Nasal Valve Collapse

Nasal valve collapse is a dynamic or static narrowing of the nasal valve region, causing nasal obstruction. The nasal valve is the narrowest part of the nasal airway, contributing about 50 percent of total airway resistance. It affects about 13 percent of those with nasal obstruction (up to 95 percent of patients with persistent obstruction after septoplasty in some series).

The internal nasal valve is the angle (10 to 15 degrees in Caucasians) between the upper lateral cartilage and the septum. It has a cross sectional area of 55 to 83 mm2 and is bounded by the head of the inferior turbinate.

The external nasal valve is the nasal vestibule, formed by the alar rim, lower lateral cartilages, the columella and the nasal sill.

Narrowing occurs from structural, dynamic or inflammatory causes:

• previous rhinoplasty or septoplasty (the commonest cause, with overresection of the lateral crura or upper lateral cartilage disruption)
• trauma
• a deviated septum
• aging (weakened lateral cartilage)
• congenital narrow nasal pyramid or weak alar cartilages
• facial nerve palsy (loss of tone of nasal dilators, the dilator naris)
• turbinate hypertrophy
• scar or synechiae
• tumours

Dynamic collapse occurs on inspiration, when the sidewall is sucked in following the Bernoulli principle, in the weak or flaccid alar and upper lateral cartilage.

• Nasal obstruction (particularly on inspiration, with exertion), the sensation of nasal blockage not relieved by decongestants, more evident on exercise, sleeping, or in cold air, and usually bilateral, with side dependency in some (worse on the side lying down).
• Difficulty breathing through the nose when in the supine position; snoring, disturbed sleep and mouth breathing.
• Collapse of the nasal sidewall on inspiration at examination: the alar sidewall (external valve) or the area at the level of the lateral cartilage (internal valve) is drawn inward on quiet or deep inspiration (seen with anterior rhinoscopy and the patient breathing deeply).
• Cottle sign (the obstruction improves with lateral traction on the cheek, drawing the soft tissue outward) and the modified Cottle test (using a cotton bud or curette to support the lateral wall at the valve), positive in about 70 to 90 percent; a negative sign makes the diagnosis less likely.
• History of rhinoplasty or nasal trauma, a narrow or pinched nasal tip, scars, a deviated septum.
• Rarely, symptoms of epistaxis, dryness and crusting.

• Clinical diagnosis: history and examination, including observation of the nose on quiet and forced inspiration (inspect from below, with the patient breathing), anterior rhinoscopy (angle and swelling), the modified Cottle manoeuvre, and nasal endoscopy to assess the septum, turbinates and the valve area; the patient reported outcomes (Nasal Obstruction Symptom Evaluation, NOSE scale scores above 30 to 50 are significant).
• Objective tests: acoustic rhinometry (measuring minimum cross sectional area, normally 0.5 to 0.7 cm2 on each side), rhinomanometry (nasal airflow resistance), and peak nasal inspiratory flow; computational fluid dynamics are research tools.
• Imaging is not generally needed; CT of the sinuses to exclude sinus disease in selected patients.
• Evaluate coexisting causes of obstruction: septal deviation, inferior turbinate hypertrophy, adenoid hypertrophy, nasal polyps, allergic rhinitis, and nasal masses; skin prick or specific IgE tests when allergy is suspected.

Management begins with conservative approaches and moves to surgery when conservative measures fail.

• Treat the coexisting conditions:
  • allergic or non-allergic rhinitis: intranasal corticosteroid such as mometasone 50 micrograms 2 sprays per nostril daily or fluticasone furoate 27.5 micrograms 2 sprays daily; second generation antihistamine such as cetirizine 10 mg daily or loratadine 10 mg daily
  • turbinate hypertrophy: medical therapy, or inferior turbinate reduction with radiofrequency, submucous resection or microdebrider
  • deviated septum: septoplasty
• Non-surgical devices: external nasal dilator strips (adhesive strips applied across the nasal bridge at night or during exercise, which elevate the sidewall) and internal nasal dilators and cones (such as Nozovent and Breathe Right), and nasal stents; these may provide temporary relief, which can help confirm the diagnosis and the benefits of surgery. Nasal exercises have no proven benefit.
• Surgical correction (functional rhinoplasty), tailored to the area of collapse:
  • Spreader grafts (cartilage grafts, usually septal or conchal cartilage, placed between the dorsal septum and the upper lateral cartilages to widen the internal valve angle), the commonest procedure, with improvement in about 80 to 90 percent; spreader flaps (autospreader) in the presence of a wide dorsum.
  • Alar batten grafts (a curved cartilage graft placed in a pocket on the lateral crus or the lateral nasal wall, to support the external valve and the alar rim), lateral crural strut grafts, alar rim grafts, and alar suspension sutures; the flaring suture for the upper lateral cartilage.
  • Butterfly grafts, and lateral crural turn in or a "bridging graft", and the Z-plasty to treat scarring or stenosis at the vestibule; and, in the case of collapse in facial palsy, a suspension suture or fascia lata sling.
  • Minimally invasive in office procedures:
    • bioabsorbable implants: a lateral nasal wall implant such as the Latera, an absorbable poly lactide implant placed through a small incision under local anaesthesia, improving symptoms in 70 to 80 percent at 12 months
    • temperature controlled radiofrequency remodelling of the lateral wall (VivAer): low power radiofrequency energy to the nasal valve tissue, with improvement in the NOSE score by about 50 percent, lasting 2 years or more
• Procedures are usually done under local anaesthesia with sedation or general anaesthesia for the open techniques, with postoperative use of an external splint and tape for 5 to 7 days, and saline irrigation; avoid nose blowing for 1 to 2 weeks.
• Follow up: 1 week, 6 weeks and 6 months; patient reported outcomes (NOSE).
• Complications: infection, haematoma, graft displacement, visible deformity, persistent obstruction and recurrence, and revision rates of about 5 to 15 percent.
• Prognosis: significant symptomatic improvement in 80 to 90 percent following surgery.