Saturday, January 15, 2011

Surgical options for treating "Internal" Nasal Valve Obstruction

There are many ways to approach surgical correction for nasal obstruction and the aesthetics of the nose. I think of it as a sort of rubiks cube, where you are presented with a unique set of  intermixed colors (representing the patients circumstances they present) which need to be solved by using algorithms and optimally researched proven solutions. Nose Revision Surgeons have their preferences and of course grafts and procedures that are in practice today were developed and popularized by well known Nose Revision Specialist.

Dr. Jack Sheen in 1984 first described spreader grafts as a method of reconstructing the internal nasal valve and/or recontouring the aesthetic appearance of the nasal dorsum in cases of primary and secondary rhinoplasty. Dr. Sheen championed the Closed approach. Dr. Jack Gunter who trained under Dr. Anderson later developed  the lateral crura strut graft and was and still is a devout advocate for the Open approach in secondary rhinoplasty. Dr. Rollin Daniels is credited for developing the technique of diced cartilage wrapped in deep temporal fascia (DC-F). The treatment for Nasal valve collapse largely depends on where exactly the collapse is occurring (can be and usually involves more then one specific area). A competent nose surgeon will know how to properly diagnose the problem and which grafts and/or surgical methods are to be employed to correct not only the breathing issues but also improve the aesthetic results where required. Sometimes more then one procedure may be required, even by different Surgeons, depending on all the issue's presented. The goal is to have a safe long term lasting positive result. Some surgeons prefer to only use your own cartilage, some will recommend irradiated cadaver cartilage, and some like synthetic material or combination of the aforementioned. Furthermore nose revision surgeons who only utilize autologous (from your own body) cartilage grafts have their harvesting site preferences which can be from the septum (if you have enough left and enough can safely remain for the L strut), the ears (auricular grafts), or the ribs (costal cartilage). Some like using bone grafts from different sources and harvest sites for dorsal augmentation. There is no one simple universal answer for all, and you the potential patient will be offered different opinions based on the Nose Revision Specialists training, abilities, experiences and beliefs. This is why it's important for those considering nose surgery to do your due diligence with research. This blogsite should be a big help to most, at least that is my desired intention. I have had 6 surgical nose procedures ( 2 major unsuccessful revisions) and can speak from experience. My main objective for this site is to inform you well enough to make an informed decision so you will avoid the mistakes I have made and therefore hopefully avoid the severe consequences that I ended up with, mostly as a result of my last surgery. I will now focus on some studies that were done on the Surgical Treatments for Internal Nasal Valve Obstruction. If you haven't already read my past posts you may want to see my postings on: Minor Surgical Procedures for treating Nasal Valve Collapse (Jan.10, 2011) , The mystery of all the different types of nose grafts (Oct.18, 2010) and Non-Surgical, Non Medical treatment for collapsed nostrils ( Nasal Valve Collapse ) Oct.31, 2010.
Internal nasal valve obstruction 
Rhinoplasty, Postrhinoplasty Nasal Obstruction: Treatment  
Author: Thomas Romo III, MD, FACS Coauthor(s): James M Pearson, MD, Paul Presti, MD, Haresh Yalamanchili, MD 
Static deformity includes: (1) inferomedial displacement of the upper lateral cartilage secondary to hump removal, (2) narrowing of the piriform aperture secondary to osteotomy, (3) scarring at the intercartilaginous junction, (4) turbinate hypertrophy, and (5) deviated nasal septum.
  • Inferomedial displacement of the upper lateral cartilage secondary to hump removal can be treated with spreader grafts, flaring sutures, butterfly grafts, or a combination thereof.
    • Methods of correcting internal nasal valve collapse are focused on the reposition of the upper lateral cartilage or the addition of structural grafts to support the lateral wall of the nose. Spreader grafts are often used for the correction of internal nasal valve collapse. These grafts reposition the upper lateral cartilage in a lateralized position and add width to the middle nasal vault. Numerous other structural grafts have been described as providing support to the lateral nasal wall. Most support the weakened upper lateral cartilage and lateralize the caudal margin of the upper lateral cartilage at the nasal valve. The techniques of repair differ among different authors and can be achieved via either the open or endonasal approach.
    • Spreader graft placement is the workhorse repair of the narrowed internal nasal valve.
      • These grafts are designed to lateralize the upper lateral cartilage by the width of the graft, thereby increasing the cross-sectional area of the nasal valve.
      • Septal cartilage can be harvested and shaped into spreader grafts. If the septum is unavailable, conchal cartilage or Medpor may be used. {For some reason the authors don't mention costal cartilage (rib) grafts which in the hands of a competent surgeon is a excellent choice}. I personally do not like the idea of Medpor which is a synthetic material.
      • The grafts are placed in a submucosal pocket between the septum and the upper lateral cartilage. These grafts are typically 1-2 mm thick and extend the entire length of the upper lateral cartilage from the cephalic border beneath the nasal bones to the caudal margin. They are anchored in place with one or two 5-0 polydioxanone horizontal mattress sutures that span from one upper lateral cartilage through the ipsilateral spreader graft, the septum, the contralateral spreader graft, the contralateral upper lateral cartilage, and then back again.
      • In a series of 29 patients with pure internal valvular incompetence treated with spreader grafts alone, Constantian and Clardy reported a 2-fold increase in postoperative airflow.
      • Andre et al reported significant improvement in nasal airway patency with autologous endonasal spreader grafts. A total of 89 patients, at an average follow-up of 12.2 months, were reviewed for symptomatic improvement of their nasal obstruction after placement of spreader grafts. Most (88%) had favorable results. Their technique involved placement of the graft within a tight-fitting subperichondrial pocket between the nasal septum and the upper lateral cartilages. Fixation of the grafts was provided via suturing, tissue glue, or simply the tension of a tight pocket.
    • Flaring sutures are a simple way to improve the cross-sectional area of the internal nasal valve by directly changing the internal valve angle.
      • Although the spreader graft moves the dorsal border of the upper lateral cartilage in a lateral direction, the angle of the internal valve is minimally affected.
      • A 4-0 polydioxanone horizontal mattress stitch extends from the caudal/lateral area of the upper lateral cartilage and across the dorsum of the nose and is anchored to the contralateral upper lateral cartilage. As the suture is tightened, both upper lateral cartilages are pulled laterally, with the dorsum serving as a fulcrum. This flaring action directly affects the internal valve angle, and its effects can be witnessed as the suture is tightened.
      • When used in conjunction with spreader grafts, the focal point of the flaring suture is moved laterally to a more optimal position. The addition of a flaring suture to conventional spreader graft placement is simple and quick and dependably improves treatment of the dysfunctional internal nasal valve. Both flaring sutures and spreader grafts serve to move the upper lateral cartilage to a lateral and externally rotated position.
    • An alternative to the flaring suture is the placement of a 3-0 Prolene suspension suture.
      • Rizvi and Gauthier published their experience with this technique in 40 patients with internal nasal valve collapse. Over a follow-up period of 2-3 years, all of the patients reported improvement of their nasal obstruction.
    • Butterfly grafts take advantage of the intrinsic curvature of conchal cartilage to improve the nasal airway.
      • The grafts may be placed endonasally or with an open approach. They are placed at the scroll area between the upper lateral cartilage and lower lateral cartilage in an attempt to widen the valve angle. The caudal border of the graft may be placed deep to the cephalic border of the lateral crura to help camouflage the graft.
      • Grafts are anchored in place with 5-0 polydioxanone to prevent migration.
      • Butterfly grafts, more than other valve-plasty maneuvers, can lead to postoperative cosmetic changes, with marked fullness along the supratip area.
  • Narrowing of the piriform aperture secondary to osteotomy can be treated with revision osteotomy with outfracture of the nasal bones to widen the valve angle.
    • Occasionally, severe valve narrowing occurs after rhinoplasty as a result of lateral osteotomy with infracture, which may not improve with any of the aforementioned procedures. These patients can be treated with revision osteotomy with outfracture of the nasal bones to widen the valve angle. The revision lateral osteotomy is made in the same line as the original osteotomy in order to mobilize the bone that was displaced too far medially. The frontal process of the maxilla and the nasal bones are then lateralized (outfractured).
    • Outfracture can adversely affect cosmesis by widening the nasal dorsum. Therefore, attempt more conservative approaches initially; however, revision osteotomy with outfracture may still be an option to correct significant nasal breathing dysfunction due to valve narrowing after rhinoplasty.
    • Pontell et al compared the cross-sectional area between infracture with the outfracture position and noted an increase of more than 200% with outfracture.14 A change of 1° in valve angle increased the area by approximately 4 mm2.
  • Scarring at the intercartilaginous junction can be treated with scar excision.
    • Scarring at the valve apex or valve angle can be corrected with scar excision followed by reconstruction with the use of a full-thickness skin graft or local mucosal flap. Finding enough adjacent unscarred lining, skin, or mucous membrane to effectively correct a contracture blunting the apex of the valve is usually difficult.
    • Full-thickness skin grafts and composite grafts are reasonable for the reconstruction of small defects. Full-thickness skin grafts are taken from the upper eyelid or postauricular area. Carefully fit these grafts into the defect using 5-0 or 6-0 absorbable sutures.
    • Larger scars or webs require Z-plasty, V- to Y-plasty, or mucosal advancement flaps from the septum or labial mucosa.
  • Deviated nasal septum can be treated with septoplasty.
    • Septal abnormalities probably represent the most frequent cause of nasal valve obstruction. The septal cartilage, bone, or both may be thickened, be deflected off the nasal spine, be twisted, be scarred, have spurs, or be affected by a combination of these.
    • A septal abnormality that occurs at the nasal valve area can produce nasal airflow obstruction, which can be corrected with the performance of a septoplasty.
Dynamic deformity includes dynamic collapse of the upper lateral cartilage.The dynamic collapse of the internal nasal valve during inspiration secondary to an unsupported upper lateral cartilage can be corrected with the placement of a butterfly graft or a batten graft at the scroll area (caudal aspect of the upper lateral cartilage) to give support to this critical area. Alar batten grafts can be used to correct internal or external nasal valve collapse.
  • For internal nasal valve collapse, place the alar batten grafts in a precise pocket at the point of maximal lateral wall collapse. This point is usually near the caudal margin of the upper lateral cartilage and cephalic margin of the lateral crura of the lower lateral cartilage, where previous volume reduction may have been performed.
  • Spreader grafts can be used in combination with alar batten grafts when excessive narrowing of the middle nasal vault is present.
  • The use of alar batten grafts is discussed in further detail in the section regarding the correction of dynamic external nasal valve collapse after rhinoplasty secondary due to overresection of lower lateral cartilage
Rhinoplasty, Internal Valve Stenosis: Treatment   
Author: David Núñez-Fernández, MD, PhD Coauthor(s): Jan Vokurka, MD, PhD,Gloria Fernández-Muñoz, MD

Surgical Therapy

Several techniques are 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.

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.

Conchal cartilage butterfly graft
This graft has been found useful by Friedman and Cook in primary rhinoplasty. 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.

Intraoperative Details
Because the valve is formed by several structures, the surgery is directed toward realigning the obstructing parts. The authors discuss treatment of the Septum, Nasal roof, Upper and Lower cartilage, Inferior Turbinates, Pyriform Aperture, Synechia or scarring of the mucosa of the valve.

Note: I personally do not agree with their recommendation of removing the anterior "head" portion of the inferior turbinates up to 2cm. There are dangers of ending up with Empty Nose Syndrome especially if you previously had a turbinate procedure.  So keep in mind some of the mentioned  options are safer then others.

Turbinate Surgery
 The turbinates provide much of the good, disease-fighting stuff in the nasal cavity and sinuses: mucus, cilia, and enzymes (such as lysozyme). If the inferior and middle turbinates are removed, the source of warming and moistening the air is gone, and then the dryness, frequent infections, crusting and local pain can result. With the absence of the mucus, cilia and enzymes, frequent infections of the sinuses can occur. This may lead to the need for further sinus surgery. 

Two methods that are safe and don't cause major harm to the cila and mucosa of the turbinates in your nose, are microdebreider assisted turbinate surgery, and somnoplasty.  They are safer then cauterizing the turbinates or using laser heated techniques.  Cutting out the turbinates could lead to serious consequences such as empty nose syndrome.  Sometimes it may be necessary to remove small portion of the turbinate bone- submocosus turbinate reduction, but preserving the mucosa is still critical for a healthy nose. 

Procedures that may result in Empty Nose Syndrome when done improperly include wide chemical or electric cautery, laser cautery, and of course, surgical removal. 
Dr. Murray Grossan 
Dr. Steven Houser  
Sinus, Polyps and other types of obstructions 

Nasal Valve Reconstruction

[Experience in 53 Consecutive Patient]

Authors:Maurice M. Khosh, MD Albert Jen, MD; Carlo Honrado, MD;Steven J. Pearlman, MD

Results  The most common cause of nasal valve obstruction was previous rhinoplasty (79%), followed by nasal trauma (15%) and congenital anomaly (6%). Spreader grafts were used in 42 patients (79%), and alar batten grafts were used in 19 patients (36%). The patients received a minimum of 1 year of follow-up. All 12 patients with external valve dysfunction showed improvement after surgery. Thirteen (93%) of the 14 patients with concomitant external and internal valve dysfunction had improvement in nasal obstruction after treatment. Twenty-four (89%) of 27 patients with internal nasal valve dysfunction reported improvement in nasal obstruction. Spreader grafts caused a widening of the middle third of the nose. Alar batten grafts resulted in effacement of deep alar creases and a widening of the nasal tip.
Conclusions  We have found that surgical correction of nasal valve obstruction is extremely effective in improving subjective nasal obstruction. Success of this procedure is predicated by correct diagnosis and appropriate surgical technique. 

For additional information see the following links:

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