External Valve Stenosis Rhinoplasty Treatment & Management

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.

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 ^[5]

• 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) ^[6]

• Alar expansion stitches with or without alar reinforcement

• Z-plasty to release internal valve scarring

• Use of postoperative stents

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.

Use the Toriumi method of alar batten graft. ^[7] 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. ^[8]

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. ^[9]

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

Use standard rhinoplasty postoperative care.

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

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

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.