TITLE: Rhinoplasty and the=
Nasal
Valve
SOURCE: Grand Rounds Presentation, UTMB, Dept. of Otolaryngology
DATE:
RESIDENT PHYSICIAN: Jeffrey Buyten, MD
FACULTY PHYSICIAN:
SERIES EDITORS: Francis B. Quinn, Jr., MD
"This material was prepared by resident physicians in
partial fulfillment of educational requirements established for the
Postgraduate Training Program of the UTMB Department of Otolaryngology/Head=
and
Neck Surgery and was not intended for clinical use in its present form. It =
was
prepared for the purpose of stimulating group discussion in a conference
setting. No warranties, either express or implied, are made with respect to=
its
accuracy, completeness, or timeliness. The material does not necessarily
reflect the current or past opinions of members of the UTMB faculty and sho=
uld
not be used for purposes of diagnosis or treatment without consulting
appropriate literature sources and informed professional opinion."
Nasal obstruction =
is a
common complaint for patients that present to otolaryngologists. The
differential diagnosis includes both physiologic and anatomic etiologies. M=
ucosal
diseases like allergic rhinitis and vasomotor rhinitis need to be optimally
treated medically. Anatomic variations attribute to nasal obstruction and
include both the cartilaginous and bony portions of the nasal skeleton.
Pre operative asse=
ssment
of patients with nasal obstruction should be thorough. The external appeara=
nce
should be scrutinized. A detailed intranasal exam with and without deconges=
tion
should be performed using anterior rhinoscopy and nasal endoscopy when
warranted. A symptom score index is useful for the patients to fill out so =
that
pre and post therapy results can be tabulated. The Cottle maneuver is usefu=
l in
identifying nasal valve obstructions but the modified Cottle maneuver is be=
tter
at identifying the level of obstruction. Also patients need to be observed
during normal and exaggerated nasal breathing because normal nasal valve
collapse occurs during exaggerated respirations. The basic physics behind
airway collapse are based on Poiseuilles law and Bernoulli’s principl=
e.
Pouiseuilles law states that fluid flow and resistance is related to the fo=
urth
power of the radius. Bernoulli’s principle involves the changes in in=
ternal
and external luminal pressure as it relates to fluid velocity. As fluid tra=
vels
through a smaller space, velocity must increase, thereby decreasing the
internal pressure which makes it more apt to collapse.
The anatomy of the=
nasal
valve was first described by Mink in 1903. This site has the highest level =
of
nasal resistance because it is the narrowest portion of the nasal cavity. T=
he
nasal valve complex is bordered superiorly by the caudal end of the upper
lateral cartilages and septum. Posteriorly the nasal valve complex is borde=
red
by the inferior turbinate. The inferior border is the nasal floor and the
lateral border is the bony piriform aperture and adjacent fibrofatty tissue.
The normal cross sectional area of the nasal valve complex is 55 to 83 mm
The most common ca=
use of
INV stenosis is deviated septum. The most commonly performed procedure to
correct this problem is septoplasty with turbinate reduction. Turbinate hyp=
ertrophy
can contribute to INV stenosis. This can be addressed using nasal sprays and
oral antihistamines. The most common surgical procedure to correct turbinate
hypertrophy is submucous resection. Studies have shown that the minimal cro=
ss
sectional area at the INV decreases after reduction rhinoplasties are
performed. Over 90% of post op nasal obstruction is not due to the septal
cartilage. Up to 64% of post op nasal obstruction is found at the internal
valve and up to 50% is found at the external valve. Patients at risk for po=
st
op stenosis have high, narrow dorsums with a weak middle vault. This is fou=
nd
in patients with long noses and short nasal bones and thin skin. Patients t=
hat
have a positive Cottle maneuver pre operatively are also at risk for post op
stenosis.
The most common su=
rgical
procedure used to address INV stenosis is spreader graft implantation. This=
was
originally described by Sheen in 1984 and has been used for both functional=
and
cosmetic procedures. Spreader graft placement corrects the lack of dorsal
support and helps restore a normal dorsal profile. The grafts can be place =
via
an open or closed approach. Cartilage is typically harvested from the septum
and carved into 1-2 mm thick matchsticks that extend the entire length of t=
he upper
lateral cartilage. A submucosal pocket is created between the septum and the
upper lateral cartilage. The grafts are sutured in place using horizontal
mattress that goes through both upper lateral cartilages, grafts and the
septum. Care should be taken to not pass through the underlying nasal mucosa
since this could narrow the INV angle.&nbs=
p;
Scuito et al widens the INV by placing traditional spreader grafts a=
nd
then suspends the upper lateral cartilages over the grafts, which further
effaces the INV angle.
Andre et al descri=
bed
endonasal placement of spreader grafts in 89 patients. They evaluated three
different fixation techniques and found that creation of a “tight fit=
ting
tunnel” had the greatest post op improvement. Endoscopic placement of
spreader grafts in cadavers was described Huang et al. A 30 degree rigid na=
sal
scope was placed into a submucoperichondrial flap. The fibrous junction bet=
ween
the upper lateral cartilage and the septum was separated using a freer elev=
ator
then the grafts were placed. Acoustic rhinometry confirmed that graft place=
ment
increased the INV cross sectional area.
A variation of the
spreader graft used for very crooked noses is the septal cross bar describe=
d by
Boccieri. A septal graft is taken and a tab is made in the dorsal septum. T=
he
rigid graft is placed so that it corrects the curve and also acts as a spre=
ader
graft on the side it is placed.
The conchal butter=
fly
graft described by Clark et al uses conchal cartilage placed via a closed
approach to increase the angle of the INV. The graft uses the natural shape=
of
the conchal graft to lend support to the weaker upper lateral cartilages. T=
he
graft is placed through intercartilagenous and full transfixion incisions. =
The
dorsal septum and dorsal portion of the graft are trimmed in order to preve=
nt
polly beak deformities post op.
Sen et al describe=
d a
spring graft which utilizes resected alar cartilage to increase the INV. The
resected cartilages are sewn together to increase their strength. Then they=
are
placed deep to the upper lateral cartilage so that the natural curve of the
grafts are used to pull the upper laterals outward.
Schlosser et al de=
scribe
the use of flaring sutures to increase the INV in a Cadaveric study. Placed
through an open approach, a horizontal mattress suture is passed through the
lateral portions of the upper lateral cartilage over the dorsum to the late=
ral
portion of the contralateral upper lateral cartilage and back. The suture is
tightened and fulcrums on the dorsum, pulling the lateral borders outward a=
nd
increasing the area of the valve. The best post operative improvements in c=
ross
sectional area were seen when spreader grafts and flaring sutures were used=
in
combination.
Mini spreader graf=
ts are
described by Boccieri. He utilizes resected alar cartilage from a cephalic =
trim
to create the graft. The resected portions are kept attached medially and a=
re
then placed between the upper laterals and the septum. The fixation of the
grafts also enables concurrent elevation of the nasal tip since the grafts =
are pedicled
to the alar cartilage.
Byrd et al describ=
ed the
autospreader flap. This graft uses “normally resected” portions=
of
the upper lateral cartilages in reduction rhinoplasty. Instead of tossing t=
he
cartilage, the underlying perichondrium is kept intact and the grafts are
rotated internally between the septum and medial edge of the upper lateral
cartilage. The technique is useful in patients with long thin noses that are
straight. Placement of the grafts for these patients decreases the likeliho=
od
of post operative INV stenosis. This technique is not adequate for patients
with deviated dorsums because the upper lateral cartilage grafts are not st=
rong
enough to straighten the septum.
Resorbable spreade=
r grafts
are used when no other autologous tissue can be used. Stal et al describe t=
he
use of Lactosorb, a polylactic and polyglycolic acid polymer, in pediatric
revision rhinoplasty patients. Lactosorb takes 12 months to absorb which is
thought to be enough time for the nasal skeleton to stabilize. When the pap=
er
was published in 2000, follow up ranged from 12-18 months with no airway
obstruction relapses or post operative complications. Gurlek describes the =
use
of polyethylene spreader grafts in revision rhinoplasty cases. He used these
grafts in 15 patient, followed them for a mean of 16 months and reported no
complications or recurrence of airway obstruction.
Nyte has presented=
case
reports of injectable spreader grafts placed in patients that did not desire
surgical intervention. He reported the use of both Radiesse (calcium
hydroxylapatite) and Restylane (hyaluronic acid). He reports that patient h=
ave
good initial results but long term follow up was not reported.
Capone et al descr=
ibed the
effect that deep plane rhytidectomy has on the nasal valve. Mid facial deep
plane lifts mimic the action of the Cottle maneuver. He evaluated 20 patien=
ts
with pre and post op acoustic rhinometry and found that the INV cross secti=
onal
area increases 22% but does decrease over time. The external nasal valve
increases an average of 5%. Overall 70% of patients reported improvement on
nasal patency scores following rhytidectomy.
Stewart et al developed a disease
specific validated quality of life scale in order to assess the outcomes of
septoplasty for nasal obstruction. The nasal obstructive symptom evaluation
(NOSE) scale asks patients to assess the severity of nasal congestion or
stuffiness, nasal blockage or obstruction, trouble with nasal breathing, and
the ability to get enough air nasally during strenuous activities. 59 patie=
nts
were assessed at multiple centers and were evaluated preoperatively, 3 mont=
hs
post op and 6 months post op. Patients underwent septoplasty with or without
turbinate reduction. The results show that patient satisfication is very hi=
gh
following surgery and that mean NOSE scores decreased from 67.5 to 23.1 post
operatively. Another interesting finding was that patients were able to
decrease the amount of oral decongestants and nasal steroids following surg=
ery.
Rhee et al used NO=
SE
scores to evaluate the effect that functional septorhinoplasty had on patie=
nts.
In addition to septoplasty and turbinoplasty, these patients had nasal tip
work, spreader grafts placed, and osteotomies. 26 patients were evaluated a=
nd
75% of patients were very happy 6 months post operatively. In contrast to
Stewart et al’s findings, these patients were not able to decrease the
amount of nasal medications they had to take. Dr Most performed a similar s=
tudy
and found that mean NOSE scores decreased&=
nbsp;
from 58.3 to 15.7 following functional septorhinoplasty.