1 INTRODUCTION

The nasal valve is defined as the flow-limiting segment of the nasal airway, located at the triangular aperture between the upper lateral cartilage and the septum. The angle formed by these two structures ranges from 10° to 15 °, and is maintained by the relationships between the nasal septum, the lower lateral cartilage, and the attachments of the facial muscles.¹

Nasal valve collapse is a common cause of nasal airway obstruction. In fact, nasal valvular incompetence may equal or even exceed septal deviation as the prime cause of nasal airway obstruction.² The valve area may be obstructed secondary to surgical procedures (such as rhinoplasty), trauma, or even aging. The complexity of nasal valve repair techniques and its variable results, coupled with the difficulty of treating previously operated patients or even the fact that advanced-age patients often do not seek medical attention for this problem, make nasal valve collapse an issue that oftentimes remains unresolved. In many cases, nasal valve collapse is not diagnosed until surgical treatment, in the form septoplasty or turbinate reduction, fails to relieve symptoms of nasal obstruction, in which case further causes are investigated. It is often impossible to know if the correction of the obstruction caused by a deviated septum and the turbinates actually unmasked an underlying valve collapse problem, or whether the ensuing increased airflow actually makes the valve collapse. Classically, obstruction of the valve area has been attributed to insufficient support of the upper or lower lateral cartilages. This represents true valve collapse. Fixed valve obstruction, however, may be secondary to a persistently deviated caudal septum after septoplasty. In these cases, lateral displacement of the valve area can overcome this obstruction.

Various techniques aimed at correcting nasal valve collapse have been described.³ Techniques designed to lateralize the superior segment of the upper lateral cartilage, involving cartilage and spreader grafts, are effective when this portion has been medially displaced.^4,5 Nasal valve obstruction may be secondary to the position of the septum (e.g. after septoplasty), and in selected cases, also amenable for repair using a nasal valve suspension technique.

The original description of a technique for repair of the nasal valve by means of a suspension of the valve to the orbital rim was described by Paniello.⁶ Significant modifications to this original technique which simplified this technique, and made it safer and equally effective were later introduced by Friedman et al.⁷ In this chapter, we describe the patient selection criteria and the simplified technique for nasal valve suspension for patients with nasal valve collapse and obstruction. The effect of improved nasal breathing in patients with OSAHS is discussed in detail in Chapter 19.

2 PATIENT SELECTION

In general, four categories of nasal valve obstruction can be identified, based on the involved valve (external or internal), and whether it is always present (fixed), or present during inspiration only (inspiratory, also referred to as nasal valve collapse). It should be noted that both types of obstruction can be present at the same time. While examining the nasal valve, both the external and the internal valves should be visualized, in order to determine the presence of obstruction. The internal valve is located at the level of the border of the upper lateral cartilage and the piriform aperture. Not only can this area be easily distorted during anterior rhinoscopy, it can also be completely overlooked with nasal endoscopy; hence, it should actually be examined prior to the introduction of the speculum or endoscope into the nose. As part of the routine evaluation, patients should be asked to take a deep breath while observing the nasal valve. A normally functioning nasal valve widens together with the nasal alae external dilator muscles, whereas in patients with inspiratory obstruction, the nasal valve collapses during inspiration. Nasal strips (Breathe Right™, CNS Inc., Whippany, NJ) are usually effective in improving airflow by widening the nasal valve area in these patients, and may serve as a kind of confirmatory test to identify potential candidates for nasal valve suspension.

Patients may have nasal valve obstruction secondary to a deviated caudal septal position, which may nevertheless be correctable by valve suspension in selected situations. The decision to correct the valve or the septum is based on the response to the Cottle maneuver, the position of the entire septum, and whether the patient has had previous septal surgery. The Cottle maneuver consists of superolateral traction being applied to the nasofacial groove, and is considered positive when it causes improvement of the nasal airway, as perceived by the patient. A positive Cottle maneuver is an adequate predictor of a successful outcome of nasal valve suspension for the treatment of nasal airway obstruction.⁸ The area of obstruction can then be identified by intranasal examination at the valve region. Direct superolateral displacement (with a cotton-tip applicator) should significantly improve the patients’ nasal airway. Patients with associated rhinitis or other causes of nasal airway obstruction should be treated appropriately prior to surgery.

3 SURGICAL TECHNIQUE (OUTLINE OFPROCEDURE)

Several key points simplify the procedure and deserve special mention before describing the technique for nasal valve suspension in detail. The necessary equipment, which includes the bone anchoring device (Mitek Soft Tissue Anchor system™, DePuy Mitek Inc., Raynham, Mass.) and needle (Fig. 20.1), has been carefully tested and chosen based on trial and error, and has proven to be crucial to the simplicity and effectiveness of the technique. The drill bit is included with the disposable bone anchor set, and it fits into the specific drill used for the procedure. The needle is perfectly sized and its contour allows for easy placement of the suture from the orbital rim to the valve area. Equipment or instrument substitutions are likely to complicate these important steps.

Fig. 20.1 The bone anchoring device (Mitek Soft Tissue Anchor system™, DePuy Mitek Inc., Raynham, Mass.) and needle.

The procedure can be performed under local or general anesthesia. The nasal valve area is examined to identify the area of collapse prior to injection of local anesthesia, in order to avoid tissue distortion. Two points representing the caudal and cephalad margins of the collapsed area are marked, and an incision is made through the mucosa, connecting both points (Fig. 20.2). This mucosal incision is an important modification from a previously reported technique.⁷