Internal Valve Stenosis Rhinoplasty Treatment & Management

When the valvular collapse is secondary to inflammation of the mucosa covering the valve (eg, secondary to allergic rhinitis or infection), proper treatment, such as anti-inflammatory agents or antibiotics, help to resolve the problem.

Collapse secondary to mechanical obstruction is more common. In this case, surgery is the only solution. Some patients use a self-adhesive stent that opens the nasal valve; however, this is only a temporary solution.

Many techniques can be used to correct a stenotic or collapsed nasal valve. Depending on the type of pathology, the surgeon can choose to use one or several methods. The scope of techniques varies from sutures to the application of grafts. The common goal is to open the valve, restoring the appropriate anatomy. Explaining each technique is beyond the scope of this article; however the following is a summary of these techniques depending on the structure modified.

Valvuloplasty

A valvuloplasty is the surgery historically used to reconstruct the nasal valve. The goal of this surgery is to open the valve by removing the returning ULC and trimming the caudal border of the cartilage. It is not the only technique used to correct valvular alterations, but it provides an excellent view of the caudal border of the ULC and can be used in conjunction with other techniques. Because the valve is formed by several different structures, other techniques may be necessary, depending on the type of deformity that produced the stenosis.

The goal of this procedure is to expose the caudal border of the ULC to correct any deformity (eg, resection of the caudal border of the ULC, excessive returning of the ULC). Steps of this procedure include the following:

1. Expose the caudal border of the ULC through an intercartilaginous incision. Avoid damaging the valvular mucosa in order to decrease the risk of a synechia. Intercartilaginous incisions are better placed 1-2 mm caudal to the border of the ULC. The area of transition from skin to respiratory epithelium is prone to developing unwanted scarring or synechiae.

2. Undermine the skin over the dorsum.

3. To obtain better exposure, gently retract the alar margin of the nostril with a 10- or 12-mm double hook.

4. Grasp the caudal border of the ULC with an Adson-Brown or similar forceps.

5. Dissect the mucosa in the underside of the ULC with the tip of a Walter or curved Iris scissors.

6. Similarly separate the upper side of the ULC from the subcutaneous tissue until the caudal border is completely visible.

7. Repeat the same procedure if the dorsum is visible from both sides.

8. Almost any deformity of the ULC can be identified this way.

9. If a septoplasty or rhinoseptoplasty was performed and the caudal border of the septum was resected, resect a similar amount of the caudal border of the ULC. This maintains the proportions between the septum and the ULC.

10. Resection of the caudal border of the ULC reduces its flexibility. To maintain it, removing a small triangle near the septum is necessary.

11. If another deformity is present, direct surgery to correct it. For example, if the ULC is twisted, a batten may be necessary to straighten it.

12. Spreader grafts can be inserted and fixed through this incision to increase the cross-sectional area of the nose.

13. When intercartilaginous incisions do not allow enough space to see and work because of the complexity of the stenosis, an open approach provides excellent exposure (ie, when spreader grafts and flaring sutures are applied in the same procedure).

14. A dry field is important in this surgery because the space is limited and bleeding can obstruct the visual field and make the procedure time consuming. To avoid this, the cul-de-sac can be infiltrated 5-10 minutes prior to the incision. Apply only a small amount of lidocaine and epinephrine (Octocaine with epinephrine [2%], Xylocaine with epinephrine [2%]). Approximately 0.5 mL is needed in each valve to avoid distortion of the structures. Help from an assistant is invaluable.

15. Suturing of the intercartilaginous incision is performed at the end of the surgery, when all other maneuvers have been completed. Some prefer to use catgut or 4-0 Vicryl with ophthalmic needles. These small curved needles are easy to handle in the confined space of the vestibule.

Spreader grafts

Described by Sheen in 1984, these grafts have proven to be a valuable resource not only to avoid the inverted-V deformity, but also to straighten a twisted dorsum (see the image below) and to increase the cross-sectional area of the valve.

The grafts are placed between the septum and the ULC (see image below), which increases the width of the roof on each side.

Even though the increase is small, it is usually enough to increase the patency of the valve. A common mistake is to make the grafts too wide. Usually, 2 mm is enough to place the suture without breaking the graft. The authors suture the graft with 5-0 nylon (see the image below).

These grafts are used by the main author as the primary method to increase the opening of the valvular area. Most authors use them in open rhinoplasty, as the suturing and placement is easier. However, it is completely possible to place them in a closed rhinoplasty. A retrospective study by Samaha and Rassouli of 100 patients indicated that endonasal placement of spreader grafts is a safe and effective treatment for internal nasal valve insufficiency. In the only aesthetic or functional complications, a cartilaginous dorsal spur was seen in three patients as the graft’s cephalic edge became visible, while in one patient, an ecchymosis developed along the dorsum, producing a hump that resolved in two months. ^[11]

Another retrospective study, by Talmadge et al, found at minimum 1-year follow-up that improvement in Nasal Obstruction Symptom Evaluation (NOSE) scores did not differ significantly between patients with nasal valve stenosis who underwent endoscopic spreader graft placement and those who were treated with open spreader graft surgery. ^[12]

Although the original technique uses one graft per side, the authors have occasionally needed to use two in case of a severe collapse of the valve, as shown in the pictures below.

Conchal cartilage butterfly graft

This graft has been found useful by Friedman and Cook in primary rhinoplasty. ^[13] It has been used traditionally for secondary surgery when too much ULC has been resected. The natural convexity and rigidity of the conchal cartilage is an excellent option to open the ULC.

The technique involves the removing a piece of conchal cartilage, trimming it to the size of the dorsal defect, and beveling the border to smooth the contour of the dorsum. It is applied through an intercartilaginous incision over the ULCs. Because the concave side is facing the ULCs, the upward pull of the graft ends will help open the valves.

A cadaveric study by Brandon et al suggested that in internal valve stenosis, nasal airflow resistance will undergo a greater decrease in association with butterfly grafts (range, 20-51%) than with spreader grafts (range, 2-29%). ^[14]

Nasal valve lift

A study by Heppt et al indicated that nasal valve stenosis can successfully be treated with a nasal valve lift. In the report, one group of patients was treated with lift only, with absorbable, polylactic acid, self-retaining cone threads employed, while a second group also underwent radio frequency turbinoplasty. In the lift-only patients, the pretreatment visual analogue scale (VAS) score for sense of obstruction averaged 7.2, with this dropping to 2.3 a week after the nasal valve lift and the arithmetic mean reaching 4.0 by 24 months following treatment. In the group that underwent lift plus turbinoplasty, the preoperative VAS score also averaged 7.2, with the arithmetic mean 1 week postoperatively being 2.4, and the average sense of obstruction at 24 months being 3.0. ^[15]

Normal preoperative examinations are performed, and no special care is required. The surgery is often performed in combination with septoplasty or rhinoseptoplasty. Local or general anesthesia can be used.

Because the valve is formed by several structures, the surgery is directed toward realigning the obstructing parts.

Septum

If a caudal deviation is causing the obstruction, a septoplasty corrects the problem. Septoplasty can be a difficult surgery because caudal deviations are commonly complex deformities of the septal framework and obtaining a completely straight septum proves to be a frustrating task. In some cases, obtaining straight cartilage from the posterior septum and transplanting it is preferable. This is particularly true in those patients with horizontal fractures of the caudal septum (eg, Chevallet fracture). The use of battens is sometimes necessary to keep the repaired septum straight.

Nasal roof

The nasal roof can be excessively narrowed after rhinoplasty or with congenital or traumatic deformities. In these cases, the use of spreader grafts, is particularly useful. ^[16] They keep the nasal profile straight, and they also increase the cross-sectional area of the entire nasal valve.

Upper lateral cartilage

If the cartilage is thick or if excessive returning of the caudal border of the cartilage occurs, modification is possible by resecting the caudal border and reshaping the valve. This is commonly a surgery performed concomitantly with septoplasty. Also, the previously mentioned spreader grafts can modify the position of the cartilage, allowing the valve to open. In case the cartilage is absent, a graft can be fashioned from septal or auricular cartilage. Another method described to open the nasal valve is to apply a flaring suture that lifts the ULCs. A combination of both techniques has recently been reported to have the best results. The ULC can be sutured using several different techniques, including mattress sutures and suspension sutures. ^[17]

This last option was described by Paniello and modified by Lee and Glasgold. ^{[18, 19]} This option involves a couple of suspension sutures anchored in the soft tissue near the infraorbital rim that lateralizes and elevates the ULC. They reported better breathing in all patients.

Lower lateral cartilage

When the alar cartilage is weakened after surgical overresection or trauma, its rigidity must be restored. The basic method consists of applying a batten of cartilage to keep the lobule rigid during inspiration. A method described by O'Halloran in 2003 consists of the removal of excessive skin in the valvular area through an incision anterior to the LLC. ^[20]

Inferior turbinate

The simplest procedure is outfracture of the inferior turbinate. A 2009 study by Buyulku performing CT scan after outfracture of the inferior turbinate during septoplasty (before the surgery and 9 months after), found that the average distance from the turbinate to the lateral nasal wall diminished 15-29%. ^[21] Although this procedure is easy to perform and has minimal complications, if mucosal edema exists, it can be insufficient to allow for an adequate airflow. In these cases, a combination of procedures can be performed.

Although complete resection of the turbinate is best avoided, conservative resection (or manicuring) of the head of the turbinate significantly decreases the total resistance offered by the internal valve. This procedure, when performed properly, is a useful tool when the other areas are difficult to correct. Unless hypertrophy is extremely large, resecting more than 2 cm from the head typically is not necessary because the airflow follows a superior direction afterwards.

When hypertrophy of the cavernous sinuses in the turbinate are the cause of obstruction, several procedures are described to reduce the bulk of the turbinal stroma. Diode-laser, electrocautery, radiofrequency, and coblation are used to produce limited damage to the cavernous sinuses and stroma and reduce the volume of the turbinate after scarring take place. Having used all of them, the lead author has had the best results with coblation. Care should be taken not to apply too much energy with these procedures, in order to avoid a potential turbinal necrosis.

Another method to reduce the volume is with the use of a microdebrider introduced in the head of the turbinate. The device suctions and cuts the stroma, effectively reducing the bulk of the turbinate.

Pyriform aperture

Narrow pyriform apertures should be handled depending on the origin of the constriction. Congenital pyriform stenosis can be produced from an excess of bone. This bone can be drilled away through a sublabial approach. If the stenosis was produced by an excessive narrowing of the nasal bones in a previous surgery, it can be handled with resection of a small wedge of bone in the narrowest area. Another approach is to displace the bones laterally (outfracture) after performing new osteotomies. In this case, performing medial and lateral osteotomies is recommended. If neither procedure is successful, conservative resection of the head of the inferior turbinate is an alternative plan. In many patients, more than one procedure is necessary to open the valve. In 2009, Seren proposed the use radiofrequency in the lateral nasal wall, near the pyriform aperture, to decrease the volume of the tissue in the area. ^[22]

Synechia or scarring of the mucosa of the valve

This situation is difficult to handle. Obstructive scarring is common after surgery. Resection of the synechia or scarring is performed with scissors. Because some synechia and scars are quite thick, a good method is to clamp the valve with a forceps for 5 minutes before the procedure in order to obtain better hemostasis. Good results have been obtained by separating both sides of the valve with a silicone sheet (Silastic). Because the author routinely uses silicone (Silastic) splints for septal surgery, the splint must simply be cut into a proper shape and size and then sutured to the septum with nylon 3-0 or 4-0 suture. A contralateral splint is recommended to avoid unnecessary damage to the mucosa.

The incisions are closed with 4-0 catgut or Vicryl, preferably with ophthalmic needles to facilitate the closure. A typical dressing is applied for the rest of the nose, depending on the surgery performed (eg, dressing and cast for rhinoplasty).

The need for hospitalization depends on the type of anesthesia used, the recovery of the patient, and the evaluation of the physician. Because the procedure is primarily performed in combination with septoplasty, the same care for this procedure applies.