New Techniques in Nasal Valve Repair

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Introduction

Sleep-disordered breathing and snoring are exceedingly common presentations to physicians. In general, the etiology is highly variable from base of tongue obstruction, laryngomalacia, retrognathia, or weak pharyngeal muscle tone, among others. These etiologies can all be exacerbated by coexistent nasal valve obstruction as it directly relates to airflow. Common etiologies of nasal valve collapse include aging, trauma, congenital, septal deviation, and, most frequently, iatrogenic after septorhinoplasty. These typically stem from weakness in the lateral wall due to overresection of the lateral crus. Increasingly, the nasal valve has been shown to affect patients with obstructive sleep apnea (OSA), which has led to the emergence of new treatments and therapies targeting nasal valve collapse.

The contribution of the nasal valve to OSA and sleep-disordered breathing has a controversial past. Studies have shown that improvement in the nasal airway, either surgical or nonsurgical, has minimal effect on the Apnea/Hypopnea Index (AHI) and the subsequent need for either continuous positive airway pressure (CPAP) or additional surgery. In contrast, other studies have shown a reduction in the AHI in patients with reduction in nasal airway resistance, be it by medical management, nasal dilators, or functional septorhinoplasty. However, despite the controversy in reduction of AHI, there is an association between decreased nasal airway resistance and improvements in CPAP compliance and patient symptomatology as defined by improvements in the Epworth Sleepiness Scale (ESS), Respiratory Distress Index (RDI), and reduction in unintentional CPAP leak rates. In summary, patients with sleep-disordered breathing can benefit significantly from adequate diagnosis of abnormal nasal anatomy, particularly as it relates to nasal valve obstruction.

The nasal airway accounts for over 50% of upper airway resistance. The area of greatest resistance is found at the internal nasal valve, which is bound by the septum medially, the upper lateral cartilage superolaterally, and the head of the inferior turbinate inferiorly. This creates a 10- to 15-degree angle for airflow to pass, which is the narrowest part of the nasal airway, and an angle <10 degrees is considered abnormal. The external nasal valve forms the nasal vestibule. The boundaries of this include the alar lobule laterally, the nasal sill inferiorly, and the columella medially, which is formed from the caudal septum and medial crura. External valve collapse is typically seen in patients with narrow nostrils, an overprojected tip, and thin or weak nasal sidewalls. Nasal valve collapse is most easily diagnosed with an adequate physical examination with observation of the lateral wall during inspiration. The diagnosis can be confirmed with a modified Cottle maneuver in which a wire loop curette is inserted intranasally underneath the upper lateral cartilage and having the patient breathe through the nose. If significant improvement is seen, a diagnosis of nasal valve collapse can be reasonably confirmed.

Management of nasal valve collapse has changed significantly over the past 20 years with new innovations in nonsurgical treatments, and surgical interventions have become increasingly evidence-based with new advances in grafting materials.