Minimally Invasive Nasal Valve Repair

1

Introduction

The nasal valve is defined as the flow-limiting segment of the nasal airway, located at the triangular aperture between the upper lateral cartilage and the septum. The angle formed by these two structures ranges from 10 to 15 degrees and is maintained by the relationships between the nasal septum, the lower lateral cartilage, and the attachments of the facial muscles. The valves constitute the narrowest point of the nasal airway and account for more than half of the total nasal airway resistance. Therefore consideration of the diameter of the nasal passage is essential in the surgical planning for nasal obstruction correction, as it could play an important role in the overall nasal airflow.

Nasal valve collapse has become a commonly identified cause of nasal airway obstruction. In fact, nasal valve incompetence may equal or even exceed septal deviation as the prime cause of nasal airway obstruction. This could potentially account for inconsistent effects or persistent obstruction observed after septoplasty, where satisfaction rates range from 43% to 90%. The valve area may be obstructed secondary to surgical procedures (such as rhinoplasty), trauma, or even aging. The complexity of nasal valve repair techniques, the variable results, and the difficulty of treating previously operated patients, coupled with advanced-age patients not seeking medical attention for this problem, make nasal valve collapse an issue that often remains unresolved.

In many cases, nasal valve collapse is not diagnosed until after surgical treatment, typically septoplasty or turbinate reduction, fails to relieve symptoms of nasal obstruction, in which case further causes are investigated. It is often impossible to know if the correction of obstruction caused by a deviated septum or the turbinates unmasks an underlying valve collapse problem or whether the ensuing increased airflow causes valve collapse. Classically, obstruction of the valve area has been attributed to insufficient support of the upper or lower lateral cartilages. This represents true valve collapse. Fixed valve obstruction, however, may be secondary to a persistently deviated caudal septum after septoplasty. In these cases, lateral displacement of the valve area can overcome this obstruction.

No studies have identified the incidence of nasal valve collapse in patients with obstructive sleep apnea/hypopnea syndrome (OSAHS). However, it is likely that nasal valve collapse is more common in OSAHS patients because they are inspiring against an obstructed airway, and increased respiratory effort is more likely to cause collapse. Many studies have attempted to treat OSAHS with valve repair without success. Although valve repair alone is not likely to cure OSAHS, it may be an important component of a multilevel approach to improve the airway.

Various techniques aimed at correcting nasal valve collapse have been described. Techniques designed to lateralize the superior segment of the upper lateral cartilage, involving cartilage and spreader grafts, are effective when this portion has been medially displaced. Nasal valve obstruction may be secondary to the position of the septum (e.g. after septoplasty), and in selected cases, also amenable for repair using a nasal valve suspension technique.

The original description of a technique for repair of the nasal valve by means of a suspension of the valve to the orbital rim was described by Paniello. Significant modifications to this original technique, which simplified the procedure and made it safer and equally effective, were later introduced by Friedman et al. In this chapter, we describe the patient selection criteria and the simplified technique for nasal valve suspension for patients with nasal valve collapse and obstruction. The effect of improved nasal breathing in patients with OSAHS is discussed in detail in Chapter 22.

2

Patient Selection

In general, four categories of nasal valve obstruction can be identified, based on the involved valve (external or internal) and whether it is always present (fixed) or present during inspiration only (inspiratory, also referred to as nasal valve collapse ). It should be noted that both types of obstruction can be present simultaneously. While examining the nasal valve, both the external and the internal valves should be visualized to determine the presence of obstruction. The internal valve is located at the level of the border of the upper lateral cartilage and the piriform aperture. Not only can this area be easily distorted during anterior rhinoscopy, it can also be completely overlooked with nasal endoscopy. Therefore it should be examined before introducing the speculum or endoscope into the nasal cavity. As part of the routine evaluation, the clinician should observe the nasal valve while the patient breathes normally and while taking deep breaths. A normally functioning nasal valve widens in concert with the nasal alae external dilator muscles. Conversely, the nasal valve collapses during inspiration in patients who have inspiratory obstruction. Obstruction of the airway by septal deviation, polyps, or other pathology will make this assessment inaccurate. Therefore many patients have no collapse before septal, polyp, and turbinate surgery, but collapse becomes evident once air airflow is restored. Nasal dilator strips are usually effective in improving airflow by widening the nasal valve in these patients and may serve as a confirmatory test to identify potential candidates for nasal valve suspension.

Patients may have nasal valve obstruction secondary to a deviated caudal septal position, which can be corrected by valve suspension in selected situations. The decision to correct the valve or the septum is based on the results of the Cottle maneuver, the position of the entire septum, and a history of septal surgery. The Cottle maneuver is performed by applying superolateral traction to the nasofacial groove and is considered positive when it causes improvement of nasal airflow as perceived by the patient. A positive Cottle maneuver can adequately predict a successful outcome of nasal valve suspension for the treatment of nasal airway obstruction. The area of obstruction can then be confirmed by intranasal examination at the level of the valve. Direct superolateral displacement (with a cotton-tip applicator) should significantly improve the patient's nasal airway. Patients with associated rhinitis or other causes of nasal airway obstruction should be treated appropriately before surgery. Objective measurements utilizing acoustic rhinometry to confirm valve collapse are discussed in Chapter 22.