External Nasal Valve Research Articles

What are some tips and pearls for preserving and improving nasal function when performing a cosmetic rhinoplasty?

Understanding nasal form and function is critical in performing successful cosmetic rhinoplasty. Careful evaluation of the patient's nasal airway with identification of areas of existing or potential obstruction is important in avoiding potential pitfalls that may compromise nasal function following rhinoplasty. This article will review surgical techniques that can be utilized to preserve and improve nasal function during cosmetic rhinoplasty. Recent literature on nasal functionality focuses on the management of the internal and external nasal valve as well as the nasal septum during rhinoplasty. Successful cosmetic rhinoplasty requires a thorough preoperative analysis of both aesthetic and functional characteristics of the nose. Close attention should be paid to the internal and external nasal valves and nasal septum before and during surgery to preserve and improve nasal function following cosmetic rhinoplasty.

Improvement of nasal breathing and patient satisfaction by the endonasal dilator Airmax®

Patients suffering from nasal obstruction due to external nasal valve dysfunction may benefit from either corrective surgery or a conservative approach with a nasal dilator. At present, devices for widening the external nasal valve region can be applied externally or endonasally. It remains unknown to what extent the en dona sal dilator Airmax® objectively improves the nasal flow and can be offered as an alternative for surgery. Thirty patients suffering from nasal obstruction due to external nasal valve problems were proposed to use the nasal dilator for 4 weeks as an alternative for corrective surgery. The improvement of nasal flow by the dilator was evaluated by measuring the peak nasal inspiratory flow (PNIF). Then, patients were asked for their willingness to continue to use the nasal dilator or to undergo nasal valve surgery. The endonasal dilator improved the mean PNIF from baseline values with a mean increase of 176.1 o/o. After a 4 week trial period, 19 of 30 patients expressed the intention to continue the use of the nasal dilator. Inappropriate size, local irritation and/or aesthetic nasal complaints were mentioned by the other patients as reasons for discontinuation of using the nasal dilator. The endonasal dilator Airmax® represents a powerful device to improve nasal breathing in the target patients and therefore represents a good alternative for corrective surgery.

Correlation between Nasal Anatomy and Objective Obstructive Sleep Apnea Severity

To determine if a correlation exists between nasal anatomical obstruction and obstructive sleep apnea severity as measured by overnight polysomnogram (PSG). Cross-sectional study. Tertiary medical center. Subjects were recruited immediately prior to an overnight, in-lab PSG. All subjects who agreed to participate underwent a standardized nasal examination performed by the senior author and then completed the Nasal Obstruction Symptom Evaluation (NOSE) questionnaire, the Snore Outcomes Survey (SOS), and the Epworth Sleepiness Scale (ESS) prior to their sleep study. In addition, tonsil size, Mallampati score, Friedman tongue position, neck circumference, uvula length, and occlusion were assessed and documented. Nasal anatomy assessments were then compared with PSG, NOSE, SOS, and ESS results. Bonferroni correction was used to account for multiple comparisons. One hundred subjects were included in the study. Fifty-nine subjects (59%) were found to have obstructive sleep apnea syndrome (OSAS) (mean apnea-hypopnea index, 13.1; range, 0-64). Severity of OSAS was associated with age (Spearman's ρ = 0.386, P = .0001). No single nasal anatomy measurement or combined nasal anatomy index was found to correlate with objective sleep-disordered breathing severity measured by PSG. The sample size should have provided 90% power to detect a significant correlation if one existed. After accounting for multiple comparisons, turbinate hypertrophy was found to correlate with the NOSE score (0.3577, P = .0305 corrected), and external and internal nasal valve collapse correlated with each other (0.4986, P < .0001 corrected). Objectively assessed abnormal nasal anatomy was not found to be significantly correlated with PSG-measured OSAS severity. Specific objective measurements of obstructive nasal anatomy were correlated to subjective measures of nasal obstruction.

How to resolve the caudal septal deviation?: Clinical outcomes after septoplasty with bony batten grafting

Caudal septal deviation interrupts normal nasal breathing, due to the narrowing of the external valve area and nasal valve angle. In this study, we found a different approach for correction of caudal septal deviation with no associated deformity of the external nose. Individual case-control study. The 39 patients completed questionnaires by interviews postoperatively for assessment of nasal obstruction. In addition, patients assessed the severity of their nasal symptoms (i.e., mouth breathing, mouth dryness, hyposmia, rhinorrhea, epistaxis, snoring, postnasal drip, and headache) preoperatively and postoperatively using a visual analog scale (VAS). Improvement in the treatment of nasal obstruction using a VAS and a questionnaire for subjective satisfaction were evaluated 3 months after septoplasty. To evaluate outcomes objectively, endoscopic photographs of the nasal cavity and acoustic rhinometry before and after surgery were evaluated. For comparison between preoperative and postoperative status, the Wilcoxon signed ranks test was used. Patients reported a significant decrease in the VAS severity of all nasal symptoms. The minimal cross-sectional area (MCA1) of the convex side after vascular constriction using acoustic rhinometry showed significant widening. Patients were divided into a turbinoplasty group and a nonturbinoplasty group, and the turbinoplasty group showed a significant increase in both the convex side and concave side in MCA1 and in the convex side in the anterior portion of the inferior turbinate. Endonasal septoplasty using bony batten grafting for caudal septal deviation resulted in an improvement of nasal obstruction symptoms and acoustic rhinometry components.

Surgical management of nasal alar rim and valve collapse

Introduction Nasal valve collapse can provoke sleep-related breathing disorders in adults. Congenital and acquired alar rim collapse necessitates surgical treatment. The purpose of the present communication is to share our experience with the procedures for reconstruction of the external nasal valve after septoplasty on the occasion of nasal septal deviation, reconstruction and rhinoplasty. Materials and methods During the period from 2000 till 2010, we treated 33 patients with bilateral alar rim collapse and 4 patients with unilateral one. Fifteen patients presented with a congenital pathology. Rhinoplasty was previously performed in 18 patients but septoplasty in four ones. There were nasal septum deformities in 32 patients. The following surgical techniques were applied: lateral rhinopexy, autologous cartilage transplantation, modified lateral rhinopexy, fixation of the cranial end of alar cartilage to the caudal end of triangular cartilages, and suturing techniques as well. In two cases, percutaneous fixation of the alar rims was carried out. Results The immediate postoperative results were satisfactory. A better aesthetics and an improved breathing function could be achieved in all the patients. The comparative evaluation of the surgical techniques identified the advantages of the external rhinoplasty approach, lateral rhinopexy, cartilage transplantation and suturing techniques. However, there patients complained of relapse two months after operation. Conclusion Based on our experience and the data from the world literature available the conclusion can be drawn that nasal valve and alar rim collapse represent a serious challenge for contemporary rhinosurgery. An individualized surgical approach to the single patients is obligatory. The aggressive surgical methods seem to be more effective. Acknowledgements P. Nedev M. Milkov R. Benchev D. Vicheva.

Lower Lateral Crural Reverse Plasty

The lateral crus plays a significant role in the aesthetic appearance of the nose. Excessive concavities of the lower lateral crura can lead to heavy aesthetic disfigurement of the nasal tip and to insufficiencies of the external nasal valve. The lateral crus of the alar cartilage may also cause a concavity of the alar rim and even collapse of the alar rim in severe cases. Surgical techniques performed on the lateral crus help to treat both functional and aesthetic deformities of the lateral nasal tip. We present a reverse plasty technique for the lateral crus, and we evaluated the advantages and disadvantages of the technique.

Rainbow Graft

Revision rhinoplasties are extremely difficult to perform even for the surgeons mastering nasal surgery. In fact, they must be skilled at adapting surgical strategies to the anatomical changes induced by primary rhinoplasty.We herein describe an original technique using an auricular cartilage graft after 6 revision rhinoplasties.The aforementioned graft succeeded in improving tip support, correct external nasal valve dysfunction and alar pinch, and providing tip definition, projection, and ptosis.In our opinion, rainbow graft is a safe approach in case of severe nasal structural deficiencies, improving both the functional and esthetic results in revision rhinoplasties.

Experimental System for the Analysis of Nasal Procedures: Initial Experience with Inferior Turbinate Reduction

Objectives: 1) Develop simple cadaveric flow/pressure analysis system for experimental use for nasal procedure simulation. 2) Assess changes in nasal airway resistance in simulated inferior turbinate (IT) hypertrophy, normal state, and reduced, out-fractured conditions. Methods: An open thermodynamic nasal cavity experimental cadaveric model was created using an Omega HHP-103 digital manometer and oxygen flow regulator. For pressure testing, one pressure measurement catheter was placed at the internal nasal valve, isolating the nasal cavity from external nasal valve resistance. The second pressure measurement catheter was placed at the choana of the tested side, and the position was confirmed endoscopically. Repeatability was tested among nasal cavities, specimens, and repeat setups. Pressure measurements were taken incrementally between 0 and 25 liters per minute (Lpm) at each of three conditions: 1) control state, without augmentation, 2) simulated IT hypertrophy with 20% benzocaine topical anesthetic gel filler placed within sub-periosteal flap, and 3) out-fractured, reduced inferior turbinates. Results: The experimental system was simple to set up and repeatable. Experimentally, nasal airway resistance measurements revealed decreased resistance under control and out-fractured configuration versus hypertrophied turbinates. Initial studies trended, under all conditions, to have exponential growth of pressure as flow rate increased. Conclusions: The physiologically isolated test system allows anatomic manipulation and measurement of resulting pressure-flow relationships. IT alterations resulted in expected pressure-flow changes, indicating future analysis at other anatomic locations, such as olfactory epithelium, septum, or middle turbinate, is feasible.

The Lateral Crural Underlay Spring Graft

The objective of this study is to evaluate the functional and aesthetic results obtained from the use of the lateral crural underlay spring (LCUS) graft for the treatment of internal and external nasal valve collapse. In this retrospective study, preoperative and postoperative functional and aesthetic results were compared in patients undergoing treatment for internal or external nasal valve collapse. Results were scored by means of a questionnaire and visual analog scale completed by the patients. Eight patients were recruited and included in this study: 6 (75%) had an improvement in their functional scores, 1 (12%) remained unchanged, and 1 (12%) scored worse. The mean difference in functional scores after the intervention was 9.4 points (p < 0.005). There was no significant difference in aesthetic scores. We found evidence that the LCUS graft is effective for relieving nasal obstruction in patients with internal, external, or combined nasal valve collapse. The amount of increased sidewall tension and rigidity as well as the increase in nasal valve angle and cross-sectional area are determined by the length of the graft, which can be varied according to need.

Nasal Gout Presenting as Nasal Obstruction

We describe a case of nasal gout presenting as nasal obstruction, a rare etiology for a common presentation. We report a single case of a 56-year-old man with history of multiple nasal traumas, obstructive sleep apnea, referred for nasal obstruction and congestion, having failed attempts at medical management. He had severe septal deviation, elements of external and internal nasal valve collapse, and a nasal dorsal mass suspicious for gouty tophus. He was brought to the operating room for septorhinoplasty through an open incision with nasal tip reconstruction, which exposed a 4 × 3-cm mass on the nasal dorsum, extending to the tip, supertip, and into the septal plane at the level of the upper lateral cartilages. Final pathologic findings revealed gouty tophus. He has done well since, and breathing and sleep are significantly improved. This case demonstrates a rare etiology for nasal obstruction that may complicate the workup, evaluation, and management of such a patient. It highlights the ways in which a rare diagnosis adds complexity to the workup and management of a patient with nasal obstruction, and serves as an important reminder about rarer pathologies that can present in an everyday clinic.

Components of the Nasal Examination

Along with patient history, the physical examination is the key component for any patient encounter. Determining what should be included in the nasal examination is critical. Practicing evidenced-based medicine calls for an integration of the clinical/surgical expertise of the provider, the individual patient's needs and preferences, and the application of the current best medical knowledge found in the literature, so the results of a survey on current practices can help physicians place their own practice in context. The author presents the results of a survey on current practices in nasal examination and gives an evidence-based review of those practices. The attendees of the 2011 Rhinoplasty Society meeting in Boston, Massachusetts, were asked to complete a questionnaire concerning components of the nasal examination in functional cases. The questionnaire was completed by 49 of 60 attendees. Results showed that anterior rhinoscopy is routinely part of the exam to assess for nasal function. The majority of respondents use a patient questionnaire to assess function, followed in decreasing frequency by response to decongestant spray to confirm evidence of turbinate hypertrophy, nasal endoscopy, computed tomography scan, rhinomanometry, acoustic rhinometry, Cottle maneuver, and response to nasal strips to assess for internal and/or external nasal valve compromise. The results of this physician survey and literature review supports the inclusion of anterior rhinoscopy, patient questionnaire, endoscopy, decongestant spray rhinomanometry, and nasal strips as important components of a nasal examination.

Repair of Nostril Stenosis Using a Triple Flap Combination: Boomerang, Nasolabial, and Vestibular Rotation Flaps

Tissue losses within the nose due to various reasons result in the loss of normal anatomy and function. The external nasal valve area is one of the most important functional components of the nose. The columella, lobule, nostril, and alar region are among the components forming the external nasal valve area. Deformities of the nostrils are among the most frequently observed features that interfere with the functional anatomy of the nose. Malformations of the nostrils often emerge subsequent to cleft lip repairs. Stenoses are a common type of pathology among nostril deformities. In cases where a stenosis has formed, breathing problems and developmental anomalies may occur. In the patient with nostril stenosis presented in this report, there was a serious alar collapse and contracture subsequent to a cleft lip repair. In order to repair the nostril stenosis, a "boomerang flap" was chosen. This boomerang flap was used in combination with a nasolabial flap, a vestibular rotation flap, and a conchal cartilage graft to achieve a satisfactory repair.

Revision of the Functionally Devastated Nasal Airway

Functional rhinoplasty can be especially challenging in a patient who has had previous surgery, trauma, anatomic abnormalities, or systemic disease affecting the nasal mucosa. A thorough analysis of the type and location of the obstruction is critical, and only after identifying the precise anatomic cause of the problem can surgical planning begin. Scarring, altered anatomy, and disrupted tissue planes all complicate this process. Structural support and nasal mucosa often require augmentation with autogenous grafts from the ear, rib, or other portions of the nasal cavity. Attention to nasal support mechanisms, the internal and external nasal valves, and internal lining during primary surgery may help to avoid future complications. Through careful analysis and planning, proper function may be restored to a functionally devastated nasal airway.

Disease‐specific quality of life outcomes in functional rhinoplasty

The goal of this study was to assess disease-specific quality of life as well as cosmetic outcomes following functional rhinoplasty in adults with nasal obstruction. Prospective observational outcomes study. Disease-specific quality of life determinations and cosmetic outcome assessments were performed using the Nasal Obstruction Symptom Evaluation scale (NOSE), the Sleep Outcomes Survey (SOS), and a cosmetic outcomes scale. Ratings were ascertained preoperatively and postoperatively at 1 to 3 and at 6 to 12 months for patients with internal nasal valve dysfunction, external nasal valve dysfunction, and both (groups 1, 2, and 3, respectively). All groups showed a significant improvement in NOSE scores at the early and the late time points (P < .0005). SOS scores significantly improved from baseline to 1-3 months after surgery (P < .0005) and to 6-12 months (P < .0005). Snoring cessation was reported in 30% of patients who snored preoperatively. The cosmetic appearance of the nose significantly improved after surgery (P < .0005). This study utilized standardized terminology to diagnosis and treat nasal valve dysfunction, and validated disease-specific quality of life measures to quantify the improvements made with specific techniques. In particular, this study showed improvement in nasal obstruction and snoring in patients with nasal valve dysfunction treated surgically, without negatively impacting nasal cosmesis. Studies utilizing consistent methods of assessment and analysis will allow for future meta-analysis, increasing the level of evidence available in the field of functional rhinoplasty, and facilitate the creation of evidence-based management algorithms.

Correlation of Nasal Obstruction with Nasal Cross-Sectional Area Measured by Computed Tomography in Patients with Nasal Septal Deviation

The objective of the present study was to investigate the relationship between the subjective sensation of nasal obstruction and the corresponding cross-sectional area for nasal airflow in patients with a deviated septum. Seventy-one patients with a diagnosis of unilateral nasal obstruction due to a deviated nasal septum were evaluated by preoperative computed tomography. Anterior anatomic characteristics (the internal nasal valve angle and the cross-sectional areas at the external nasal valve, the head of the inferior turbinate, and the head of the middle turbinate) and posterior anatomic factors (the cross-sectional areas at the openings of the frontal sinus, maxillary sinus, and end of the nasal septum) were examined. Associations between the computed tomography measurements and the subjective severity of nasal obstruction were analyzed with a visual analog scale (VAS). Anterior and posterior anatomic characteristics were associated with the subjective severity of nasal obstruction. Anterior anatomic factors were related to the VAS scores of patients with anterior septal deviation, and posterior anatomic factors were related to the VAS scores of patients with posterior septal deviation. This study indicated that the anterior and posterior parts of the nasal cavity are both related to nasal obstruction. In some patients, the posterior part of the nasal cavity was more important than other locations in causing nasal obstruction.

A Novel V- Silicone Vestibular Stent: Preventing Vestibular Stenosis andPreserving Nasal Valves

This report presents a novel style of placing nasal stents. Patients undergoing surgical procedures in the region of nasal vestibule and nasal valves are at risk of developing vestibular stenosis and lifelong problems with the external and internal nasal valves; sequels of the repair. The objective of the report is to demonstrate a simple and successful method of an inverted V- Stent placement to prevent potential complication of vestibular stenosis and nasal valve compromise later in life. Following a fall on a sharp edge of a metallic bed, a sixteen month old child with a deep lacerated nasal wound extending from the collumellar base toward the tip of the nose underwent surgical exploration and repair of the nasal vestibule and nasal cavity. A soft silicone stent fashioned as inverted V was placed bilaterally. The child made a remarkable recovery with no evidence of vestibular stenosis or nasal valve abnormalities. In patients with nasal trauma involving the nasal vestibule and internal and external nasal valves stent placement avoids sequels, adhesions, contractures, synechia vestibular stenosis and fibrosis involving these anatomical structures. The advantages of the described V- stents over the traditional readymade ridged nasal stents, tubing's and composite aural grafts are: a) technical simplicity of use, b) safety, c) less morbidity, d) more comfortable, and e) economical. To our knowledge, this is the first report of such a stent for prevention of vestibular stenosis and preserving nasal valves.

Transoral Submucosal Resection of the Inferior Turbinate

In the presence of turbinate dysfunction, an inferior turbinectomy for persistent hypertrophy of bone and/or mucosa may be performed. We sought to explore anatomic feasibility of a transoral turbinectomy. After transoral inferior turbinectomy in 12 cadavers, average distances from the external nasal valve to inferior turbinate and from pyriform aperture to inferior turbinate were compared. Average "area of access" was calculated. Preoperative and postoperative nasal length, tip projection, and alar-base width were also compared. Average distance from external nasal valve to inferior turbinate was 32.4 mm. Average distance from aperture to inferior turbinate was 2.4 mm (P < 0.0001). Average "areas of access" to nasal vault through the external nasal valve and mouth were 183.9 mm(2) and 243.6 mm(2) (P = 0.07), respectively. The transoral approach provides a larger "area of access" to the turbinate, a statistically significant reduction of distance to target, no postoperative changes in nasal soft tissue, and easier instrumentation.

Functional Outcomes after Lateral Crural J-Flap Repair of External Nasal Valve Collapse

We evaluated the lateral crural J-flap technique in the surgical repair of external nasal valve collapse with standardized and validated outcome measurements. Prospective data were gathered on consecutive cases, performed by a single surgeon between 2007 and 2010, of adult patients who underwent a lateral crural approach to repair of external nasal valve collapse. Data were collected on diagnosis, surgical outcomes, and complications. Outcome measures included the Nasal Obstructive Symptom Evaluation and the Rhinoplasty Outcome Evaluation. Fifteen patients were included in the study. Their follow-ups ranged from 9 to 13 months. All patients had statistically significant improvements in Nasal Obstructive Symptom Evaluation scores. There was no significant change in perceived nasal appearance after surgery as measured by the Rhinoplasty Outcome Evaluation. There were no surgical complications. The lateral crural J-flap approach to repair of external nasal valve collapse is a technically straightforward and relatively safe procedure. The efficacy is excellent at the 1-year follow-up examination.

Lower Lateral Crural Reverse Plasty: A Technique to Correct Severe Concavities of the Lateral Crus

Excessive concavities of the lower lateral crura can lead to heavy aesthetic disfigurement of the nasal tip and to insufficiencies of the external nasal valve. This study reviewed experience with the lower lateral crural reverse plasty technique that uses the existing cartilage to create the desired lower lateral cartilage contour and provides sufficient alar rim support. A retrospective review was conducted with a follow-up period ranging from 9 to 33 months. The technique was applied in primary (n = 13) and secondary (n = 3) open rhinoplasties to correct severe concavities of the lower lateral cartilages. Two case examples and intraoperative photographs are presented to illustrate the technique and its results. The lower lateral crural reverse plasty proved its applicability for the functional and aesthetical correction of severe lower lateral crura concavities. By dissecting the distorted lateral crus, turning it around, and suturing it back in place, surgeons can "reconstruct" a new lateral crus with existing cartilage. No additional cartilage is needed, and no harvesting at a different location needs to be performed. After rhinoplasty, no alar rim instabilities were observed. In three cases, even preexisting instabilities were corrected. Aesthetically enduring results were observed, and no overcorrection or alar retraction was seen. With the lower lateral crural reverse plasty, severe concavities of the lower lateral crura can be corrected. This technique is a useful and reproducible procedure, performed without additional tissue to achieve functionally and aesthetically satisfying and enduring results.

External nasal valve collapse repair: The limited alar–facial stab approach

Permanent treatment for external nasal valve collapse (ENCV) is primarily surgical. In some situations, instead of a major operation, the placement of structural alar rim graft may be all that is needed. Alar rim graft placement is usually achieved through a marginal incision as a part of a rhinoplasty. We compared the aesthetic and functional outcomes of a simple technique in which the graft is placed via an external incision in the alar-facial groove with the outcomes of the more commonly used method. All patients who underwent ENCV repair in 2007 and 2008 were reviewed. Fifteen cases in which grafts were placed using the alar-facial stab technique were identified. Twenty cases with marginal incision graft placement in that time period were then randomly selected. All of the patients underwent concurrent additional procedures such as rhinoplasty/septorhinoplasty. The aesthetic and functional assessments of both techniques were explored by means of blinded observers rating the aesthetic outcome and patients rating their functional outcome through the use of questionnaires. A retrospective cohort study. A comparison between the patients' subjective results showed no difference between the outcomes of these two techniques (P > .05). The blinded surgeon evaluators could not differentiate between the different approaches utilized in the vast majority of cases studied. The alar-facial stab incision with alar rim grafting for treatment of ENCV is a very simple and effective technique that does not require significant rhinoplasty experience and may be performed in the office under local anesthesia.