Internal Nasal Valve Research Articles

Pyriform Aperture Enlargement for Internal Nasal Valve Obstruction in Adults: Systematic Review and Surgical Classification

Pyriform aperture enlargement or "pyriplasty" is an uncommonly used procedure for internal nasal valve obstruction in adults besides functional rhinoplasty, inferior turbinate reduction, and septoplasty. A systematic review of the literature was performed to analyze current surgical techniques, their suggested indications, and their related outcome in terms of success and complications. The search was performed on PubMed, EMBASE, SCOPUS, and Cochrane databases. The systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies on congenital, traumatic, tumoral, or infectious internal nasal valve obstruction were excluded. Eight articles were finally included. Three types of pyriplasty have been described according to the level of bone resection: low-level pyriplasty through the sublabial approach, mid-level pyriplasty through endonasal approach, and extended pyriplasty through either approach. Indications included (1) clinically or radiologically narrow pyriform aperture, (2) previously unsuccessful internal nasal valve surgery, (3) lateral nasal wall collapse, and (4) inferior turbinate's head hypertrophy. Subjective improvement of nasal obstruction was reported in these 4 indications. No major complication was encountered. Pyriplasty for nasal obstruction is a simple and safe procedure that could be effective in selected cases. However, level of evidence is currently low, and success rate may vary with indications and pyriplasty techniques. Moreover, there is no clear definition of normal pyriform aperture dimensions to date. Further prospective studies are thereby necessary and should include radiological analysis of pyriform aperture and validated nasal obstruction measurement tools.

Cephalic lateral crural advancement flap

BackgroundIn lower lateral cartilage (LLC) surgery, cephalic trimming poses risks for the collapse of the internal and external nasal valves, pinched nose, and drooping deformity. The cephalic lateral crural advancement (CLCA) technique presented herein was aimed at using a flap to increase nasal tip rotation and support the lateral crus, in addition to the internal and external nasal valves, by avoiding grafts without performing excision.MethodsThis study included 32 patients (18 female and 14 male) and the follow-up period for patients having undergone primer open rhinoplasty was 12 months. The LLC was elevated from the vestibular skin using the CLCA flap. A cephalic incision was performed without cephalic trimming. Two independent flaps were formed while preserving the scroll ligament complex. The CLCA flap was advanced onto the lower lateral crus while leaving the scroll area intact. The obtained data were analyzed retrospectively.ResultsThe mean age of the patients was 31.6 years (range, 20–51 years). The Rhinoplasty Outcome Examination scores after 12 months varied from 90 to100 points, and 93% of patients reported perfect satisfaction. At a 1-year follow-up, the patients’ nasal patency (visual analogue scale) rose from 4.56±1.53 (out of 10) to 9.0±0.65 (P<0.001).ConclusionsThe CLCA flap led to better nasal tip definition by protecting the scroll area, increasing tip rotation, and supporting the internal and external nasal valves without cephalic excision.

The Impact of Maxillary Expansion on Adults' Nasal Breathing: A Systematic Review and Meta-Analysis.

Nasal surgery fails to restore nasal breathing in some cases. Maxillary constriction is suggested as a major cause of failure. It is thought that maxillary constriction leads to the closure of the internal and external nasal valves. Moreover, it is well established in the literature that maxillary expansion, both in adults and children, increases upper airway volume. However, it is yet unclear whether maxillary expansion may improve nasal function.Review Methods: Pubmed (Medline), the Cochrane Library, EMBASE and Trip Database were checked by two authors from the Rhinology Study Group of the Young Otolaryngologists section of the International Federation of Otorhinolaryngological Societies. Two authors extracted the data. The main outcome was expressed as the value (in variable units) prior to treatment (T0), after expansion procedures (T1), after the retention period (T2), and after a follow-up period (T3). A total of 10 studies (257 patients) met the inclusion criteria. The data pooled in the meta-analysis reveals a statistically significant reduction of 0.27 Pa/cm3/s (CI 95% 0.15, 0.39) in nasal resistance after palatal expansion As far as subjective changes are concerned, the pooled data for the change in the NOSE score shows a statistically significant mean reduction after maxillary expansion of 40.08 points (CI 95% 36.28, 43.89). The initial available evidence is too limited to suggest maxillary expansion as a primary treatment option to target nasal breathing. However the data is encouraging with regards to the effect of maxillary expansion on nasal function. Further higher quality studies are needed in order to define clearer patient selection criteria, distinguish optimal techniques, and demonstrate long-term efficacy in long term follow up studies.

Effect of Lateral Crural Procedures on Nasal Wall Stability and Tip Aesthetics in Rhinoplasty.

To evaluate the lateral nasal wall stability, nasal function, and cosmesis when creating an aesthetically pleasing nasal tip subunit utilizing lateral crus (LC) altering procedures. Retrospective cohort. In this retrospective cohort study, cosmetic rhinoplasty patients undergoing LC procedures with available lateral wall insufficiency (LWI) scores were included. An LWI grading system was used to evaluate internal (zone 1) and external (zone 2) nasal valves objectively. Secondarily, Nasal Obstruction Symptom Evaluation (NOSE) Score, Visual Analog Scale (VAS) and Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) results were evaluated. Based on the LC intervention, the cohort was divided into six groups: lateral cural strut graft (LCSG), mini-LCSG, lateral crural overlay (LCO) with and without additional support, cephalic trimming, and cephalic turn-in flaps. Subjects undergoing LCO with and without support, LCSG, and mini-LCSG showed significant improvement in zone 1 LWI (P = .042, P = .041, P < .001, and P < .001, respectively), while cephalic trimming and turn-in/hinged flaps had no effect. Subjects undergoing LCO with support and LCSG showed significant improvement in zone 2 LWI (P = .022, P = .004), while LCO without support, mini-LCSG, cephalic trimming, and turn-in flaps showed no effect on LWI. The SCHNOS-C and VAS-C showed significant improvement in all subgroups (P < .05) when comparing pre- to postoperative values. Alar-spanning sutures did not significantly change zone 1 scores but did conceal zone 2 improvements in LCSG and LCO with support groups. Selected LC procedures are robust techniques for improving tip cosmesis independently without compromising nasal lateral wall stability. Some LC procedures can improve nasal valves patency in tip surgery. Laryngoscope, 131:E1830-E1837, 2021.

Surgical Management of the Internal Nasal Valve: A Review of Surgical Approaches.

Nasal valve collapse is relatively common with a lifetime prevalence of up to 13%. Etiologies include prior rhinoplasty, other surgical procedures, facial paralysis, congenital defects, trauma, and aging. Internal nasal valve collapse leads to impairment of nasal breathing, which significantly disturbs quality of life. Many approaches to increase the cross-sectional area of the internal nasal valve have been described. The main categories reviewed in this article are cartilage grafting, implants, and suture suspension techniques. Cartilage grafting techniques include alar batten graft, butterfly graft, spreader graft, autospreader graft, and alar composite graft. The implant technique includes the titanium butterfly implant. The suspension techniques included are the transconjunctival approach, Mitek bone anchor, flaring suture, lateral pull-up, and piriform rim suspension. Surgeons must carefully consider functionality, cosmesis, and technical difficulty when selecting an approach. We review indications, general approach, benefits, and considerations for a number of available techniques to help surgeons decide what approach might be best suited to the individual patient. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Anatomic Optical Coherence Tomography (aOCT) for Evaluation of the Internal Nasal Valve

Anatomic Optical Coherence Tomography (aOCT) for Evaluation of the Internal Nasal Valve

Functional and aesthetic outcomes of spreader graft and auto-spreader flap after nasal hump removal

BackgroundFollowing the reduction of the nasal hump to a desired level, spreader grafts are usually positioned to prevent the complication of nasal valve collapse. Auto-spreader flap is a new technique that gained more popularity recently and can be used as an alternative to spreader graft. This RCCT compared between both techniques aesthetically and functionally as well as the operative time.ResultsForty patients, 17 males (42.5%) and 23 females (57.5%), were included. The mean duration of operation in auto-spreader flap was 11.8 ± 3.4 min, while it was 19.2 ± 3.2 min in spreader graft. The difference between the two procedures was statistically significant (P < 0.05). Functional assessment of nasal obstruction was done for all patients in both groups preoperative that was (75.6 ± 19.9) which showed marked improvement when re-evaluated 3 moths postoperatively (18.9 ± 14.7), and after 6 months NOSE scale was (29.1 ± 20.2). The overall aesthetic satisfaction was 62.5% (25 of 40) irrespective of the surgery done. Sixteen out of 20 patients in spreader group and 9 out of 20 in auto-spreader flap group.ConclusionAuto-spreader flap and spreader graft are very effective surgical procedure for treatment of nasal obstruction due to internal nasal valve dysfunction, but the auto-spreader flap had shorter operative time. However, spreader graft has a superior aesthetic outcome.

In vitro evaluation of regional nasal drug delivery using multiple anatomical nasal replicas of adult human subjects and two nasal sprays.

Quantifying drug delivery to the site of action using locally-acting nasal suspension sprays is a challenging but important step toward understanding bioequivalence (BE) between test and reference products. The main objective of this study was to investigate the in vitro deposition pattern of two common but different locally-acting nasal suspension sprays using multiple nasal cavities. Twenty anatomically accurate nasal replicas were developed from high-resolution sinonasal computed tomography scans of adults with healthy nasal airways. The airways were segmented into two regions of anterior and posterior to the internal nasal valve. Both sides of the septum were considered separately; hence, 40 nasal cavities were studied. The positioning of the spray nozzle in all 40 cavities was characterized by the head angle, coronal angle, and the insertion depth. Despite using a controlled protocol to minimize the anterior losses, a wide range of variability in posterior drug delivery was observed. The observed intersubject variability using this in vitro method may have important implications for understanding BE of locally-acting nasal suspension sprays.

Correction of Septal Perforation/Nasal Airway Repair.

Rhinoplasty is a double-edged sword regarding the functional nasal airway; it can enhance and improve the nasal airway if done properly, and can severely compromise the nasal airway if not done properly. The composition of the nasal airway includes the internal and external nasal valves, nasal septum, and inferior turbinates. Each of these areas can be addressed by several techniques, described in the body of the text. Nasal septal perforation is another potential complication that may result from septal surgery, which has nonsurgical and surgical methods to treat, and is also described in the body of the text.

Repair of Alar Defects Using the Alar Rotation Flap: Our Experience with 394 Patients.

The purpose of this study was for the authors to describe their patient selection, surgical technique, and results with the alar rotation flap for surgical defects of the nasal ala. The authors performed a retrospective analysis of all alar rotation flaps performed between June of 2006 and February of 2019. Three hundred ninety-four patients were identified, and follow-up encounters were reviewed to assess for complications and need for revision procedures. The alar rotation flap was performed on 394 patients over a 13-year period. The mean defect size was 9.3 ± 2.8 mm by 7.2 ± 2.3 mm. Three hundred nineteen patients (81 percent) were evaluated postoperatively, with a mean average duration of follow-up of 2.3 years (range, 6 days to 11.9 years). Complications included hemorrhagic crust along the incision line [n = 9 (3 percent)], flap edema [n = 7 (2 percent)], internal nasal valve dysfunction [n = 3 (1 percent)], depressed surgical scar [n = 2 (1 percent)], hematoma [n = 1 (0.5 percent)], and paresthesia [n = 1 (0.5 percent)]. The alar rotation flap is a reliable one-stage flap for small- to medium-size partial-thickness defects of the nasal ala that can produce topographic restoration with minimal risk of aesthetic or functional complication. Therapeutic, IV.

Patient-Perceived Nasal Appearance After Septorhinoplasty With Spreader Versus Extended Spreader Graft.

Standard spreader grafts (SSGs) are commonly used in septorhinoplasty to treat internal nasal valve narrowing and have been shown to improve nasal airway obstruction. Extended spreader grafts (ESGs) have also been proven effective for correcting nasal deviation. To date, the effectiveness of ESGs using patient-reported outcome measures has not been demonstrated, and results of ESGs have not been compared to SSGs. This study aims to assess satisfaction and nasal appearance in patients who have undergone septorhinoplasty with SSG versus ESG. Prospective cohort study. Five hundred sixty-eight patients who underwent septorhinoplasty with SSGs and 126 patients who underwent septorhinoplasty with ESGs between 2012 and 2018 were administered the Nasal Obstruction Symptom Evaluation (NOSE) scale and FACE-Q Satisfaction With Nose, FACE-Q Satisfaction With Nostrils, and FACE-Q Social Functioning scales pre- and postoperatively. Pre- and postoperative NOSE and FACE-Q scores, negative inspiratory force (NIF), and changes in these values were compared between groups. Results demonstrated clinically and statistically significant improvement at follow-up for both groups. There was no significant difference between the SSG and ESG groups in mean improvement of NOSE scores, FACE-Q scores, and NIF at follow-up of 6 months and at 12 months. This study demonstrates that SSGs and ESGs both provide clinically and statistically significant improvement, and no significant difference in functional outcome. Both techniques can be effective. The etiology of the nasal obstruction and/or deformity should be considered when deciding which type of spreader graft to use. 3 Laryngoscope, 131:765-772, 2021.

Unilateral Nasal Obstruction Causes Symptom Severity Scores Similar to Bilateral Nasal Obstruction.

The objective of this paper is to investigate the differences between unilateral and bilateral nasal obstruction with subjective symptomatology in nasal obstruction. This is a retrospective chart review of prospectively collected data of patients with nasal obstruction presenting to a facial plastic and reconstructive surgery clinic for evaluation and treatment. Patient demographics including age and gender were recorded along with nasal physical exam findings. These included internal valve narrowing (IVN), external valve narrowing, internal valve collapse, external valve collapse, and septal deviations (inferior and superior). Findings were reported for the left, the right, and both sides. Nasal valve and septal findings were recorded on 3- and 4-point Likert scales, respectively, for each side of the nose. A total of 1,646 patients were included in the study. On univariate analysis, a significant correlation was seen between Nasal Obstruction Symptom Evaluation (NOSE) scores and all individual exam findings (p < 0.001). On multiple linear regression, total, left, and right septal deviation (p < 0.001, p = 0.001, p = 0.007, respectively) and total, left, and right IVN (p < 0.001, p = 0.003, p < 0.001) were all predictive of an increased NOSE score. Patients with unilateral septal deviation or internal nasal valve narrowing have symptoms of nasal obstruction similar to those with bilateral nasal obstruction. Unilateral and bilateral septal deviation and internal nasal valve narrowing are predictive of having an increased NOSE score. Unilateral nasal obstruction should be recognized and treated as a cause for severe symptomatic nasal obstruction despite a normal contralateral nasal exam.

Spreader Graft for Severe Deviation of Nasal Septum with Obstruction of the Internal Nasal Valve: Clinical and Functional Results.

Difficulty in nasal ventilation is one of the most frequently occurring problems in otorhinolaryngology and its correct diagnosis is the key step to solve it. The dysfunctions in the valve area are a frequent cause of chronic nasal obstruction, though commonly ignored. The objective of the study is to analyze the clinical and functional outcomes in a group of patients with septal deviations and valve compromise treated with spreader graft with endonasal approach. Thirty-five patients with septal deviation with compromise of the internal nasal valve (INV; area II of Cottle), treated with spreader graft and a minimum follow-up of 12 months, were included for analysis. Patients were evaluated with video nasosinusal endoscopy, photography, the Nasal Obstruction Symptom Evaluation (NOSE) questionnaire, and rhinomanometry (RM). Postoperative complications were recorded. The results obtained in the pre- and postoperative NOSE scores showed significant differences (p = 0.001), as also in pre- and postoperative RM tests (p < 0.001). Two complications were reported in the 35 patients; thus the complication rate in our sample was 6%. The use of spreader grafts, with endonasal approach, as nasal septum's tutors improved perpendicular septal deviations with compromise of the INV (area II), reaching an effective functional improvement in the nasal airway, with low rate of complications.

Coupling Pressure Sensing with Optical Coherence Tomography to Evaluate the Internal Nasal Valve.

To evaluate endoscopic long-range optical coherence tomography system combined with a pressure sensor to concurrently measure internal nasal valve cross-sectional area and intraluminal pressure. A pressure sensor was constructed using an Arduino platform and calibrated using a limiter-controlled vacuum system and industrial absolute pressure gauge. Long-range optical coherence tomography imaging and pressure transduction were performed concurrently in the naris of eight healthy adult subjects during normal respiration and forced inspiration. The internal nasal valve was manually segmented using Mimics software and cross-sectional area was measured. Internal nasal valve cross-sectional area measurements were correlated with pressure recordings. Mean cross-sectional area during forced inspiration was 6.49 mm2. The mean change in pressure between normal respiration and forceful inspiration was 12.27 mmHg. The direct correlation between pressure and cross-sectional area as measured by our proposed system was reproducible among subjects. Our results demonstrate a direct correlation between internal nasal valve cross-sectional area and nasal airflow during inspiration cycles. Endoscopic long-range optical coherence tomography coupled with a pressure sensor serves as a useful tool to quantify the dynamic behavior of the internal nasal valve.

Use of anatomically-accurate 3-dimensional nasal airway models of adult human subjects in a novel methodology to identify and evaluate the internal nasal valve

The optimal method for radiographic evaluation of the internal nasal valve (INV) has not been established. The objective of this study was to develop a method to assess the cross-sectional area and the angle of the INV using anatomically-accurate 3D digital nasal airway models. Axial CT images of the paranasal sinuses of twenty adult subjects with healthy nasal airways (50% female and 50% age ≥ 50) were used to create the models. Patients with significant radiographic evidence of sinonasal disease were excluded. A primary cutting plane that passed through the edge of the nasal bone, upper lateral cartilage, and the head of the inferior turbinate was defined in coronal view. This primary coronal cutting plane was then rotated in 5° increments anteriorly while ensuring the anatomic criteria for the INV were still met. The cutting plane resulting in the minimum INV area was identified as the optimal cutting plane and the total cross-sectional area of INV in this plane,198.79 ± 54.57 mm2, was significantly less than the areas obtained using the existing methods for radiographic evaluation of the INV. The angle between the optimal cutting plane and nasal dorsum was 75.00 ± 10.26°, and the corresponding INV angle was 10.77 ± 6.02°.

Impact of rapid palatal expansion on the internal nasal valve and obstructive nasal symptoms in children.

The aim of this study is to evaluate the impact of rapid palatal expansion (RPE) on the nasal airway subjectively byutilizing patient-reported outcome measures (PROM) and objectively by evaluating validatedinternal nasal valve (INV) measurements obtained from cone beam computed tomography (CBCT) in pediatrics. In this retrospective cohort study, subjects who underwent RPE from March to December 2018 with cone beam CT and Nasal Obstruction Symptom Evaluation (NOSE) scores were included. Exclusion criteria included craniofacial deformity, allergies, asthma, recent nasal trauma, or surgery. INV measurements (angle and cross-sectional area), diastema, midpalatal suture opening, and NOSE scores were evaluated. Fifty-one subjects met the inclusion criteria with a mean age of 10.1 ± 2.6. Pre-expansion mean NOSE score was 32.55 (moderate) while post-expansion was 13.92 (mild). Mean NOSE score improved significantly by an average of 18.63 following post-expansion (P < 0.0001). The patients' right and left INV angles increased significantly by a mean of 2.42° and 2.65° respectively (P < 0.0001). Right and left INV cross-sectional areas increased significantly by an average of 14.35mm2 (P < 0.0001) and 14.17mm2 (P < 0.0001) respectively. An average expansion of the diastema and the suture was 1.60mm and 3.05mm respectively (P < 0.0001), with an average of 6.29mm of expansion. We found the amount of diastema expansion to correlate with change in NOSE score (R = - 0.32, P = 0.022). Age and diastema showed a negative correlation (R = - 0.44, P = 0.0019), while INV angle and diastema showed a statistically significant positive correlation (R = 0.28, P = 0.048). RPE showed improvement in both NOSE scores and objective measures of the INV. This may show the possibility of considering RPE in managing resistant pediatric nasal airways. Future studies should include collaboration with pediatric otolaryngologists, with the inclusion of pediatric patients with persistent nasal obstruction.

Versatile Applications of Different Septal Correction Techniques in Rhinoplasty

Nasal obstruction due to septal deviation is a commonproblem. In addition to the functional problem it may causean aesthetic deformity. Several septal correction techniqueshave been evolved over the years either through open or theendoscopic approaches. Beside the classic Insitu septal correctiontechniques; extracorporeal septoplasty represents aneffective tool in the management of severely deviated septum.The internal nasal valves are the narrowest part of the upperairway system. Their reconstruction is very essential step fora successful functional outcome. In the current study, theauthors compared between two groups of patients. The firstgroup was the extracorporeal septoplasty and the second group was the Insitu septoplasty. In both groups; they used spreadergrafts for the internal valve reconstruction. The procedurethen was conducted with the same essential steps of rhinoplastyaccording to each case individually. A validated subjectivescore for functional assessment of the improvement (NOSE)was used. NOSE score was used for subjective assessment ofthe results before and 6 months after the procedure. Statistically,results were nearly the same between the two groups after 6months. The authors concluded that both techniques wereeffective in the management of moderate to severe septaldeviation provided that the internal valve was constructedwith spreader grafts.

The Keystone, Scroll Complex, and Interdomal Area of the Nose: Histologic and Anatomical Observations.

Comprehensive knowledge of nasal anatomy is essential for obtaining aesthetically and functionally pleasing results in rhinoplasty. In this study, the authors described the anatomy, histology, and clinical relevance of the interdomal region, keystone, and scroll complex. The current study examined these areas in 26 fresh cadaver heads. All cadavers were fresh, and no conservation or freezing processes were applied. All dissections were performed by the first author. It was determined that the structure that connected the middle crura in the interdomal region actually came together in the transverse plane and contained abundant capillaries within. It was observed that chondroblasts with high regenerative potential were present in the keystone area, and there was very tight attachment between periosteum and perichondrium. The scroll complex was found to be more flexible and thin and had fewer regenerative cells compared to the keystone region. With its unique anatomy and histology, the keystone acts as a transition area between the flexible and fixed units of the nose. The scroll complex should be taken into consideration during rhinoplasty because of its effects on fixation of the skin in the lateral supratip area and functional effects on internal and external nasal valves. The interdomal ligament, in contrast, acts as a transition between both middle crura rather than a real ligament.

A Cure for PAINS? A Novel Approach to Management of Proton-Associated Internal Nasal Valve Stenosis.

Acquired internal nasal stenosis as a result of radiotherapy to the sinonasal region can be highly distressing for patients and difficult to correct surgically. We describe our experience using a controlled radial expansion balloon to dilate the area of stenosis, followed by stenting to the region. We achieved excellent results in 3 patients using this technique, with improvement in subjective nasal airflow across 100% of stenoses and complete resolution in 83%. This technique offers a simple and low-morbidity option for the management of acquired anterior nasal stenosis and is of particular value in cases of irradiation, which has the potential for poor tissue healing.

Nasal Airflow Changes With Bioabsorbable Implant, Butterfly, and Spreader Grafts.

Internal nasal valve compromise is a major cause of nasal obstruction, with a growing number of ways to treat this condition. In this study, we compared the effects of butterfly graft, spreader graft, and the bioabsorbable nasal implant on nasal airflow resistance. Cadaver study. Computational fluid dynamics (CFD) simulations were completed from nine preoperative and postoperative cadaveric subjects. Each cadaveric head underwent placement of a bioabsorbable nasal implant (BNI) (Spirox Latera; Stryker ENT, Plymouth, MN), butterfly graft, or spreader graft. Pre- and postoperative computed tomography (CT) scans were used to generate three-dimensional models of the nasal airway used in steady-state CFD simulations of airflow and heat transfer during inspiration. Butterfly graft placement resulted in a mean improvement in nasal airway resistance of 24.9% (±7.3), whereas BNI placement resulted in a 6.7% (±1.2) improvement, and spreader graft placement also resulted in a consistent improvement of 2.6% (±13.5). Pressure within the main nasal cavity was consistently lower following butterfly graft placement versus a spreader graft or BNI. Butterfly and spreader graft placement also resulted in modest improvements in airflow allocation, whereas BNI demonstrated more variation (-1% to 12%). Heat flux was not significantly different; however, a small improvement in total heat flux was seen with all three interventions. The results of this study demonstrate reduction in nasal airway resistance in all three surgical interventions, with the butterfly graft demonstrating superiority to the other two techniques. However, these data only reflect a static environment and not dynamic changes in airflow seen during respiration. NA Laryngoscope, 130:E817-E823, 2020.