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External Valve Stenosis Rhinoplasty Treatment & Management

  • Author: Alicia R Sanderson, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Mar 15, 2016
 

Medical Therapy

External nasal valve dilator strips often provide temporary relief by increasing the size of the nasal valve area and decreasing congestive symptoms. However, these strips can be cosmetically unacceptable to some individuals.

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Surgical Therapy

Various surgical options are available to help improve airflow in airways that are obstructed because of a deficient external nasal valve. Options include the following:

  • Septoplasty to address caudal deflection
  • Narrowing a wide columellar base
  • Composite conchal graft to address full- or partial-thickness defects of lateral nasal wall structures secondary to trauma or surgical resection or as a stiffening structure for congenital or senescent weakness [3]
  • Onlay batten grafts to provide additional lateral wall support
  • Lateral crural strut graft
  • Nasal floor conchal grafts to open an excessively narrowed inferior nares
  • Use of a stitch spreader to help maintain alar stability
  • Reversing the lateral crura
  • Lateral crural composite flaps with mattress suture (lateral crural curling) [4]
  • Alar expansion stitches with or without alar reinforcement
  • Z-plasty to release internal valve scarring
  • Use of postoperative stents
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Preoperative Details

Use the surgeon's standard preoperative preparation for either external or endonasal rhinoplasty. Obtain preoperative photographs. Surgeons should counsel the patient on possible cosmetic changes. Alar batten grafts can result in effacement of the deep alar creases and widening of the nasal tip.

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Intraoperative Details

Use the Toriumi method of alar batten graft.[5] The Toriumi method is useful for collapse of external valve secondary to deficiencies of the lower lateral cartilage that lead to collapse. The Toriumi method is not appropriate for absolute narrowing of the piriform aperture or for cases of significant scarring of the valve; however, conchal grafts to the nasal floor or a Z-plasty to release scar may be used in these instances.

Endonasal approach

See the list below:

  • Administer local anesthesia of 1% lidocaine and epinephrine (1:100,000).
  • Use a 6- to 8-mm incision internally at the site of maximal collapse.
  • Harvest a cartilage batten (septal or conchal) 10-15 mm long and 6-8 mm wide. Be sure that the cartilage batten is sturdy enough to prevent collapse on inhalation.
  • In the senior author's experience, use of a 0.85 mm Medpor onlay graft over the lower lateral cartilage has been effective with minimal cosmetic changes.
  • Develop a subcutaneous pocket under the area of collapse that extends just medially to the piriform aperture to avoid the lateral nasal artery. Make a pocket near the lobule to help camouflage the batten.
  • Be sure to measure and make the pocket precisely the size of the graft to avoid movement after placement.
  • If the pocket is sized properly, suture closure is not necessary.

A study of 39 patients suggested that external valve narrowing due to caudal septal deviation can be successfully treated via endonasal septoplasty with bony batten grafting. Using a visual analogue scale, patients reported postoperative improvement in the severity of nasal symptoms, while acoustic rhinometry revealed significant widening of the minimal cross-sectional area of the convex side.[6]

External approach

See the list below:

  • Use the standard external approach.
  • Only dissect to the junction of the medial and lateral third of lateral crura.
  • Dissect a precise pocket over the maximal area of collapse lateral to the piriform rim and insert the graft.
  • If the pocket is not precise or the graft does not fit tightly, use a suture to fix the graft to the lateral third of lower lateral cartilage.
  • Lateral crural strut grafts include autogenous cartilage that is sutured to the undersurface of the lower lateral cartilage. The purpose is to strengthen and correct deformities in the lateral crura without a visible graft. [7]

External approach

See the list below:

  • Vestibular skin undermined off lateral crus
  • Vestibular skin left attached to caudal border of crus
  • Cartilage grafts carved to 3-4 mm wide and 15-25 mm length
  • Cartilage grafts placed on undersurface of lateral crus and secured with 2-3 5-0 Vicryl sutures
  • Graft extends laterally to the piriform apeture rim
  • Lateral end of strut graft placed caudal to alar groove to prevent visibility
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Postoperative Details

Use standard rhinoplasty postoperative care.

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Follow-up

Use the surgeon's standard protocol for follow-up care of either external or endonasal rhinoplasty.

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Complications

Complications are similar to those observed with any rhinoplasty and include the following:

  • Bleeding
  • Infection
  • Poor cosmetic outcome
  • Continued valve insufficiency
  • Too-large graft with extrusion or external deformity
  • Poorly sized pocket with graft migration
  • Postoperative scar contracture
  • Need for further surgery
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Outcome and Prognosis

Most properly selected patients can expect significant improvement in symptoms and objective airway improvement. Recognizing external valve collapse and its etiology is important during the evaluation of every candidate for rhinoplasty or septorhinoplasty. By thoroughly addressing all the potential causes of airway obstruction, the chances for an outstanding outcome are improved.

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Contributor Information and Disclosures
Author

Alicia R Sanderson, MD Fellow in Facial Plastics and Reconstructive Surgery, Department of Otolaryngology, University of California, Irvine

Alicia R Sanderson, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery

Disclosure: Nothing to disclose.

Coauthor(s)

Peter A Weisskopf, MD Neurotologist, Arizona Otolaryngology Consultants; Head, Section of Neurotology, Barrow Neurological Institute

Peter A Weisskopf, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Dean Toriumi, MD Associate Professor, Department of Otolaryngology, University of Illinois Medical Center

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

Daniel G Becker, MD Assistant Professor, Department of Otorhinolaryngology-Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, University of Pennsylvania School of Medicine

Daniel G Becker, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons

Disclosure: Nothing to disclose.

Acknowledgements

Craig Cupp, MD Head, Program Director, Department of Otolaryngology, Division of Facial Plastic-Reconstructive Surgery, Naval Medical Center San Diego

Craig Cupp, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, and Wyoming Medical Society

Disclosure: Nothing to disclose.

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 Sep-Oct. 17 (5):347-50. [Medline].

  2. Gruber RP, Lin AY, Richards T. Nasal strips for evaluating and classifying valvular nasal obstruction. Aesthetic Plast Surg. 2011 Apr. 35 (2):211-5. [Medline].

  3. Fanous N, Hier MP. Collapsed nasal-valve widening by composite grafting to the nasal floor. J Otolaryngol. 1996 Oct. 25(5):313-6. [Medline].

  4. Gruber, Ronald P.; Melkin, Edward T.; Strawn, J. Bradley. External Valve Deformity: Correction by Composite Flap Elevation and Mattress Sutures. Aesth Plast surg. May 2011. 35:960-964.

  5. Toriumi DM, Josen J, Weinberger M, Tardy ME Jr. Use of alar batten grafts for correction of nasal valve collapse. Arch Otolaryngol Head Neck Surg. 1997 Aug. 123(8):802-8. [Medline].

  6. Chung YS, Seol JH, Choi JM, et al. How to resolve the caudal septal deviation? Clinical outcomes after septoplasty with bony batten grafting. Laryngoscope. 2014 Aug. 124(8):1771-6. [Medline].

  7. Gunter, Jack P. M.D.; Friedman, Ronald M. M.D. Lateral Crural Strut Graft: Technique and Clinical Applications in Rhinoplasty. Plastic and Reconstructive Surgery. April 1997. 99(4):943-952.

  8. Ballert JA, Park SS. Functional rhinoplasty: treatment of the dysfunctional nasal sidewall. Facial Plast Surg. 2006 Feb. 22(1):49-54. [Medline].

  9. Egan KK, Kim DW. A novel intranasal stent for functional rhinoplasty and nostril stenosis. Laryngoscope. 2005 May. 115(5):903-9. [Medline].

  10. Khosh MM, Jen A, Honrado C, Pearlman SJ. Nasal valve reconstruction: experience in 53 consecutive patients. Arch Facial Plast Surg. 2004 May-Jun. 6(3):167-71. [Medline].

  11. Latte J, Taverner D. Opening the nasal valve with external dilators reduces congestive symptomsin normal subjects. Am J Rhinol. 2005 Mar-Apr. 19(2):215-9. [Medline].

  12. Mendelsohn MS, Golchin K. Alar expansion and reinforcement: a new technique to manage nasal valve collapse. Arch Facial Plast Surg. 2006 Sep-Oct. 8(5):293-9. [Medline]. [Full Text].

  13. Vaiman M, Shlamkovich N, Kessler A, Eviatar E, Segal S. Biofeedback training of nasal muscles using internal and external surface electromyography of the nose. Am J Otolaryngol. 2005 Sep-Oct. 26(5):302-7. [Medline].

  14. Vidyasagar R, Friedman M, Ibrahim H, Bliznikas D, Joseph NJ. Inspiratory and fixed nasal valve collapse: clinical and rhinometric assessment. Am J Rhinol. 2005 Jul-Aug. 19(4):370-4. [Medline].

  15. Cochran CS, Ducic Y, DeFatta RJ. Restorative rhinoplasty in the aging patient. Laryngoscope. 2007 May. 117 (5):803-7. [Medline].

 
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