AIJOC

10.5005/jp-journals-10003-1109
Management of the Internal Nasal Valve
REVIEW ARTICLE

Management of the Internal Nasal Valve

Li Shia Ng, Stephen Lo

ABSTRACT reduction, the fibrous attachment between the nasal septum

Nasal obstruction is one of the most common nose complaints. and upper lateral cartilages may be disrupted and if this is
Internal nasal valve dysfunction is an important cause of nasal not adequately repaired, the lateral nasal wall collapses.
obstruction, particularly in patients who have a previous history Another mechanism by which rhinoplasty may result in
of nasal trauma or reduction rhinoplasty. Correct assessment
collapse is via osteotomies, with medial displacement of
is crucial for accurate diagnosis and appropriate management
planning. Various surgical and nonsurgical modalities for the nasal bone and upper lateral cartilage attached to it. Other
addressing the problem of internal nasal valve collapse are being causes include facial nerve paralysis, which results in a
reviewed in this paper. Each technique have their own nonfunctional dilator naris muscle that plays a part in
advantages and disadvantage, and the choice depends on the keeping the lateral nasal wall open. Aging can also weaken
underlying pathology, patient preference, availability of graft
material. The rhinoplasty surgeon should have a thorough the fibroareolar tissues of the nasal sidewall and trauma
understanding of the available options as part of his/her may disrupt the patency of the nasal airway around the
armamentarium in dealing with internal nasal valve pathology. internal nasal valve.
Keywords: Internal nasal valve, Rhinoplasty. Upper lateral cartilage collapse may be static or dynamic,
How to cite this article: Shia Ng L, Lo S. Management of the unilateral or bilateral. Signs suggestive of internal nasal
Internal Nasal Valve. Int J Otorhinolaryngol Clin 2013;5(1):43-45. valve collapse are weak/malformed nasal cartilages,
Source of support: Nil inspiratory collapse of lateral nasal wall or ptotic nasal tip.
Anterior rhinoscopy can reveal deviation of the nasal
Conflict of interest: None declared
septum, scarring and stenosis of the internal nasal valve
INTRODUCTION region and inferior turbinate hypertrophy. Decongestion
should be performed to determine if the nasal obstruction
Nasal valve collapse is a commonly overlooked cause of nasal
can be relieved medically. If so, the patients should pursue
obstruction. The nasal valve area can be divided into the
medical therapy prior to considering surgery. The Cottle
external and internal valve. The internal nasal valve is the
maneuver is the traditional method for diagnosing nasal
narrowest segment of the nasal airway and collapse of this
valve collapse. This maneuver involves retracting the cheek
region can give rise to significant increase in airway resistance.
adjacent to the nasal alae superolaterally and in a positive
INTERNAL NASAL VALVE ANATOMY test patients experience an audible or subjective
improvement of symptoms. However, this test is not always
Lying about 1.3 cm deep to the nares, the internal nasal valve
reliable. The modified Cottle maneuver has been proposed
is bordered medially by the dorsal septum, laterally by the
to more accurately diagnose the area of collapse, by using
caudal margin of the upper lateral cartilage and inferiorly by
an ear curette intranasally to support the lower and upper
the head of the inferior turbinate. In the Caucasian population,
lateral cartilages separately and assessing if nasal patency
the internal nasal valve angle measures about 10 to 15 degrees
is increased.
and any further narrowing of this angle can result in collapse
According to the American Academy of Otolaryngology
of the internal nasal valve area. (AAO) clinical consensus for nasal valve compromise, this
PATHOPHYSIOLOGY OF INTERNAL NASAL condition is best evaluated with history and anterior
VALVE COLLAPSE rhinoscopy. Endoscopy and photography is useful but not
routine and radiography is not useful. There is a lack of
Any cause of narrowing around the internal nasal valve
gold standard objective test for the diagnosis of internal
region, such as septal deviation, hypertrophied inferior nasal valve collapse. Acoustic rhinometry and rhinomano-
turbinate and pyriform aperture stenosis can result in metry is not universally available or accepted and the current
acceleration of airflow. According to Bernoulli’s principle, role of these investigations is mainly in research.
this increase in speed occurs simultaneously with a decrease
in intraluminal pressure. In addition, if the lateral nasal wall MANAGEMENT OF INTERNAL
is weak, the entire lateral nasal wall collapses. NASAL VALVE COLLAPSE

DIAGNOSIS OF INTERNAL NASAL VALVE COLLAPSE Nonsurgical Management

A patient with previous nasal fracture or rhinoplasty can Patients who are unfit or unwilling to go for operation can
present with internal nasal valve collapse. As part of hump be managed conservatively with external adhesive strips or

Otorhinolaryngology Clinics: An International Journal, January-April 2013;5(1):43-45 43

Li Shia Ng, Stephen Lo

internal nasal springs to hold the internal nasal valve open. Other grafts include the upper lateral splay graft6 and
The downside of management with these splints is that they butterfly graft,7 which are placed below and above the upper
can be uncomfortable to wear and some may find it lateral cartilages respectively. These cartilage grafts are
cosmetically unacceptable. harvested from the concha and makes use of the natural
Vaiman1 performed a small placebo-controlled study curvature of the concha to spring the upper lateral cartilages
with 40 patients for the treatment of nasal valve collapse open. The disadvantage of placement of these grafts is
with high frequency transcutaneous and intranasal electrical excessive widening of the nasal dorsum. Alar batten grafts8
stimulation of nasal muscles. Twelve out of 20 patients in are used to support flaccid lateral nasal wall but may result
the treatment group, compared to seven in the placebo group, in alar fullness.
had subjective improvement of symptoms. However, there Suture techniques, such as the flaring sutures and lateral
was rapid decline of improvement after termination of suspension sutures9 have been described to pull the upper
treatment. The same author2 described biofeedback training lateral cartilages laterally and widen the nasal valve angle.
using electromyography and a home exercise program for Specific surgeries can also be performed to address the cause
nasal muscle building. This therapy improved nasal of narrowing, such as scar resection or Z-plasty10 for nostril
obstruction subjectively in all patients, and in 86% of the stenosis.
patients, surgery was avoided. Nyte3 described a technique There is a lack of studies describing treatment approa-
of spreader graft injection using Radiesse (calcium ches in patients with severe refractory internal nasal valve
hydroxyapatite microspheres in sodium carboxymethyl- collapse (both dynamic and static), who have failed to
cellulose carrier gel) for internal nasal valve collapse. This respond to conventional surgery.11 In our institution, we
involves a three-point injection to widen the internal valve treat these cases using a double-Y titanium plate technique.
angle.
HOW WE DO IT?
Surgical Management Under local anesthesia, a 1.5 cm alar-facial groove incision
Surgery remains the primary mode of treatment for nasal is made. Deep to the incision, a pocket is created, superficial
valve collapse (AAO consensus). However, the evidence is to the upper lateral cartilage medially, and to the anterior
based mostly on uncontrolled studies (grade C evidence). wall of the maxilla laterally. A 0.5 mm thick double-Y
Septoplasty and inferior turbinate reduction surgery are titanium plate (Matrix Midface, Synthes, Switzerland) is
simple surgeries that can widen the internal nasal valve area, placed into the pocket, with the medial end stitched to the
but do not directly address the problem of lateral wall upper lateral cartilage and the lateral end secured to the
collapse or narrow nasal valve angle. To address the above anterior maxillary wall with two 4 mm screws. The
problems, the aims of surgery are (1) to widen the nasal procedure can be performed bilaterally if indicated and
valve angle, (2) to reposition upper lateral cartilages and wounds were closed with 6/0 Prolene Polypropylene suture.
(3) to add structural graft to support the lateral nasal wall. The double-Y titanium plate fixation of the upper lateral
The mainstay of treatment of internal nasal valve cartilage is a minimally invasive procedure that can be done
collapse is spreader graft placement, which has been under local anesthesia. It provides a potentially permanent
popularized by Sheen.4 Spreader grafts widen the nasal valve and sturdy anchor for the upper lateral cartilage, addressing
angle, as well as strengthen the nasal valve area and the disadvantages of conventional procedures. However,
esthetically, can restore width to an esthetically pinched, the risks of implant extrusion and infection have to be
narrow nose. However, accidental damage to nasal mucosa considered. Nevertheless, this technique is an option for
during insertion of graft can result in scar formation and patients who do not improve after conventional surgery.
further narrowing of the nasal valve angle.
CONCLUSION
Variations of the spreader graft include the spreader flap,
which was described by Gruber.5 This method does not A variety of surgical techniques have been described to deal
require a graft and involves rolling up of the upper lateral with nasal valve collapse. As far as we are aware, there are
cartilage upon itself. Unlike the spreader graft, which can no randomized controlled trials on nasal valve surgery.
be placed via a closed or open rhinoplasty approach, the Published literature in nasal valve surgery is frequented by
spreader flap can only be performed via the open approach. technical description of surgical technique rather than
Esthetically, dorsal height may be lost due to shortening of evidence of long-term patient benefit. The patho-
the upper lateral cartilage. physiological role of the internal nasal valve in nasal

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Management of the Internal Nasal Valve

obstruction has improved considerably, but the many 8. Toriumi DM, Josen J, Weinberger M, Tardy ME Jr. Use of alar
surgical techniques described may reflect the uncertainty batten grafts for correction of nasal valve collapse. Arch
Otolaryngol Head Neck Surg 1997 Aug;123(8):802-08.
in the comparative benefit of each technique. 9. Paniello RC. Nasal valve suspension. An effective treatment
for nasal valve collapse. Arch Otolaryngol Head Neck Surg 1996
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A nonsurgical technique for internal nasal valve collapse. ABOUT THE AUTHORS
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4. Sheen JH. Spreader graft: A method of reconstructing the roof Li Shia Ng
of the middle nasal vault following rhinoplasty. Plast Reconstr
Associate Consultant, Department of Otorhinolaryngology, National
Surg 1984 Feb;73(2):230-39.
University Hospital, Singapore
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Reconstr Surg 2007 May;119(6):1903-10.
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Stephen Lo
Nov;102(6):2169-77. Adjunct Assistant Professor, Department of Otorhinolaryngology
7. Clark JM. The ‘butterfly’ graft in functional secondary National University of Singapore School of Medicine, Chief of Facial
rhinoplasty. Laryngoscope 2002 Nov;112(11):1917-25. Plastic Surgery, Tan Tock Seng Hospital, Singapore

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