ENT E-Update masthead
MUSC Otolaryngology - Head & Neck Surgery E-Update                 February 2016 
Greetings Colleagues!

Our ENT E-Updates are designed to provide brief, practical, clinical updates in areas where we all struggle in managing our patients. I hope you are finding these newsletters useful. Your feedback or questions about the E-Update articles, your patients, or any other ENT issue are always welcome. Write to us at entupdate@musc.edu - And please forward this E-Update to your colleagues who may also benefit from sharing the latest ENT topics. As always, your support is deeply appreciated.

Yours sincerely,
Paul R. Lambert, M.D.
Professor and Department Chair

Cartilage Grafting in Nasal Valve Repair
Samuel L. Oyer, M.D.
Figure 1. Arrows demonstrate pinching of the middle vault with an hourglass shaped brow-tip aesthetic line that is often associated with INV narrowing.
Nasal obstruction is characterized by a decreased ability to breathe through one or both sides of the nose. Causes of nasal obstruction generally fall into three broad categories: anatomic structural issues, mucosal inflammation, and intranasal masses. Determining the exact cause of the obstruction is paramount to successfully treating the obstruction. While nasal obstruction can be caused by any combination of these factors, this article will focus on structural causes.
The most common structural issues leading to nasal obstruction are septal deviation and inferior turbinate hypertrophy. Concomitant nasal valve collapse can also be present, however, and may be overlooked as a major source of obstruction if there are additional abnormalities present. 1 The external nasal valve (ENV) represents the triangular area between the columella, nasal floor, and soft tissue of the nasal rim while the internal nasal valve (INV) is bordered by the dorsal septum, caudal edge of the upper lateral cartilage, and head of the inferior turbinate. Narrowing of either valve can occur in a fixed fashion or dynamically with inspiration.
DIAGNOSIS
Since there is no definitive test for nasal valve collapse diagnosis relies on a careful examination along with a thorough understanding of the normal anatomy of the nasal valve. The external nose should be examined and palpated to ascertain the position and caliber of the underlying nasal bones, upper lateral cartilages (ULC), lower lateral cartilages (LLC), and septum. If the external nose is twisted or crooked, one would expect to find deviation of the nasal septum and often associated collapse of the INV. The nasal sidewall should follow a gentle curve from the brow to the nasal tip. For some patients this line is narrowed in the middle vault creating an hourglass shape (Figure 1) suggesting INV narrowing. The ENV is best assessed from the base view and has an overall triangular shape with straight nostril margins. A scalloped shape nasal base (Figure 2) or nostril margins that collapse during gentle inspiration (Figure 3) points to weakness of the ENV.
Figure 2
Figure 2. Nasal base view showing static ENV collapse with scalloping of the alar sidewalls rather than the ideal triangular shape.
Figure 3. Nasal base view showing dynamic ENV collapse. The left image depicts the patient at rest while the right image shows the same patient breathing in through the nose gently.   Note the narrowing of the ENV during inspiration.
Intranasal exam may demonstrate a caudal septal deviation or turbinate hypertrophy that narrows the ENV while lateral sidewall collapse or a high dorsal septal deviation can narrow the INV. Septal deviations in the area of the INV are difficult to fully address with a conventional septoplasty alone and often require additional intervention to produce a patent valve. Nasal endoscopy is useful to identify additional underlying abnormalities that can contribute to nasal obstruction.
The Cottle maneuver involves manually elevating the medial cheek to open the nasal valves while inquiring about a subjective improvement in breathing. Although this test can suggest nasal valve collapse false positive results are common. The modified Cottle maneuver is much more specific for nasal valve collapse. This test assesses subjective breathing improvement while supporting the nasal valves with a small instrument, such as a cerumen curette, placed inside the nose. With this test both the INV and ENV can be independently tested to determine the main site of obstruction. It is important not to exaggerate the nasal patency produced and only support the valve as much as could be achieved surgically, but if a significant improvement in breathing is noted, there is a high likelihood of improvement with surgical intervention. 2
TREATMENT
External Nasal Valve
Collapse of the ENV is often due to weakness of the alar sidewall. The nasal ala consists primarily of fibrofatty soft tissue without native cartilage to provide support. In some patients the LLC are malpositioned in a more cephalic direction than normal and provide even less support for the ala and the ENV (Figure 4) This can also produce a widened or bulbous nasal tip with scalloping along the alar margins creating an "isolated tip" appearance. Surgical repair involves freeing up the lateral crura from both the vestibular skin and soft tissue attachments and repositioning the cartilage in a more caudal position under the alar groove. The cartilage is then supported by lateral crural strut grafts commonly made from septal cartilage that sit deep to the lateral crural cartilage and rest in a pocket over the pyriform aperture. 3
Alternatively, if the lateral crura are in a normal position, the sidewall can be supported with a batten graft placed superficial to the lateral crura that also rest over the pyriform aperture. This graft can easily be placed through an endonasal approach or as part of an open rhinoplasty. It is critical that the batten graft spans from a lateral point of stability over the pyriform bone to a medial point of stability over the LLC.
Figure 4
Figure 4. Arrows demonstrate cephalic malposition of the lateral crura of the LLC. This creates extra fullness of the supratip with inadequate support of the ala and ENV collapse.
Internal Nasal Valve
The INV can be narrowed medially along the dorsal septum or laterally due to ULC collapse at the sidewall. Different techniques are required to address these two locations, so correct diagnosis of the site of collapse is critical to adequately treat the obstruction.
Narrowing of the medial portion of the INV is classically repaired with spreader grafts along with straightening of the dorsal septum. Spreader grafts are secured between the dorsal septum and ULC to widen the narrow angle of the INV. Precise placement is essential as a graft that is placed too low may actually obstruct the airway. Septal cartilage is most commonly used, or part of the ULC can be "turned in" as a spreader. If these are unavailable, auricular or costal cartilage are alternatives.
Lateral collapse of the ULC requires providing outward support to the ULC. The butterfly graft has been well described for this purpose.4 This graft takes advantage of the natural curvature and elasticity of auricular cartilage. A butterfly shaped graft is placed over the nasal dorsum and secured to the caudal aspect of the ULC on each side, supporting the INV. Alternatively, a flaring suture5 placed as a horizontal mattress suture tied over the nasal dorsum, has been described for the same purposes. Additional support of the lateral INV can be achieved with a batten graft similar to the ENV. In this case the batten graft rests over the ULC or scroll region of the INV and spans from a stable point along the nasal sidewall to a pocket over the pyriform aperture.
References:
  1. 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;17(5):347-350.
  2. Fung EF, Hong P, Moore C, Taylor SM. The effectiveness of modified cottle maneuver in predicting outcomes in functional rhinoplasty. Plast Surg Int. 2014:618313
  3. Toriumi DM, Asher SA. Lateral crural repositioning for treatment of cephalic malposition. Facial Plast Surg Clin North Am. 2015;23(1):55-71.
  4. Friedman O, Coblens O. The conchal cartilage butterfly graft. Facial Plast Surg. 2016;32(1):42-48.
  5. Park SS. The flaring suture to augment the repair of the dysfunctional nasal valve. Plast Reconstr Surg. 1998;101(4):1120-1122.
Samuel L. Oyer, M.D.
Assistant Professor
Facial Plastic & Reconstructive Surgery
M.D.: Indiana University
Residency: Medical University of South Carolina
Fellowship: Johns Hopkins Hospital
Special Interests: Facial paralysis, facial reconstruction, facelifts, rhinoplasty, moh's reconstruction, botox injections, brow lifts, scar revision, nasal obstruction
Email: oyer@musc.edu

E-Update Articles 
Look for these articles in upcoming issues 
   
M arch:   
Important Changes in the TNM Classification Guidelines

April: Otology & Neurotology

May: Rhinology


To view any of our past E-Updates visit our
MUSC Otolaryngology-Head & Neck Surgery | WEBSITE | EMAIL