Nasal valve collapse

Ear, Nose & Throat Journal, March, 2004 by Craig Murakami

One of the most common causes of nasal obstruction is internal valve collapse. The cross-sectional area of the internal nasal valve is determined by the angle formed by the connection of the upper lateral cartilage with the septal cartilage. As this angle narrows, the cross-sectional area decreases. The inferior turbinate and lateral nasal soft tissue constitute a minor portion of the internal nasal valve.

An internal nasal valve is considered to have collapsed when the angle of the valve is less than 10[degrees] to 15[degrees]. Its etiology can be congenital, traumatic, or iatrogenic. (1) In the latter case, collapse is often caused by over-resection of the nasal dorsum and upper lateral cartilages during septorhinoplasty. Such an overly aggressive operation can result in concurrent dorsal concavity (saddle-nose deformity) or a narrowing of the middle third of the nose (hourglass deformity).

Sheen described the use of spreader grafts secured between the upper lateral cartilages and the septum to increase the internal nasal valve angle by lateralizing the upper lateral cartilages. (2) The placement of flaring sutures through the caudal lateral border of the upper lateral cartilages has also been described as an aid to increasing the valve angle. (3) However, these methods do not correct for any concomitant saddle-nose deformity.

The use of a single dorsal onlay spreader graft can correct both internal valve collapse and concurrent saddle-nose deformity (figure 1). It might also correct an hourglass deformity, depending on the width of the graft. This procedure begins as a typical open septorhinoplasty, with careful separation of the upper lateral cartilages from the septum and without disruption of the nasal mucosa. The onlay spreader graft is placed centrally over the septum and then sutured with 6-0 Proline or 5-0 PDS (polydioxanone) to each upper lateral cartilage. Not only does this procedure correct the deformity (figure 2), it moves the upper lateral cartilages into a more anatomically desirable position by fixating the grail laterally and anteriorly. (4) Finally, to close the incision, a trans-septal mattress suture must be placed correctly beneath the graft to prevent mucosal webbing of the nasal septal angle.

[FIGURES 1-2 OMITTED]

The nasal walls may also require medial osteotomies to further open the nasal valve region. Collapse of the lateral nasal soft tissue can be corrected with batten grafts, and prominent inferior turbinates can be reduced by a variety of techniques.

References

(1.) Haight JS, Cole P. The site and function of the nasal valve. Laryngoscope 1983;93:49-55.

(2.) Sheen JH. Spreader graft: A method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plast Reconstr Surg 1984:73:230-9.

(3.) Alsarraf R, Murakami CS. The saddle nose deformity. Facial Plast Surg Clin North Am 1999:7:303-10.

(4.) Park SS. The flaring suture to augment the repair of the dysfunctional nasal valve. Plast Reconstr Surg 1998;101:1120-2.

>From the Section of Otolaryngology, Virginia Mason Medical Center, Seattle.