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February 2011SCOTTSDALE—Problems with the nasal valve that lead to difficulty with breathing can be tricky, in terms of both diagnosis and treatment, said a group of experts here at the Triological Society’s Combined Sections Meeting on Jan. 28.
Such cases require care in determining the precise nature and cause of the problem, but with the proper approach, otolaryngologists can deliver great results to patients, the panelists said.
Reviewing All Possibilities
W. Russell Ries, MD, associate professor of otolaryngology at Vanderbilt University in Nashville, said that even though the term “stenosis” is often used to describe this kind of issue, it actually boils down to a problem of function. “When you talk about a stenosis, to me it means some type of lumen that has been narrowed,” he said. “And nasal valve compromise is more of a functional compromise.”
Talking to the patient is crucial, Dr. Ries said. “The history is most important in treating these patients,” he said. “When you talk to the patient, you can almost make the diagnosis.”
Both Dr. Ries and Jeffrey Spiegel, MD, chief of facial plastic and reconstructive surgery at Boston University, referred to a consensus statement on nasal valve compromise published last year (Otolaryngol Head Neck Surg. 2010;143(1):48-59). That paper emphasized the fact that nasal valve compromise exists as a distinct clinical entity apart from other causes of nasal obstruction and that it can be caused by a wide columella, collapse, high septal deviation, large turbinates, drooping of the nose tip or caudal septal deviation. The statement also concluded that the Cottle maneuver and anterior rhinoscopy can be helpful in evaluating for nasal valve compromise.
But, while he applauded the paper overall, Dr. Spiegel said he has not found the Cottle maneuver very helpful, because the test can be unspecific, producing positive results in too many patients. Addressing the panel, Roger Crumley, MD, MBA, professor and chairman of otolaryngology-head and neck surgery at the University of California, Irvine, commented that he, like Dr. Spiegel, believed the Cottle Maneuver to be of little value. Similarly, Dr. Spiegel commented that anterior rhinoscopy may not be helpful in diagnosing valve dysfunction, because the simple act of inserting the nasal speculum can distort the anatomy enough to cloud the diagnosis.
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.
“Unfortunately, I see a lot of this in my practice,” Dr. Toriumi said. “It’s a combination of repair with lateral wall structural grafting. But I also have to replace tissue. I have to put vestibular lining back.”
Also challenging are cases of previous intercartilaginous incisions that haven’t healed properly, leaving scarring.Once the scar tissue is removed, “you’re left with raw mucosal surface, and in order to correct that, you need to bring in tissue,” he said.
William Shockley, MD, chief of facial plastic and reconstructive surgery at the University of North Carolina in Chapel Hill, discussed the tension nose, in which the dorsum is too high, and the saddle nose, in which the dorsum is too low. Both can be linked to nasal obstruction.
Neither problem has been well studied, so there is not much data on the effect that surgeries have had on patients with nasal obstruction.
But Dr. Shockley said that they generally yield good results. “For the tension nose,” he said, “if you can lower the dorsum, widen the cartilaginous vault and, secondarily, deproject the nasal tip, they typically get improvement in their cross-sectional nasal airway, and usually an improvement in internal and external nasal valve function.”
Similarly, if the saddle nose is corrected by elevating the dorsum, supporting the middle vault, reprojecting the tip and correcting any tip ptosis, there is generally improved internal nasal valve function and, in some patients, better external function, too, Dr. Shockley said.
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