1
VALVE PROBLEMS

Both valves function as Starling resistors: They remain stable until a certain transmural pressure causes them to flutter or collapse and obstruct the nasal airway. Normal internal valves collapse during forced inspiration at a ventilatory flow rate of 30 L/min.

Problem is when the valves collapse even during normal nasal breathing
Causes

Most commonly post rhinoplasty and trauma but may be congenital.

Factors that predispose patients to postrhinoplasty valve problems include
1.
tall, thin nose
2.
short nasal bones (normal should be halfway along radix to septal angle. <25% is short)
3.
narrow middle third
4.
pliable cartilage
5.
multiple previous surgeries;
6.
advanced age
Classification (Kern and Wang)
1.
mucocutaneous a.
mucosal swelling secondary to rhinitis
2.
Skeletal/structural a.
Deformities affecting the internal nasal valve area i.
Static deformity
1.
Inferomedially displaced upper lateral cartilage a.
Due to disruption of the join between upper laterals and septum; UL and LL; and UL and nasal bone b.
Causes the medially unsupported upper laterals to fall toward the narrowed dorsal septal edge
2.
Narrowing of pyriform aperture a.
Overly aggressive lateral osteotomies and infracturing
3.
Scarring at intercartilaginous junction a.
Improper placement and poor closure of intercartilaginous incisions
4.
Turbinate hypertrophy a.
head of the inferior turbinate contributes to the internal nasal valve are
5.
Deviated nasal septum a.
When deviated at the nasal valve area ii.
Dynamic deformity - Collapsed upper lateral cartilage secondary to disruption of support from the nasal bone, septum, and lower lateral cartilage

b.
Deformities affecting the external nasal valve i.
Static deformity
1.
Tip ptosis, narrow slitlike nostrils, thin alar rims, wide columella a.
Tip ptosis may be due to structural weakness post rhinoplasty or due to excess soft tissue bulk (ie rhinophyma) - results in a more superior redistribution of airflow within the vestibule
2
2.
Cicatricial stenosis ii.
Dynamic deformity
1.
Collapsed lower lateral cartilage secondary to excessive excision
2.
Nasal muscle deficiency a.
Secondary to facial palsy, aging or iatrogenic(devascularization, partial denervation, or fibrosis)

3
INTERNAL VALVE
Features of middle vault collapse and incompetent internal valve
1. Caved in appearance of middle vault (dorsal contour)
2. Inverted V deformity on front view
3. Impaired function – unilateral or bilateral appearance
4. (UL-septal angle < 15 o)
History

Exclude rhinitis

History of trauma, previous surgery, medications
Examination

Examine before and after application of topical 1% phenylephrine (identify reversible mucosal edema)

Look for other causes: septal deviations, inferior turbinate hypertrophy, and external nasal valve collapse

On frontal view – look for unilateral or bilateral disruption of the brow-tip aesthetic line (hourglass silhouette – narrowest portion should be through the middle vault)

Cottle manoeuvre – pull ipsilateral cheek laterally to open valve – symptoms should improve. Non specific as this test also improves turbinate hypertrophy and anterior septal deviation. False-negative results are observed in patients with scars or webs in the valve that prevent it from opening.

Modified Cottle manoeuvre – put curette into nose to support internal or external valve.

Direct inspection of the valvular area during quiet breathing. Look for medialization of the caudal margin of the upper lateral cartilages – don’t use speculum as this opens up the valve.

0

nasendoscopy
Investigations

Rhinomanometry - evaluate the airflow resistance offered by each cavity, but it does not provide information about the location of the obstruction

Acoustic rhinometry - analysis of sound waves reflected from the nasal cavities. It provides an estimate of the cross-sectional areas of the nose as a function of the distance from the nostril.
Management

4

Address the cause o If rhinitis – then trial medication o Stuctural – potential causes from septum, upper and lower lateral cartilage, floor of the nose, head of the inferior turbinate
Surgery
Deviated Nasal septum
 the most frequent structural cause of nasal valve obstruction.

Septoplasty o Conservative cartilage excision

o Reposition, reshape, morselize the warped cartilage o Cartilage scoring on the concave side
5 o Removing wedges from the convex side o Osteotomize a hypertrophied maxillary crest o Batten grafts may be required

Submucous resection o extensive resection of cartilage and bone, including part of the vomer and part of the perpendicular plate of the ethmoid. o A 1-cm caudal and dorsal strut is typically left to support the lower two thirds of the nose.

Incisions o Part of open rhinoplasty – approach septum thru the anterior septal angle o If addressing septum alone, endonasal approach via hemitransfixion or Killian incisions

Inferomedial displacement of the upper lateral cartilage
6
Aim to reposition the upper lateral cartilage or adding structural grafts to support the lateral wall of the nose.
1.
Spreader grafts (Sheen 1984)

7
 the workhorse repair of the narrowed internal nasal valve

Functions:
1.
widens the dorsal roof (preserve dorsal aesthetic lines)
2.
increases the angle of the internal valve aperture.
3.
contour irregularities in the middle vault
4.
strengthens septum

Grafts – septal cartilage, conchal cartilage, rib, vomer, Medpor
 placed in a submucosal pocket between the septum and the upper lateral cartilage.
 grafts are typically 1-2 mm thick and extend the entire length of the upper lateral cartilage

Anchoring mattress sutures are use - span from one upper lateral cartilage through the ipsilateral spreader graft, the septum, the contralateral spreader graft, the contralateral upper lateral cartilage, and then back again.

Take care to not disrupt the nasal mucosa because this could lead to web formation and further valve stenosis.
2.
Flaring sutures (Parks PRS 1998)
 directly changes the internal valve angle. May be used with a spreader

4-0 nylon horizontal mattress stitch extends from the caudal+lateral area of the upper lateral cartilage and across the dorsum of the nose and is anchored to the contralateral upper lateral cartilage. This area is typically hidden under the scroll of the lateral crus, which is retracted inferiorly for sufficient exposure

As the suture is tightened, both upper lateral cartilages are pulled laterally, with the dorsum serving as a fulcrum
3.
Butterfly grafts

8
 may be placed endonasally or by using an open approach.

Placed at the scroll area between the upper lateral cartilage and lower lateral cartilage to widen the valve angle
 anchored in place using 5-0 PDS to prevent migration.

Butterfly grafts, more than other valve-plasty maneuvers, can lead to postoperative cosmetic changes, with marked fullness along the supratip area. Caudal border of the graft may need to be placed deep to the cephalic border of the lateral crura to minimise this problem
Narrowing of the piriform aperture

More prone following low-low osteotomies
 revision osteotomy with outfracture of the nasal bones to widen the valve angle

Outfracture can have adverse effects on cosmesis by widening the nasal dorsum.

Other options – inferior turbinectomy, osteotomy of wedge of bone at narrowest portion
Scarring at the intercartilaginous junction
 corrected by scar excision followed by reconstruction using a full-thickness skin graft or local mucosal flap.
Turbinate hypertrophy

Conservative turbinate resection – only 2cm or less needs to be taken
Synechia or scarring of the mucosa of the valve

Difficult – excise scar and splint with silicone sheet.
EXTERNAL VALVE (Constantian, PRS 93(5) p919)
= Lateral crus of alar cartilage plus vestibular and external skin lining.
Causes of external valve collapse
1. surgical (post rhinoplasty is the commonest cause of external valve collapse)
2. congenital
3. post-traumatic
Features of external valvular incompetence
1. Collapse of ala on inspiration (even quiet inspiration)
2. Patients often flare their nostrilsn
3. Notched, creased or everted alar walls

9
4. Weak, hypoplastic or malpositioned lateral crus on palpation
5. Positive Cottle manouvre (lateral traction on the cheek improves airway) - a non specific test positive with all causes of airway obstruction.
Management
Static deformity

Tip ptosis - horizontal mattress from the dome of the lower lateral cartilage to the periosteum of the nasal bones.

Soft tissue ptosis - thick sebaceous skin at the supratip area along the borders of the nasal subunits can be excised to produce an aesthetically pleasing scar.

Cicatritional stenosis – primary resection, composite grafts, local flaps. Small webs may need stenting after division
Dynamic deformity

Flaccid collapse of lower lateral cartilages o Usually follows over resection o Manage with batten grafts – conchal or septal (0-15 mm long and 4-8 mm wide – wider out laterally) o Ensure the graft is of sufficient length to be seated in the soft tissue from the bony piriform aperture to the middle crura. o The soft tissue pocket is usually at the level of the supra-alar crease at the junction of the upper lateral cartilage and lower lateral cartilage with internal valve collapse or into a pocket caudal to the cephalically positioned lateral crura with external valve collapse

Nasal musculature deficiencies may be treated with slings or perialar wedge resection
Complications
1) Recurrent obstruction a.
Inadequate treatment b.
Development of synechiae c.
failure to identify concomitant allergic or nonallergic rhinitis, or other structural causes
2) Hematoma a.
Septal hematoma may cause septal necrosis b.
Avascular cartilage can be viable for up to 3 days c.
Manage with drainage through a mucoperichondrial incision. Packing, ice packs, antibiotics

10
3) Epistaxis a.
Treat with nasal packing
4) Infection a.
Tosic shock syndrome rare
5) CSF leak a.
avulsion or damage to the cribriform plate. b.
managed by bed rest, nasal packing, and oral antibiotics. Spontaneous resolution usually occurs. c.
Look for signs and symptoms of meningitis
6) Septal perforation a.
crusting, epistaxis, and a whistling sound b.
Diagnosis is made by using anterior rhinoscopy, c.
repaired with a variety of mucosal flaps if it is less than 1.5 cm.
7) Cosmetic deformity a.
inadequate residual L-strut b.
sunken dorsum with a supratip saddle formation. c.
Other problems - widened alar rim margins, a drooping nasal tip, a retracted columnella, excessive bulk from batten grafts
8) Graft extrusion, migration
9) Anosmia a.
Rare – usually transient