External Valve Stenosis Rhinoplasty
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Mink first coined the term nasal valve in 1903. Initially, he described the nasal valve as the slitlike opening between the caudal end of the upper lateral cartilage and the nasal septum. Since then, the term nasal valve has broadened to include both an internal nasal valve (Mink’s description) and an external nasal valve. The external nasal valve is described as the region caudal to the internal valve, bounded laterally by the nasal alar and medially by the septum and columella.
Nasal valves (internal and external) may function as Starling resistors (collapsible tubes attached to rigid tubes). The transmural pressure increases as the airflow velocity increases, which leads to collapse and a decrease in airflow. This may be a mechanism to prevent large volumes of unheated and unhumidified air from reaching the lower respiratory tract. In individuals with either acquired or congenital external valve collapse, this mechanism functions at too low a transmural pressure, which leads to premature collapse and difficulty with nasal breathing.
The nose can be modeled as a tube. The Bernoulli principle demonstrates that the speed of a fluid through a tube is greatest where the diameter of the tube is the least. Where the velocity is the greatest, the pressure is the lowest. Because the nasal valves (internal and external) are choke points for the flow of air, the difference between intranasal and atmospheric pressure is the greatest at these points, which leads to the greatest potential for collapse. Individuals with alae collapse who report airflow deficiency with inspiration are candidates for surgical correction.
Nasal valve collapse or obstruction has many potential etiologies. Some of the more frequent causes include the following:
Congenital malformation, weakness, or cephalad rotation of the lower lateral cartilage
Deficiency of the lateral crus of the lower lateral cartilage secondary to previous surgery with overaggressive resection of cartilage
Trauma that leads to loss of tissue
Full-thickness surgical resection of the alar with insufficient reconstruction
Aggressive narrowing of the nasal tip during rhinoplasty (see the Medscape Reference article Postrhinoplasty Nasal Obstruction Rhinoplasty)
Caudal septal deflection that narrows the valve and causes increased velocity of airflow with a larger transalar pressure differential
Facial nerve palsy that leads to loss of nasal dilators
Sequelae of aging that leads to loss of nasal alar stiffness
Overprojection of nasal tip that leads to slitlike nares with increased velocity of airflow
A study by Chambers et al suggested that nasal valve dysfunction is underdiagnosed and should be taken into account as a possibility in patients with septal deviation, prior to the performance of septoplasty, particularly in those patients who demonstrate severe dorsal septum deflection and a narrow middle vault. The study involved 40 patients who, despite having undergone septoplasty, still suffered from nasal obstruction, requiring valve correction. These included 38 patients (95%) with moderate or severe internal nasal valve narrowing, 19 patients (48%) with internal nasal valve collapse, 18 patients (45%) with external nasal valve narrowing, and 16 patients (40%) with external nasal valve collapse. Aside from internal nasal valve narrowing, the most common anatomical causes of obstruction were dorsal septum deflection (26 patients; 65%) and a narrow middle vault (16 patients; 40%), indicating these as risk factors for valve dysfunction in patients with failed septoplasty. [1]
Any process, condition, or trauma that weakens the lower lateral cartilage or alar walls or that narrows the entrance to the nose can lead to collapse of the external valve. Upon inspiration, the increase in transmural pressure across the nasal ala leads to collapse of the external valve.
In obtaining patient history, elicit the following:
Previous history of nasal surgery or trauma
History of facial nerve injury
Nasal obstruction, either with normal nasal respiration or with forced inspiration
Seasonal variations in nasal obstruction
A complete nasal examination to exclude other causes of nasal obstruction is mandatory. More specific findings may include the following:
Observed external valve obstruction
Caudal septal deflection
Width of columella base
Nasal alar collapse
Exaggerated medial movement of alar cartilage upon deep inspiration
Encroachment of the lateral portion of the crus into the vestibule
Presence of tip bossae
Deep alar grooves
Other fixed vestibular obstruction
Apparent improvement in symptoms when cotton-tipped applicators or cerumen loops are used to support the external nasal valve (when collapse is evident), with specific improvement in airflow and relief of symptoms
Any airway compromise caused by obstruction of the external nasal valve is an indication of external valve stenosis/collapse. Before an attempt is made to stiffen or to suspend the lateral ala, a reasonable approach is to address fixed obstructions first. This approach helps to determine if the collapse is secondary to the decreased area that causes larger transmural pressures. Caudal septal deflections by themselves can contribute to valve collapse, but recognition of a deficient lateral nasal sidewall is important to fully address the decrease in airflow. The most absolute indication is the symptomatic collapse of the alar upon inspiration.
The internal nasal valve is the slitlike opening between the caudal end of the upper lateral cartilage and the nasal septum. The external nasal valve is described as the region caudal to the internal valve bounded superolaterally by the caudal edge of the upper lateral cartilage, laterally by the nasal alar and bony piriform aperture of the maxilla, and medially by the septum and columella. The ligamentous attachment of the lateral crus to the bony maxilla provides support for the lateral border area. The primary muscles responsible for maintaining the patency of the nasal valve include the nasal and dilator naris muscles. The measured area of the nasal valve ranges from 55-64 mm2.
If the patient considers any cosmetic changes in the shape of the nose unacceptable, he or she is a poor candidate for any attempt at surgical correction of a collapsing external nasal valve. However, patients who have internal obstructions secondary to scarring or a narrow vestibule may be helped by procedures designed to increase the cross-sectional area of the external nasal valve.
Chambers KJ, Horstkotte KA, Shanley K, Lindsay RW. Evaluation of Improvement in Nasal Obstruction Following Nasal Valve Correction in Patients With a History of Failed Septoplasty. JAMA Facial Plast Surg. 2015 Sep-Oct. 17 (5):347-50. [Medline].
Gruber RP, Lin AY, Richards T. Nasal strips for evaluating and classifying valvular nasal obstruction. Aesthetic Plast Surg. 2011 Apr. 35 (2):211-5. [Medline].
Fanous N, Hier MP. Collapsed nasal-valve widening by composite grafting to the nasal floor. J Otolaryngol. 1996 Oct. 25(5):313-6. [Medline].
Gruber, Ronald P.; Melkin, Edward T.; Strawn, J. Bradley. External Valve Deformity: Correction by Composite Flap Elevation and Mattress Sutures. Aesth Plast surg. May 2011. 35:960-964.
Toriumi DM, Josen J, Weinberger M, Tardy ME Jr. Use of alar batten grafts for correction of nasal valve collapse. Arch Otolaryngol Head Neck Surg. 1997 Aug. 123(8):802-8. [Medline].
Chung YS, Seol JH, Choi JM, et al. How to resolve the caudal septal deviation? Clinical outcomes after septoplasty with bony batten grafting. Laryngoscope. 2014 Aug. 124(8):1771-6. [Medline].
Gunter, Jack P. M.D.; Friedman, Ronald M. M.D. Lateral Crural Strut Graft: Technique and Clinical Applications in Rhinoplasty. Plastic and Reconstructive Surgery. April 1997. 99(4):943-952.
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Egan KK, Kim DW. A novel intranasal stent for functional rhinoplasty and nostril stenosis. Laryngoscope. 2005 May. 115(5):903-9. [Medline].
Khosh MM, Jen A, Honrado C, Pearlman SJ. Nasal valve reconstruction: experience in 53 consecutive patients. Arch Facial Plast Surg. 2004 May-Jun. 6(3):167-71. [Medline].
Latte J, Taverner D. Opening the nasal valve with external dilators reduces congestive symptomsin normal subjects. Am J Rhinol. 2005 Mar-Apr. 19(2):215-9. [Medline].
Mendelsohn MS, Golchin K. Alar expansion and reinforcement: a new technique to manage nasal valve collapse. Arch Facial Plast Surg. 2006 Sep-Oct. 8(5):293-9. [Medline]. [Full Text].
Vaiman M, Shlamkovich N, Kessler A, Eviatar E, Segal S. Biofeedback training of nasal muscles using internal and external surface electromyography of the nose. Am J Otolaryngol. 2005 Sep-Oct. 26(5):302-7. [Medline].
Vidyasagar R, Friedman M, Ibrahim H, Bliznikas D, Joseph NJ. Inspiratory and fixed nasal valve collapse: clinical and rhinometric assessment. Am J Rhinol. 2005 Jul-Aug. 19(4):370-4. [Medline].
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Alicia R Sanderson, MD Fellow in Facial Plastics and Reconstructive Surgery, Department of Otolaryngology, University of California, Irvine
Alicia R Sanderson, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery
Disclosure: Nothing to disclose.
Peter A Weisskopf, MD Neurotologist, Arizona Otolaryngology Consultants; Head, Section of Neurotology, Barrow Neurological Institute
Peter A Weisskopf, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Dean Toriumi, MD Associate Professor, Department of Otolaryngology, University of Illinois Medical Center
Disclosure: Nothing to disclose.
Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;Cliexa;The Physicians Edge;Sync-n-Scale;mCharts<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; .
Daniel G Becker, MD Assistant Professor, Department of Otorhinolaryngology-Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, University of Pennsylvania School of Medicine
Daniel G Becker, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons
Disclosure: Nothing to disclose.
Craig Cupp, MD Head, Program Director, Department of Otolaryngology, Division of Facial Plastic-Reconstructive Surgery, Naval Medical Center San Diego
Craig Cupp, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, and Wyoming Medical Society
Disclosure: Nothing to disclose.
External Valve Stenosis Rhinoplasty
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