryl is used to attach the graft to both upper lateral cartilages in a single interrupted fashion (Fig. 21.4).
5. The skin flap is then replaced and percutaneous suture is placed in a mattress fashion to coapt the skin and endonasal lining to the graft using a 5.0 PDS suture. The suture is removed in 5 days.
image

Fig. 21.4 Splay conchal graft.

This is a very simple technique especially in a patient with weak septal cartilage or in a patient in whom septal cartilage is unavailable for graft harvest. It can widen the nasal dorsum but if sculpted properly this widening is not perceived as a problem to the patient. It is most applicable for use on a patient with thick skin.

3.1.2 TECHNIQUES TO RECONSTRUCT THE EXTERNAL NASAL VALVE

Alar batten graft2,12,13

1. Prior to anesthesia, a surgical marking pen is used to mark the area of the lateral nasal sidewall corresponding to external valve or sidewall collapse. As the patient inhales, the area of maximum flaccidity is marked.
2. An open rhinoplasty approach is recommended. Septal cartilage or auricular cartilage is harvested. The graft is fashioned to meet the required length per preoperative markings. Effective graft size is approximately 14 mm in length and 8 mm in width. The width of the graft should be 4–5 mm wider than the existing alar cartilage (Fig. 21.5).
3. The graft is placed anterior to the pyriform aperture and extends 2 mm superior to the rim. Using 5.0 Vicryl, the graft is sutured medially, centrally and laterally.
image

Fig. 21.5 Alar batten graft.

Columelloplasty

The width of the columella often plays an important role in narrowing the nostril. Strengthening the columella and narrowing the footplates can improve nasal airflow.14

1. Using an open approach, the columellar footplates are exposed. Soft tissue is dissected from the caudal edges of the medial alar crura.
2. The basal third of the medial crural footplate is exposed and a 15 blade is used to transect the cartilage.
3. A strut graft is then fashioned from septal cartilage and placed between the footplates. The graft and footplates are then sutured together using a 5.0 Vicryl (Fig. 21.6).
image

Fig. 21.6 Columelloplasty.

This procedure is not indicated on all patients. It is useful to narrow the columella and widen the nostril sill. Sometimes the bony nasal spine and pyriform crest contribute to narrowing and need to be trimmed as well. This procedure can also correct abnormalities at the base of the nostril due to wide or asymmetric columellar footplates.

Nasal valve suspension technique

This technique is a simple approach, providing an internal suspension suture to elevate the nasal valve. It is most beneficial for the treatment of internal nasal valve collapse but I have seen improvement in external valve collapse also. The technique involves anchoring sutures into the inferior orbital rim and guiding sutures to suspend the nasal valve. Cartilage harvesting is not involved. The technique was originally described by Paniello15 and advancements in this technique have been described over the years.16

Technique

1. The area of nasal collapse is marked preoperatively. Specifically, the caudal and cephalad margins that represent the area of maximal collapse are marked. These two points should be about 5 mm apart.
2. Under general anesthesia, orbital shields are placed. Access to the infraorbital rim can be through a standard transconjunctival incision medially or a subcillary incision. The incision should be medial to the infraorbital nerve and lateral to the lacrimal punctae. In patients with thick skin or rhytids, a natural crease can be used.
3. An 11 blade is used to make a small 3 mm incision down to the periosteum. A periosteal elevator facilitates clearing a 3 3 3 mm area on the orbital rim. A Mitek Soft tissue anchor system is optimal for anchoring sutures to the orbital rim (1.3 mm Micro quick anchor; Ethicon). A drill is used to make a small hole in the orbital rim. The anchor is then placed into the hole and the sutures released. The bone anchor must sit flush with the bone in order to prevent a palpable foreign body sensation postoperatively.
4. The end of one suture is threaded through a large curved needle. The needle is then advanced through the incision toward the endonasal mucosa. The plane of advancement is deep to the facial muscles and superficial to the maxillary periosteum. The needle should exit at the cephalad point of nasal valve collapse first. The needle is then retrieved intranasally and passed from the internal nasal mucosa back toward the orbital rim incision (Fig. 21.7).
5. The suture is then tied. Once the sutures are tightened, observe the area of collapse and adjust the tightness of the suture accordingly. Slight overcorrection may be necessary. If there is any skin dimpling, this indicates that the needle tract passed too superficially and will need to be redirected in a deeper plane.
6. The skin incision is closed with a 6.0 chromic.

The advantage of this technique is that it is simple and effective. It does not require cartilage harvesting. In my experience the results have not caused widening of the nasal tip or dorsum. This is a good procedure to consider in cosmetic surgical patients.

In summary, no one procedure will be applicable to all patients. Knowledge of a variety of techniques is essential in order to customize your approach to correct the patient’s specific defect.

REFERENCES

1. Akcam T, Freidman O, Cook T. The effect on snoring of structural nasal valve dilation with a butterfly graft. Arch Oto Head Neck Surgery. 2004;130:1313-1318.

2. Kosh M., Jen A., Honrado C., Pearlman S. Nasal valve reconstruction. Arch Facial Plastic Surg. 2004;6:167-171.

3. Constantain M, Clardy R. The relative importance of septal and nasal valvular surgery in correcting airway obstruction in primary and secondary rhinoplasty. Plastic Reconst Surg. 1996;98(1):38-58.

4. Becker D., Becker S. Treatment of nasal obstruction from nasal valve collapse with alar batten grafts. J Long-Term Effects of Med Implants. 2003;13(3):259-269.

5. Sheen JH. Spreader graft: a method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plast Reconstr Surg. 1984;73:230-239.

6. Ozturan O. Techniques for improvement of the internal nasal valve in functional-cosmetic nasal surgery. Acta Otolaryngol. 2000;120:312-315.

7. Andre R, Paun S, Vuyk H. Endonasal spreader graft placement as treatment for internal nasal valve insufficiency. Arch Facial Plast Surg. 2004;6:36-40.

8. Gupta A, Brooks D, Stager S, Lindsey W. Surgical access to the internal nasal valve. Arch Facial Plast Surg. 2003;5:155-158.

9. Boccieri A. Mini spreader grafts: a new technique associated with reshaping of the nasal tip. Plastic Reconst Surg. 2005;116(5):1525-1534.

10. Deylamipour M, Azarhoshandh A, Karimi H. Reconstruction of the internal nasal valve with a splay conceal graft. Plastic Reconst Surg. 2005;116(3):712-722.

11. Stucker F, Lian T, Karen M. Management of the keel nose and associated valve collapse. Arch Otolaryngol Head Neck Surg. 2002;128:842-846.

12. Kalan A, Kenyon G, Seemungal T. Treatment of external nasal valve (alar rim) collapse with an alar strut. J Laryngol Otol. 2001;115:788-791.

13. Romo III T, Sclafani A, Sabini P. Use of porous high density polyethylene in revision rhinoplasty and in the plattyrrhine nose. Aesth Plast Surg. 1998;22:211-221.

14. Ghidini A, Dallari S, Marchioni D. Surgery of the nasal columella in external valve collapse. Ann Otol Rhinol Laryngol. 2002;11:701-703.

15. Paniello R. Nasal valve suspension. Arch Otolaryngol Head Neck Surg. 1996;122:1342-1346.

16. Friedman M, Ibrahim H, Syed Z. Nasal valve suspension: an improved, simplified technique for nasal valve collapse. Laryngoscope. 2003;113:381-385.

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