A Clinical Challenge: Nasal valve compromise can be a dicey problem, panelists say

In some, tip repositioning may produce better breathing results, and a ptotic tip might be the culprit, he said. The greatest challenge occurs when a valve dysfunction is suspected but the patient also has a deviated septum. In these cases, the physician will have to make the difficult decision about what is really the cause.

“I think this is where the finesse comes in,” Dr. Spiegel said. “You really have to make your best judgment.”

Getting good results is often possible, but not without careful attention to diagnosis, said Stephen Park, MD, vice chair of otolaryngology-head and neck surgery at the University of Virginia in Charlottesville.

“We believe, if a patient walks in, we should be able to allow [him or her] to breathe better through [his or her] nose,” Dr. Park said. “And that distinguishes us from many of the other disciplines…. But there is a challenge to it. And I think one of the key parts is making a very good assessment.”

Otolaryngologists must first verify that there is some actual obstruction of the nasal passage. “Are we determining whether or not there is an objective correlation with their subjective complaints?” he said. “And, not infrequently, there isn’t.”

Additionally, otolaryngologists should not forget valve pathology when making their evaluations, rather than just looking for things like deviated septa and enlarged turbinates. It’s also important to distinguish between a static problem and a dynamic problem that occurs only when a patient breathes, since remedies for those issues proceed in different directions.

Surgery

Finally, the end goal has to be finding the “epicenter” of the problem and focusing surgical efforts there.

In the case of a static narrow internal valve, flaring sutures attached to the upper lateral cartilage can have substantial benefits, giving a little extra opening to the airway, Dr. Park said. “A very subtle change to your upper lateral cartilage from a flaring suture can have a huge impact in terms of nasal function,” he added.

When using a batten graft, he said, it can sometimes be tempting to place the graft in a convenient spot rather than within the area of greatest collapse. “Putting the pocket in a non-anatomic position might be awkward but is more effective,” he said.

Dean Toriumi, MD, professor of otolaryngology-head and neck surgery at the University of Illinois at Chicago, said that procedures to correct nasal valve compromise can get especially difficult in cases of vestibular stenosis caused by overaggressive alar base reductions that have left nasal openings too small for easy breathing.