Management of Inner Nasal Valve Insufficiency

Kantas I., Balatsouras D. , Vafiadis M. , Apostolidou M. , Korres S. , Danielides V.

Journal of Otolaryngology-Head & Neck Surgery, Vol 37, No 2 ( April ), 2008: pp 212- 2 18

ABSTRACT

Objective: To determine the efficacy of the upper lateral caudal edge management in treating patients with inner nasal valve insufficiency and collapse.

Design: This was a prospective study in a group of patients suffering from nasal obstruction owing to nasal valve insufficiency. Forty-three patients, who had undergone septoplasty and inferior turbinectomy, were included. All patients presented with nasal obstruction resulting in persistent functional problems. An anatomically narrow nasal valve, valve collapse, or both were found during the clinical examination.

Setting: A tertiary referral center.

Methods: Revision was undertaken using a new technique to restore the nasal valve, based on upper lateral caudal edge management.

Main Outcome Measures: Improvement in nasal airway patency evidenced by patient questioning, by clinical inspection of the nose, and by rhinomanometric results.

Results: None of the patients had major complications. In 28 (65.1%) patients, symmetrically improved nasal airway patency and elimination of the subjective sensation of inspiratory collapse were found. In 12 (27.9%) patients, a remarkable asymmetric improvement in nasal obstruction was evident. Two (4.6%) patients reported a moderate breathing improvement, and in only one (2.3%) patient, a revision was needed. The mean follow-up time was 18 months.

Conclusions: Our proposed method is an effective therapeutic approach in the management of inner nasal valve insufficiency. It reconstitutes the normal tension of the inner nasal valve and reestablishes the stiffness and resistance of the lateral nasal wall. It can be performed under local anesthesia in cooperative patients, with minimal morbidity and a high rate of success.

SOMMAIRE

Objectifs : Determiner l’efficacite de la prise en charge du rebord caudal du cartilage alaire superieur dans le  traitement  des patients ayant une insuffisance et un affaissement de la valve nasale int erne.

Devis: C’etait une etude prospective avec un groupe de patients souffrant d’obstruction causee par une insuffisance de la valve nasale. Ouarante-trois patients, ayant subi une septoplastie et une turbinectomie inferieure ont ete inclus. Tous les patients presentaient une obstruction nasale entrainant des problemes fonctionnels persistant s. Une valve nasale etroite anatomiquement, un affaissement de la valve ou les deux etaient rencontres lors de l’examen clinique.

l ocalisation: Un centre tertiaire de reference.

Methodes: Une revision a ete faite en utilisant une nouvelle technique pour restaurer la valve nasale, basee sur la gestion du rebord caudal du cartilage alaire superieur .

Variables evaluees: L’amelioration de la permeabilite des voies nasales mise en evidence par un questionnaire remis aux patients, par l’examen clinique du nez et par des resultats rhino-manom etriques .

Resultats : Aucun des patients n’a eu de complication majeure. Nous avons trouve chez 28 (65.1%) des pat ient s, une amelioration symetrique de la permeabilite des voies aeriennes et !’elim inat ion de la sensation subjective d’affaissement lors de !’inspiration . Chez 12 (27.9%) des pat ient s, une amelioration remarquable mais asymetrique de !’obstruction nasale etait evidente. Deux (4.6%) patients ont rapporte une amelioration moderee de la respiration et chez seulement (2.3 %) des patients, une revision a ete necessaire. Le temps moyen de suivi etait de 18 mois.

Conclusions: Notre methode que nous proposons est une approche therapeutique efficace dans la gestion de l’insuffisance de la valve nasale inte rne. Elle reconstitue la tension normale de la valve et retablit la rigidite et la resistance du mur lateral du nez. Elle peut etre pratiquee sous anesthesie locale chez les patients cooperatifs , avec un taux de morbidite minimal et un taux de succes eleve.

Keywords: nasal breathing, nasal obstruction, nasal surgery, nasal valve, septoplasty 

Τηε nasal valve represents a crucial anatomic part of the nose, the functional mechanism of which remains obscure. Many authors studied its structure and evaluated its structural parts and their contribution to abnormal function.1 ‘ ² It was recently proposed that the true locus of nasal valve insufficiency lies lateral to the valve,  in the fibrolamellar tissue that connects the lateral aspect of the lateral crus to the bony piriform aperture. Failure of this region is considered responsible for nasal valve ins uffi­ ciency3.

Nasal valve collapse can be classified as congenital, traumatic,   senile,   mucosa!,   neurogenic,   or    id io pathic.3

Clinical evaluation of the condition may be obtained using the Cottle maneuver,3 whereas rhinomanometry and acoustic    rhinomanometry   may   assist    in  diagnosis.4-⁶

Several surgical techniques have been proposed for re­ construction of this specific area,  with varied results.⁷  13 In this study, we present the results of surgical treatment of a group of patients with nasal valve insufficiency who were treated with a new method of managing the caudal edge of the upper lateral cartilage.

Methods

Forty-three patients suffering from nasal valve obstruction and treated in our settings from 1998 to 2003 were included in the study. Patients ranged in age from 22 to 63 years (mean 37.7 years). Twenty-six of them were male and 17 were female. All patients had previously undergone septoplasty and inferior turbinectomy, occasionally more than once, with unsuccessful results because the problem ιn the last 32 patients (19 males and 13 females), intranasal findings were evaluated objectively by active anterior rhinomanometry (AAR) and acoustic rhinometry (AR). After suctioning the nasal cavities, a decongestant (0.001% xylometazoline hydrochloride) was applied and AAR and AR were performed 10 to 20 minutes after decongestion. The NR6 rhinomanometer and the  Al acoustic rhinometer (GM Instruments Ltd, Kilwinning, UK) and adequate software (NR6RHINO version 3.11, GM Instruments Ltd) were used. The equipment detected inspiratory nasal flow and nasal resistance at the 150 Pa reference pressure and minimal cross-sectional area (MCA). In AAR, both nasal cavities were measured separately and nasal resistance was accepted after 10 respirations if the maximal variation coefficient was 5%. In AR, acoustic rhinograms for each nasal cavity were accepted after averaging three rhinograms within the limits of a maximum 2% standard deviation (SD). The patients who underwent AAR and AR preoperatively were examined 3 months postoperatively for evaluation of the surgical outcome, under the same conditions, and using identical equipment. Data regarding MCA, nasal flow and nasal resistance were expressed as mean ± SD.

Patients who presented with a narrow nasal valve resulting from a postoperatively remaining segment of scoliotic quadrangular cartilage or perpendicular plate were excluded from our study. These patients were reoperated on by using revision septoplasty. The nasal valve was reconstructed and corrected after removal and straightening of the scoliotic septum.

The majority of our patients (74.4%) were operated on under local anesthesia. After intravenous sedation was of inner valve insufficiency had been overlooked. In seven induced, the patients were administered topical intra­ of them, a rhinoplastic operation had been performed.

On clinical examination, the Cottle maneuver was positive, and significant improvement in nasal airflow with instrument elevation of the nasal valve was evident. Nasal cavities were examined meticulously with the aid of a 30° nasal endoscope to determine accurately the failed area. A narrow nasal valve (angle less than 10°), valve collapse, or both were found. nasal decongestion of the inferior turbinate with 2% oxymetazoline in e-soaked sterile neurosurgical pledgets. Complimentary local anesthesia and decongestion for better hemostasis were achieved by infiltration of lidocaine 1% with 1:100 000 epinephrine,  submucosally,  in the area of the inferior nasal meatus and the region of upper lateral cartilage. Eleven patients (25.6%) preferred to be operated on under general anesthesia.

A marginal incision was made by a number 15 surgical knife, following the curvature of the palpated caudal edge of the upper lateral cartilage (Figure 1). Following a supra­ and infraperichondrial dissection, the upper lateral cartilage was exposed. A 2 to 3 mm strip of its caudal edge was trimmed in most cases. When the caudal edge was deviated or very thick, a triangular strip of the upper lateral cartilage was resected, which contained only cartilage. Its base was caudal and its apex cephalad (Figure 2). The amount of cartilage to be resected was judged by evaluating the size and anatomy of the nose and was individualized for every patient. As a general rule, the surgeon should be conservative. After trimming the cartilage, we stitched the incision using 2-0 Vicryl sutures. In cases in which the nasal valve collapsed, resulting in pinched nose deformity, cauterization by an ultrasound needle was also undertaken. The needle was inserted over the end of the inferior turbinate in the area of fibrolamellar tissue, lateral to the nasal valve (Figure 3).

With the previously described techniques, the broadening  of the nasal valve was obtained owing to the strengthening of the lateral nasal wall, as illustrated in Figure 4. In this figure, al represents the result of metatraumatic scarification and stiffening of the nasal wall at the region of postoperative trauma after removal of the cartilage, and a2 represents a similar result obtained at the fibrolamellar region after ultrasound cauterization, whereas b symbo­lizes the region of the removed upper lateral cartilage. In the same figure, force Fl denotes the pulling force of the lateral edge of the upper lateral cartilage after cauterization, and force F2 symbolizes the traction of this cartilage upward owing to resulting scarified tissue, which strengthens and stiffens the lateral nasal wall. The resultant Fs pulls the triangular cartilage upward and outward, causing stretch­ ing and broadening the nasal valve.

Intraoperatively, patients were administered an anti­ biotic intravenously and an antibiotic in conjunction with an anti-inflammatory agent orally for 3 days postoperatively. The nose was irrigated with normal saline for 1 week.

Results

The mean follow-up was 18 months (range 12-24 months). one of the patients developed a major complication, either during the operation or postoperatively.  Nasal packing was not required in any patient.  The most common minor complication was mild postoperative intranasal edema and transient edema of the lower lid, which resolved during the first postoperative week. Twenty-eight (65.1%) patients reported significantly improved symmetric nasal airway patency.   Twelve (27 .9% ) of them reported a remarkable improvement in the nasal airway patency, mainly on one side. Only two (4.65%) patients reported poorly improved nasal breath­ ing, and in the remaining one patient (2.3%), revision

was considered necessary.

Rhinomanometric measurements performed 3 months postoperatively (Table 1) demonstrated a statistically significant nasal flow increase and decreased nasal resistance, although not at a statistically significant level. The acoustic rhinometry data showed a significant MCA increase. These data proved a significant improvement in the nasal airway.

On clinical examination, a patent nasal airway was found in most cases, with the exception of the patient in whom revision surgery was undertaken. In addition to functional airway improvement, in several patients, a substantial cosmetic improvement in nasal appearance was observed (Figure 5), although, in most of them, a change in appearance was not noticed. Only seven patients with excessive valve collapse noted cosmetic improvement owing to reduced pinching of the nasal tip. An excessive widening in two patients resulted in a suboptimal aesthetic improvement (Figure 6), although the functional objective had been met.

Discussion

Nasal valve collapse is a common cause of nasal airway obstruction. In many cases, valvular effects may surpass septa) deviation as the primary cause of nasal airflow obstruction. Although many techniques have been devised to correct both the functional and cosmetic aspects of this problem, none are unanimously successful. Some suture techniques, either alone or in combination with a spreader or splay grafts, have been proposed by several authors as the ideal solution to the problem .^{7 13} The aim of these techniques was to broaden the inner nasal valve and to reestablish the stiffness and resistance of the lateral nasal walls, improving airflow at this area.

Initially, we applied the flaring suture technique ¹⁰ in a series of eight patients, operated on before 1998. Although satisfactory results were obtained by this technique, the method is technically challenging, and general anesthesia is required. Additionally, minor postoperative complications were usual, such as transient facial and lower lid edema and hypesthesia of the infraorbital nerve with transient facial numbness. For these reasons, we abandoned this technique.

The use of spreader grafts to pull open the nasal valve edge and reconstitute the rigid midline continuity of the upper lateral cartilages has also been recommended .14 1 5 Furthermore, the extended spreader grafts have been advocated as an alternative technique in correction of the severely crooked nose when combined with nasal valve stenosis.14 15  When this technique is applied in cases of a narrow nasal valve, it may provide some widening of the middle third of the nose. However, the stiffness and resistance of the lateral nasal wall (lateral crura ), in cases of valve collapse, are not reestablished, and an open technique is usually required.

Heterologous-porous high-density polyethylene sprea­ der grafts were used to straighten the severely crooked middle third of the nose and to reestablish nasal valve function. ¹⁶ The disadvantages of this method include foreign body reaction or extraction or palpability of the graft. We applied the method of spreader grafts in seven patients, before 1998, by opening the nasal valve using the spreader graft, which was harvested from the concha or the septum. Unfortunately, quite often this technique resulted in an unacceptable cosmetic appearance because of the excessive widening of the caudal portion of the nose. Additionally, patients complained about temporary dorsal stiffness. Another disadvantage of this method is that its application in revision septoplasties is hindered by the absence of an adequate cartilage graft, and, usually, tragus cartilage is needed.

The alar batten grafts have been used as an alternative intervention to repair nasal valve collapse.¹⁷ Septa! or conchal cartilages were used as structural support at the collapsing lateral crura. The disadvantage of this technique may be the overweighting of the lateral cartilage, extreme thickness, and protrusion to the nasal cavity,  reducing nasal airway patency. We applied this method to five patients, before 1998, with unsatisfactory results.

O’Halloran introduced the lateral crural J-flap repair of nasal valve collapse as the surgical intervention of choice, applied in a series of 19 patients with valvular insufficiency.3 The author reported remarkable improvement in 89% of his patients regarding nasal obstruction and the cosmetic appearance of the nose. This technique aimed to restore the normal anatomy of the inner nasal valve, which is the same objective of the technique we used, although it was approached in a different way. The author argued that the technique of dissecting the lower lateral cartilage and removing a J-flap consisting of cartilage and mucosa results in the strengthening of the region of the fibrolamellar tissue that connects the lateral aspect of the lateral crus to the bony piriform aperture. Our method is based on the same principle, but we believe that the problem is better confronted by strengthening the upper lateral cartilage, which is thicker and more resistant to collapse after strengthening by postoperative scars. Additionally, ultra­ sonic cauterization at the region of the fibroareolar tissue has a direct effect in stiffening this junction between the lateral crus and the piriform aperture.

It should be stressed that in all cases, the function of the nasal valve should be especially considered in cases of nasal obstruction and inspiratory insufficiency.  Many otolaryngologists fail to accurately estimate the importance of this specific part of the nasal structure and overlook its functional value. We strongly believe that our applied technique is a reliable method in treating nasal valve insufficiency, nasal valve collapse, or both. Our results were satisfactory in a long-term follow-up, slightly longer than most other series reported. By using this method, the resulting trauma induces postoperative production of connective tissue that strengthens the lateral crus, pulling open the nasal valve edge. This restores the normal tension of the inner nasal valve and reestablishes the stiffness and resistance of the lateral nasal wall. Furthermore, our technique may be applied in cases of functional-cosmetic rhinoplasties that require considerable nasal hump reduction and specifically in elongated and narrow noses to avoid postoperative further narrowing of the nasal valve. It can be performed under local anesthesia and can be implemented as an office procedure because it is safe and effective and does not require expensive instrumentation. Another advantage of our technique is its uncompromised application in patients with nasal valve stenosis after septoplasty. In these cases, it is usually quite difficult to harvest cartilage from the operated septum,  as is required in the method of spreader grafts for example, so our method appears to be fully appropriate in noses that have already undergone surgery.

In conclusion, the problem of the narrowed nasal valve may be confronted by our technique in every aspect: (1) the angle of the nasal valve is widened; (2) collapse of the upper lateral cartilage is corrected by removing the strip of the caudal edge of the cartilage and by resecting another triangular strip, thus creating posttraumatic scars and adhesions stretching and stiffening the upper lateral cartilage; and (3) the junction between the lateral aspect of the lateral crus and the fibroareolar tissue is strengthened by ultrasonic cauterization.

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