Management of Nasal Valve Dysfunction
Article information
Abstract
Nasal valve dysfunction can substantially impact nasal airflow and overall quality of life. This review provides a comprehensive examination of nasal valve dysfunction, including its mechanisms, classification, and surgical management. The nasal valves include internal and external valves, each of which plays a crucial role in regulating nasal airflow. Subclassification of the external nasal valve into alar and rim valves helps specify the site of obstruction when present and informs the choice of surgical intervention. Dynamic nasal valve obstruction, often characterized by inspiratory collapse of the nasal valve, must be distinguished from static obstruction, which refers to nasal valve stenosis. Accurate identification of the location and mechanism of nasal valve dysfunction is essential for effective management. Various surgical procedures target specific components of the nasal valve and can produce favorable functional outcomes. The selection of surgical procedures, whether individually or in combination, should be tailored to the characteristics of nasal valve dysfunction and the external nasal characteristics of the patient. Strict adherence to proper surgical techniques is imperative for achieving optimal treatment outcomes.
INTRODUCTION
Functional rhinoplasty comprises a range of surgical procedures designed to correct nasal deformities that lead to respiratory difficulties, with the goal of improving the appearance of the nose as well as respiratory function [1]. As functional rhinoplasty involves interventions targeting nasal valve problems, individuals experiencing nasal obstruction stemming from nasal valve dysfunction frequently present as candidates [2].
First described by Mink in 1903, the nasal valve—a narrow triangular space formed by the upper lateral cartilage, the head of the inferior turbinate, and the septum—has been recognized as a key contributor to nasal obstruction [3]. A critical component responsible for regulating airflow through the nose, this valve is situated at the narrowest segment of the nasal cavity. It contributes to the point of greatest airway resistance and serves as a key determinant of nasal physiology, impacting nasal obstruction and overall quality of life [4]. The importance of the nasal valve can be understood through the principles of fluid dynamics, particularly the Poiseuille law, which establishes the relationships between fluid flow, pressure, and radius. According to this law, fluid flow is directly proportional to the pressure and radius, while it is inversely proportional to the fluid viscosity and length [5]. Another concept that explains the function of the nasal valve is the Bernoulli principle, which states that as air speed increases, pressure decreases. This suggests that when air passes quickly through the nasal valve, it causes a decrease in pressure, which can exacerbate nasal obstruction [6]. Thus, the nasal valve plays a key role in nasal physiology and is closely associated with nasal obstruction, which can profoundly affect an individual’s quality of life.
The nasal valve is typically divided into the internal nasal valve and the external nasal valve. The internal nasal valve is positioned approximately 1.5 cm from the nostril and is defined by the nasal septum on the medial side, the caudal edge of the upper lateral cartilage on the lateral side, and the inferior turbinate on the inferior side [7-9]. The angle of the internal nasal valve usually ranges between 10° and 20°, reflecting the valve’s anatomical characteristics [10]. In contrast, the external nasal valve is commonly described as the nasal entrance. It is framed by the columella and the medial footplate on the medial side, the alar rim on the lateral side, and the posterior aspect of the internal nasal valve [11].
Racial variations in the nasal valve anatomy must be considered [12]. Previous research has demonstrated notable differences in nasal valve angle between Asians and Caucasians: in one study, the angle of the internal nasal valve was approximately 22.0° in Asians compared to 15.5° in Caucasians [10]. Additionally, Asians tend to have thicker skin, which can help prevent the collapse of the lateral nasal wall [13,14]. Consequently, Asians may experience fewer nasal valve issues than Caucasians. These anatomical differences meaningfully influence the choice of surgical procedures to address nasal valve dysfunction.
Globally, a variety of techniques are utilized to treat nasal valve dysfunction. The selection of appropriate surgical intervention hinges on identifying the underlying causes of nasal obstruction, differentiating between static and dynamic obstructions, and accurately pinpointing the anatomical location of the dysfunction. Additionally, surgical interventions can impact the patient’s aesthetic appearance. Therefore, to choose the most suitable procedure for the patient, it is critical to evaluate any concurrent nasal deformities and to consider the potential aesthetic changes associated with each option. This review offers a comprehensive overview of the management of nasal valve dysfunction, with emphasis on selection among common surgical techniques.
We have utilized a variety of photographs to enhance understanding, and consent for their use has been obtained.
MECHANISM AND EVALUATION OF NASAL VALVE DYSFUNCTION
In patients with nasal valve dysfunction, it is important not only to identify the area of dysfunction but also to understand the mechanism of obstruction. Dynamic obstruction is typically characterized by nasal valve collapse during inspiration, resulting from the collapse of more flexible airway segments due to a pressure differential between the external and internal nasal air [15]. The primary goal in treating dynamic obstruction is to reinforce the flexible or weakened airway segment. In contrast, static obstruction refers to nasal valve stenosis that reduces patency, potentially narrowing the nasal airway and restricting airflow (Fig. 1). Treatment for these patients is focused on opening and widening the narrowed airway. Therefore, distinguishing dynamic from static obstructions is essential for treatment planning. Static and dynamic obstructions can often coexist in patients, which presents additional complexities for corrective intervention.
Dynamic and static obstruction of the external nasal valve. (A, B) Dynamic obstruction during inhalation. (C) Static obstruction of the left nasal valve.
To properly manage nasal valve dysfunction, clinicians must determine the epicenter of collapse and identify any concomitant nasal deformities. This can be achieved through a comprehensive nasal airway examination, including anterior rhinoscopy, endoscopy, computed tomography (CT), and specific nasal airway maneuvers. Anterior rhinoscopy and endoscopy enable direct visualization of the nasal valve region, aiding in the detection of collapse and deformity. CT imaging offers additional insights into the structure of the nasal airway posterior to the stenotic nasal passage. The Cottle maneuver involves gently pulling the cheek adjacent to the nose in the lateral direction. A positive result, characterized by improved airflow, suggests nasal valve dysfunction [16]. However, caution is necessary to avoid overly lateralizing the cheek, as this could produce a false-positive result. This maneuver generally improves the function of both internal and external nasal valves. Consequently, while a positive Cottle test signals a nasal valve issue, it does not precisely localize the epicenter of the collapse. In the modified Cottle maneuver, a small curette is inserted into the nasal passage to provide gentle support at various points within the nasal valve, aiming to achieve a subjective improvement in breathing and to pinpoint the site of collapse or stenosis (Fig. 2). These maneuvers are instrumental for clinicians in diagnosing and planning appropriate interventions for patients with nasal airway issues. In addition to these techniques, subjective assessments such as the Nasal Obstruction Symptom Evaluation and visual analog scale, along with objective measurements like peak inspiratory flow rate and acoustic rhinometry, can offer valuable insights into nasal obstruction [17-21].
Diagnostic maneuvers for nasal valve dysfunction. (A) Cottle maneuver. (B) Modified Cottle test.
CLASSIFICATION OF NASAL VALVE DYSFUNCTION
The nasal valve is commonly divided into the internal and external valves. The internal nasal valve, which is the narrowest part of the nose, exists at the junction of the upper and lower lateral cartilages, a region known as the scroll area [22]. This area is composed of vertical and longitudinal ligaments, and the cartilage is tightly integrated with the overlying skin and the superficial musculoaponeurotic system [23]. The scroll area, along with the attachments of the medial crus of the lower lateral cartilage to the caudal septum and upper lateral cartilage, is crucial in providing structural support to the nasal tip (Fig. 3) [24].
Anatomical landmarks of the internal nasal valve. (A) Illustration of the right internal nasal valve. (B) Endoscopic view of the right internal nasal valve. (C) Endoscopic view of the denuded internal nasal valve following mucosa removal. UL, upper lateral; T, inferior turbinate; S, septum; ULC, upper lateral cartilage.
Although the definitions and anatomical borders of the internal nasal valve are well established, confusion persists regarding the external nasal valve area. This area has been described either as the region beneath the lower lateral cartilage or, at times, as the area closer to the nostrils [11,25,26]. In this review, to provide a clearer anatomical delineation of the external nasal valve and related surgical procedures, we further classified this valve into the alar and rim valves (Fig. 4). The alar valve, which is the proximal (inner) region of the external nasal valve, is typically associated with the alar groove. It is bordered medially by the caudal septum and laterally by the alar cartilage and soft tissues. Consequently, alar valve dysfunction can be further categorized into issues related to the caudal septum, alar cartilage, or lateral soft tissue. Septoplasty is required to correct alar valve problems stemming from a deviated caudal septum [27-29]. If alar valve dysfunction is due to recurving alar cartilage (Fig. 5), surgical techniques aimed at the alar cartilage, such as lateral crural strut graft or lateral crural flip-flop, may be employed. When the primary cause of alar valve dysfunction is the lateral soft tissue, an alar batten graft spanning the soft tissue of the lateral wall can be utilized. In contrast, the rim valve is the distal (outer) region of the external nasal valve. This valve consists of the columella, medial footplates of the lower lateral cartilage, alar rim, and nostril sill. For patients with rim valve dysfunction, surgical interventions such as columelloplasty, alar rim graft, and alar rim vestibuloplasty can be applied, depending on the epicenter of collapse.
Schematic diagrams of the nasal valve. 1, internal nasal valve; 2, alar valve; 3, rim valve.
Recurvature of the alar cartilage. The recurvature in the alar cartilage may induce static obstruction in the nasal valve impeding airflow. (A) Frontal view. (B) Basal view.
MANAGEMENT OF NASAL VALVE DYSFUNCTION ACCORDING TO THE EPICENTER OF DYSFUNCTION
Understanding the distinct regions of the nasal valve is crucial for the evaluation and selection of appropriate surgical techniques. Table 1 presents the common surgical procedures employed to manage nasal valve dysfunction, categorized based on the epicenter of dysfunction.
Common surgical procedures based on the classification of nasal valve dysfunction
SURGICAL PROCEDURES FOR INTERNAL NASAL VALVE DYSFUNCTION
Spreader graft
The spreader graft is a standard surgical technique for middle vault reconstruction in cases of internal nasal valve dysfunction [30]. Since its introduction in 1984, the procedure has been effective in restoring the internal nasal valve, improving the aesthetic lines of the nasal dorsum, and providing support to correct a deviated dorsal septum [31]. It can be performed using either an endonasal or an open rhinoplasty approach. Typically, cartilage harvested from the septum is shaped into a rectangular graft and inserted into a submucoperichondrial pocket between the upper lateral cartilage and the dorsal septum (Fig. 6). Alloplastic alternatives have also been reported [32,33]. The spreader graft is frequently combined with other techniques to optimize outcomes. One study reported significant improvements in both objective and subjective measures of internal nasal valve function, under static and dynamic conditions, following the use of a spreader graft [34]. Another study indicated that nasal airway resistance decreased in 52.9% of patients who underwent the spreader graft procedure [35].
Spreader graft. A cartilage graft is inserted into a pocket between the upper lateral cartilage and the dorsal septum to restore the internal nasal valve. (A) Before and (B) after insertion of bilateral spreader grafts.
The spreader flap technique resembles the spreader graft and has yielded comparable outcomes [36]. This technique involves folding the upper lateral cartilage inward to function as a “graft,” occupying the same anatomical space as a conventional spreader graft [15,37]. This modified technique offers similar advantages, including the reduction of an overly wide nasal dorsum, particularly when the upper lateral cartilage is thinner than the spreader graft [38]. A clinical trial that compared spreader grafts with spreader flaps found no significant differences between the techniques in terms of nasal obstruction, patient satisfaction with cosmetic results, or changes in the minimal cross-sectional area of the nose [39].
Flaring suture
The flaring suture technique of the upper lateral cartilage can be employed to correct internal nasal valve dysfunction. This method involves placing horizontal mattress sutures on both upper lateral cartilages, using the dorsal septum as a fulcrum to increase the angle and cross-sectional area of the internal nasal valve (Fig. 7). To prevent the cheese-cutting effect, an onlay graft is often applied to the dorsum. One benefit of the flaring suture technique is its simplicity, as it does not necessitate the use of additional grafts. However, this technique may result in the widening of the nasal dorsum, potentially altering the appearance of the nose [40]. A comparative study of patients who underwent either spreader graft or flaring suture procedures showed similar improvements in nasal resistance in both groups [35]. The flaring suture technique is typically performed alongside other surgical interventions, such as spreader grafts, which may improve surgical outcomes [41].
Flaring suture with an onlay graft. Horizontal mattress sutures are applied to both upper lateral cartilages over an onlay graft positioned above the dorsum.
Butterfly graft
The butterfly graft, first introduced by Hage in 1964, provides simultaneous improvement of the internal nasal valve and the alar valve [42]. Conchal cartilage is often chosen for butterfly grafts due to its elasticity and naturally curved surfaces [43]. The harvested conchal cartilage is shaped into a butterfly-like configuration and positioned on the superficial aspect of the upper lateral cartilage and the cephalic edge of the lower lateral cartilage (Fig. 8) [44]. This technique effectively increases the angle of the internal nasal valve and reinforces the upper lateral cartilage, producing an overall lift that includes the caudal margin of the upper lateral cartilage. The butterfly graft is particularly advantageous when correcting associated deformities such as supratip depression or saddle nose deformity [15]. The literature highlights positive outcomes of the butterfly graft in both functional improvement of the internal nasal valve and cosmetic changes. Clark and Cook [44] reported high rates of improvement in nasal airway function (97%) and cosmetic appearance (86%) among patients who received the butterfly graft. Furthermore, a long-term study of 500 patients over a 15-year period showed that 87% experienced improvement in nasal obstruction and 53% saw cosmetic enhancement following the butterfly graft procedure [45].
Butterfly graft. A cartilage graft is positioned at the junction of the upper and lower lateral cartilages, improving the function of both the internal nasal valve and the alar valve. (A) Before and (B) after placement of the butterfly graft.
SURGICAL PROCEDURES FOR ALAR VALVE DYSFUNCTION
Alar batten graft
The alar batten graft provides added support for the alar valve, particularly the soft tissue in its lateral wall. A cartilage graft of adequate size and strength is positioned primarily on the soft tissue lateral wall of the alar valve. As shown in Fig. 9, the term “non-anatomical location” is used to emphasize that the graft is not placed above the lateral crus of the alar cartilage but rather within the soft tissue lateral wall, extending into the pyriform aperture. Care must be taken to bevel the edges of the graft to avoid excessive bulging in the lateral walls. The primary objective of the alar batten graft is to address alar valve collapse; however, it can also correct internal nasal valve collapse by positioning the caudal end of the cartilage graft onto the cephalic portion of the lateral crus [46]. Sufyan et al. [47] demonstrated that nasal obstruction significantly improved and the use of nasal sprays decreased in patients who received an alar batten graft. Similarly, a study of 67 patients who underwent this procedure reported that 91% experienced reduced nasal congestion and 88% reported better quality of life following the procedure [48].
Design of the alar batten graft. A cartilage graft is positioned non-anatomically, primarily on the lateral wall soft tissue.
Lateral crural flip-flop method
The lateral crural flip-flop technique is designed to correct concavity, thus restoring proper support to the alar valve. This approach is applicable when alar valve collapse is due to recurvature, which is the paradoxical concavity of the lateral crura. To address the collapse, the deformed segment of the lateral crura is removed while preserving the vestibular mucosa. The excised cartilage is then inverted so that the concavity is oriented inward. This cartilage is subsequently sutured to the remaining lower lateral cartilage to ensure stable fixation (Fig. 10). The lateral crural flip-flop technique has the benefit of eliminating the need for additional cartilage harvesting. However, the cartilage to be flipped must possess adequate structural integrity to provide support. Should this not be the case, alternative strategies such as lateral crural strut grafts or onlay grafts may be employed to reinforce the lateral cartilages [49].
Lateral crural flip-flop. (A) Deformed lateral crura. (B) Excision of the deformed segment of cartilage. (C) Flipping of the excised cartilage. (D) Suturing of the excised cartilage to the lower lateral cartilage.
Lateral crural strut graft
The lateral crural strut graft is an effective procedure for addressing alar valve collapse resulting from lateral crural deformity. The procedure involves creating a pocket between the vestibular mucosa and the lateral crura, into which an autologous graft is inserted. The graft is then secured to the lateral crura with sutures to provide reinforcement and lateralization, supporting the alar valve (Fig. 11). During the procedure, the surgeon must ensure that the graft remains positioned below the native cartilage to avoid external visibility [46]. If the lateral crura are not suitable for reconstruction, they may be resected and replaced with grafts from the septal, conchal, and/or rib cartilages. Care must be taken to bevel the edges and to position the lateral end within a pocket to ensure symmetry and proper angulation of the lateral crus.
Lateral crural strut graft. (A) Curled lateral crura. (B) Creation of a pocket between the vestibular mucosa and the lateral crura. (C) Insertion of the cartilage graft.
SURGICAL PROCEDURES FOR RIM VALVE DYSFUNCTION
Columelloplasty
A wide columella may contribute to nasal obstruction by narrowing the rim valve. In such cases, columelloplasty is a useful procedure. A columellar incision is made along the caudal border of the medial crus, followed by resection of the soft tissue. When a wide, flared, or bulky medial footplate is present, judicious resection and approximation may be adjunctively performed (Fig. 12). A study involving 35 patients who underwent columelloplasty revealed favorable cosmetic outcomes, improved breathing, and an absence of complications. The study noted marginally superior outcomes when both the soft tissues and the medial footplate were removed, compared to the removal of soft tissue alone [50].
Columelloplasty. (A) Wide columellar base. (B) Medial footplate and soft tissue resection. (C) After columelloplasty.
Alar rim graft
The alar rim graft is an effective procedure for addressing rim valve collapse by reinforcing the alar rim and improving the aesthetic curve between the nasal tip and the nasal ala [51]. Cartilage grafts are carefully shaped into a thin, elongated form and placed along the inner aspect of the alar margin in the subcutaneous pocket (Fig. 13). While the alar rim graft is typically performed through a marginal incision, the alar-facial stab technique can also be used [52]. A study examining the outcomes of alar rim grafts in 31 patients found that the grafts supported the external natural valve and improved nasal base harmony [53]. Another study on alar rim grafts reported favorable results in the improvement of alar retraction [54].
Alar rim graft. (A) Creation of subcutaneous pockets on the inner aspect of the alar cartilage. (B) Insertion of the cartilage graft. (C) Suture placement following alar rim graft.
Alar rim vestibuloplasty
Alar rim vestibuloplasty is performed for stenosis of the rim valve. The operative technique is tailored to the specific deformity and typically involves the concurrent use of skin and cartilage grafts [55]. Stenosis of the rim valve may result from congenital factors, infections, burn injuries, nasogastric tube placement, and iatrogenic causes [55,56]. Alar rim vestibuloplasty involves a series of steps: scar lysis, rim reinforcement using a cartilage graft, skin grafting to repair defects, and adjunctive placement of a silastic sheet for graft support (Fig. 14). In patients with rim valve stenosis, alar rim vestibuloplasty is a reasonable option for improving nasal airflow and yields favorable functional and aesthetic outcomes with minimal complications [57].
Alar rim vestibuloplasty. (A) Left rim valve stenosis. (B) Scar lysis. (C) Cartilage graft for rim support. (D) Harvesting of a skin graft from the retroauricular area. (E) After skin grafting. (F) Silastic sheet bolstering. (G) After alar rim vestibuloplasty.
Nasal valve surgery and its impact on the external nasal appearance
Nasal valve surgery can impact the external appearance of the nose. However, for most patients, nasal aesthetics are improved following the procedure. Preoperatively, it is crucial to inform patients of potential changes to the external appearance of the nose. When addressing internal nasal valve dysfunction, the use of a spreader graft may cause a slight widening of the middle dorsum. The alar batten graft necessitates careful beveling of the cartilage to minimize the risk of sidewall bulging. As previously mentioned, the butterfly graft may be particularly suitable for patients with mild supratip depression, as it can introduce supratip fullness or pollybeak deformity in patients with an otherwise normal appearance. The lateral crural flip-flop technique can improve the aesthetics of the lower third of the nose by smoothing prominent alar grooves. Additionally, an alar rim graft can correct mild retraction by inducing a caudal shift of the alar rim. In summary, it is important to assess the patient’s preexisting nasal aesthetics when planning nasal valve surgery and to carefully choose the most appropriate surgical approach.
CONCLUSION
The nasal valve plays a key role in maintaining the nasal passage, impacting nasal breathing and overall quality of life. Nasal valve dysfunction should be suspected in patients who report nasal obstruction. Our review focuses on common procedures employed to treat nasal valve issues. Furthermore, we explore the mechanisms underlying nasal valve dysfunction and the classification of the nasal valve. A thorough knowledge of the nasal anatomy and underlying mechanisms is crucial when selecting surgical interventions. Furthermore, the epicenter of nasal valve dysfunction must be identified, and any accompanying nasal deformities should be assessed. This comprehensive understanding equips surgeons to select the appropriate procedure for each patient, promoting symptom relief and aesthetic satisfaction.
HIGHLIGHTS
▪ Functional rhinoplasty improves both appearance and breathing, specifically addressing issues related to nasal valve dysfunction.
▪ The nasal valve plays a key role in maintaining the nasal passage, which in turn influences breathing and overall quality of life.
▪ Identifying the epicenter and mechanism of nasal valve dysfunction is crucial for appropriate surgical planning.
▪ A thorough understanding of the nasal anatomy enables surgeons to choose the best procedure for each patient, resulting in improved symptom relief and heightened aesthetic satisfaction.
Notes
No potential conflict of interest relevant to this article was reported.
AUTHOR CONTRIBUTIONS
Conceptualization: TBW. Data curation: all authors. Formal analysis: all authors. Investigation: DYL. Methodology: all authors. Project administration: TBW. Resources: TBW. Supervision: TBW. Validation: TBW. Visualization: DYL. Writing–original draft: DYL. Writing–review & editing: all authors.