Rhinoplasty, Postrhinoplasty Nasal ObstructionAuthor: Thomas Romo III, MD, FACS
Coauthor(s): James M Pearson, MD,Paul Presti, MD, Haresh Yalamanchili, MD
External nasal valve collapse is due to collapse of the nostril margin at the opening of the nose (alar collapse) with moderate-to-deep inspiration through the nose. This phenomenon is usually observed in patients with narrow slitlike nostrils, a projecting nasal tip, and thin alar sidewalls.
This article focuses on only postrhinoplasty-related external valvular collapse. Constantian and Clardy reviewed 160 patients treated for external nasal valve incompetence. Surgical reconstruction was performed with septal cartilage or with composite conchal cartilage-skin grafts. Using rhinomanometry, Constantian and Clardy found that correction of external valvular incompetence increased total nasal airflow during quiet ventilation by more than 2-fold over preoperative values. Thus, the external nasal valve may play a crucial role as the cause of nasal airway obstruction in some patients.
Kern and Wang divide the etiologies of nasal valve dysfunction into mucocutaneous and skeletal/structural disorders. The mucocutaneous component refers to the mucosal swelling (secondary to allergic, vasomotor, or infectious rhinitis) that can significantly decrease the cross-sectional area of the nasal valve and thus reduce nasal airway patency. The skeletal/structural component refers to any abnormalities in the structures that contribute to the nasal valve area. This includes the nasal septum, upper and lower lateral cartilage, fibroareolar lateral tissue, piriform aperture, head of the inferior turbinate, and floor of the nose.
- Static deformity
- Tip ptosis
- Cicatricial stenosis
- Dynamic deformity
- Collapsed lower lateral cartilage secondary to excessive excision
- Nasal muscle deficiency
External nasal valve collapse can be diagnosed based on observation of the nostril margin to determine if the alae collapse with moderate-to-deep nasal inspiration. One nostril can be occluded to facilitate this maneuver. Next, a modified Cottle maneuver can be performed with a cerumen curette placed intranasally to support the internal or external nasal valve to determine specifically if improvement in nasal airflow results. Minimal distraction of a collapsed internal valve or stabilization of the external valve during inspiration can dramatically increase airflow on the affected side and confirm the diagnosis. The patient can usually appreciate an immediate improvement in airflow when a flaccid or collapsible valve is supported during inspiration.
More recently, Hilberg et al introduced acoustic rhinometry as a noninvasive and reliable objective method for determining the cross-sectional area of the nasal cavity. Acoustic rhinomanometry is based on the analysis of sound waves reflected from the nasal cavities. Also, analysis can be done before and after topical decongestants are applied, allowing discrimination of mucocutaneous versus structural blockage. Standards for age, race, ethnicity and sex have been recently published.
Co-Authors:Craig Cupp, MD, Peter A Weisskopf, MD
EtiologyNasal valve collapse or obstruction has many potential etiologies. Some of the more frequent causes include the following:
- Deficiency of the lateral crus of the lower lateral cartilage secondary to previous surgery with overaggressive resection of cartilage
- Congenital deficiency of cartilage or cephalad rotation of lower lateral cartilage
- Trauma that leads to loss of tissue
- Full-thickness surgical resection of the alar with insufficient reconstruction
- Aggressive narrowing of the nasal tip during rhinoplasty (see the eMedicine article Rhinoplasty, Postrhinoplasty Nasal Obstruction)
- Caudal septal deflection that narrows the valve and causes increased velocity of airflow with a larger transalar pressure differential
- Facial nerve palsy that leads to loss of nasal dilators
- Sequelae of aging that leads to loss of nasal alar stiffness
- Overprojection of nasal tip that leads to slitlike nares with increased velocity of airflow
Any process, condition, or trauma that weakens the lower lateral cartilage or alar walls or that narrows the entrance to the nose can lead to collapse of the external valve. Upon inspiration, the increase in transmural pressure across the nasal ala leads to collapse of the external valve.Indications
Any airway compromise caused by obstruction of the external nasal valve is an indication of external valve stenosis. The most absolute indication is the symptomatic collapse of the alar upon inspiration.