The American Academy of Otolaryngology-Head and Neck Surgery recognizes surgical repair of the nasal valve as a distinct surgical procedure that can improve nasal obstruction symptoms for appropriately selected patients with nasal valve collapse.
Nasal valve dysfunction is a common clinical cause of symptomatic nasal airway obstruction due to either narrowing or collapse of the nasal valve.1 The nasal valve consists of external and internal components. The external nasal valve is defined as the area bounded by the caudal septum, medial crus of the lower lateral cartilage, alar cartilage and fibrofatty tissue, and the nasal sill. The internal nasal valve is bounded by the septum, head of the inferior turbinate, and the upper lateral cartilage. Etiologies of external and internal nasal valve dysfunction can be further broken down into static and dynamic causes. Static nasal valve dysfunction is seen at rest, due to anatomic narrowness or obstruction; dynamic nasal valve dysfunction occurs when the patient inspires. Dynamic collapse is also described by the term lateral nasal wall insufficiency. The region of collapse can be divided into two zones, with Zone 1 roughly corresponding to the internal nasal valve and Zone 2 corresponding to the external nasal valve.2
The diagnosis of symptomatic nasal valve dysfunction is a clinical diagnosis, made by patient history and physical exam. These diagnoses are made by a qualified Otolaryngologist as a part of a thorough physical examination of the nose.1-5 Nasal endoscopy is not required for the diagnosis of nasal valve dysfunction, as the nasal valve region is easily visualized by anterior rhinoscopy and external nasal examination. However, nasal endoscopy is useful as a diagnostic tool in identifying additional causes of nasal airway obstruction.1 Computed tomography scans do not measure dynamic collapse and are not accurate in characterizing the nasal valve.6 Photographic documentation does not reliably diagnose collapse of the internal nasal valve.1,3 Subjective improvement in nasal breathing with the Cottle or modified Cottle maneuver confirms the diagnosis of nasal valve collapse.7
The treatment of nasal valve dysfunction may involve techniques that include cartilage grafting and open surgical repair, suture suspension techniques, and implants or radiofrequency treatment aimed at stabilizing the nasal valve.8-13 Surgical repair of the nasal valve can be performed as a standalone surgical procedure or in conjunction with other procedures to improve nasal obstruction. These may include septoplasty, turbinate reduction, endoscopic sinus surgery, among others. These procedures, such as septoplasty, may be complementary to nasal valve repair, but are not effective substitutes as they do not address nasal valve dysfunction. When feasible, surgical treatment to address all contributing anatomic sites should be performed concomitantly, based on patient and physician shared decision making. Requiring septoplasty and/or turbinate surgery prior to nasal valve surgery is not recommended, as this may lead to unnecessary increases in surgical encounters.
Nasal valve repair in appropriately selected patients is effective for symptom relief and quality-of-life improvement.14-16 When nasal valve dysfunction is diagnosed, conservative therapy may include nasal cones or external nasal dilator adhesive strips. However, these are not feasible for around the clock use and are not viewed as a viable long-term treatment. Medical treatment (i.e., intranasal steroids), may address inferior turbinate hypertrophy. This treatment does not address the majority of the anatomic components of the nasal valve. Therefore, medical treatment is not recommended as a means of addressing nasal valve dysfunction.1,17
The nasal valve may be stabilized using office-based treatments, such as implants or radiofrequency treatment. For patients who require anatomic widening and definitive stabilization of the nasal valve, surgical treatment of nasal valve collapse, along with treatment of other possible causes of nasal airway obstruction, is required to optimize patient outcomes. Failure to perform nasal valve repair, when indicated, is a common cause of incomplete symptom resolution for patients with nasal obstruction and nasal valve dysfunction.14-18
- Rhee JS, Weaver EM, Park SSet al. Clinical consensus statement: Diagnosis and management of nasal valve compromise. Otolaryngol Head Neck Surg 2010; 143:48-59.
- Most SP. Trends in functional rhinoplasty. Archives of Facial Plastic Surgery. 2008 Nov 3;10(6):410-3.
- Ishii LE, Rhee JS. Are diagnostic tests useful for nasal valve compromise? Laryngoscope 2013; 123:7-8.
- Tsao GJ, Fijalkowski N, Most SP. Validation of a grading system for lateral nasal wall insufficiency. Allergy Rhinol (Providence) 2013; 4:e66-68.
- Wittkopf M, Wittkopf J, Ries WR. The diagnosis and treatment of nasal valve collapse. Curr Opin Otolaryngol Head Neck Surg 2008; 16:10-13.
- Shafik AG, Alkady HA, Tawfik GM, Mohamed AM, Rabie TM, Huy NT. Computed tomography evaluation of internal nasal valve angle and area and its correlation with NOSE scale for symptomatic improvement in rhinoplasty. Braz J Otorhinolaryngol 2020; 86:343-350.
- Fung E, Hong P, Moore C, Taylor SM. The effectiveness of modified cottle maneuver in predicting outcomes in functional rhinoplasty. Plast Surg Int 2014; 2014:618313.
- Brandon BM, Stepp WH, Basu Set al. Nasal Airflow Changes With Bioabsorbable Implant, Butterfly, and Spreader Grafts. Laryngoscope 2020; 130:E817-e823.
- Clark JM, Cook TA. The ‘butterfly’ graft in functional secondary rhinoplasty. Laryngoscope 2002; 112:1917-1925.
- Gunter JP, Friedman RM. Lateral crural strut graft: technique and clinical applications in rhinoplasty. Plast Reconstr Surg 1997; 99:943-952; discussion 953-945.
- Miller PJ, Dayan SH. The bow-tie mattress suture for the correction of nasal cartilage convexities and concavities. Arch Facial Plast Surg 2010; 12:354-356.
- Stolovitzky P, Sidle DM, Ow RA, Nachlas NE, Most SP. A prospective study for treatment of nasal valve collapse due to lateral wall insufficiency: Outcomes using a bioabsorbable implant. Laryngoscope 2018; 128:2483-2489.
- Toriumi DM, Josen J, Weinberger M, Tardy ME, Jr. Use of alar batten grafts for correction of nasal valve collapse. Arch Otolaryngol Head Neck Surg 1997; 123:802-808.
- Kandathil CK, Spataro EA, Laimi K, Moubayed SP, Most SP, Saltychev M. Repair of the Lateral Nasal Wall in Nasal Airway Obstruction: A Systematic Review and Meta-analysis. JAMA Facial Plast Surg 2018; 20:307-313.
- Lindsay RW. Disease-specific quality of life outcomes in functional rhinoplasty. Laryngoscope 2012; 122:1480-1488.
- Rhee JS, Poetker DM, Smith TL, Bustillo A, Burzynski M, Davis RE. Nasal valve surgery improves disease-specific quality of life. Laryngoscope 2005; 115:437-440.
- Gruber RP, Lin AY, Richards T. Nasal strips for evaluating and classifying valvular nasal obstruction. Aesthetic Plast Surg 2011; 35:211-215.
- Rhee JS, Arganbright JM, McMullin BT, Hannley M. Evidence supporting functional rhinoplasty or nasal valve repair: A 25-year systematic review. Otolaryngol Head Neck Surg 2008; 139:10-20.