The internal nasal valve

What repeats

Five findings that hold across the literature.

It is the narrowest point, and its angle is measured in single degrees

The internal nasal valve is bounded by the septum on the inside, the caudal margin of the upper lateral cartilage on the outside and the inferior turbinate below. It sits about 1.3 cm inside the nose, and the angle between the upper lateral cartilage and the septum measures 10 to 15 degrees in the Caucasian population. Because it has the smallest cross-sectional area in the nasal airway, it is the point most sensitive to any change in dimension, whether from anatomy or from surgery.

Rests on: Liu et al., anatomy and physiology of the nasal valves · Schuman and Senior, treatment paradigm · and nasal anatomy.

Collapse is common and frequently unrecognised

Nasal valve collapse has a lifetime prevalence reported up to 13%. The causes are previous rhinoplasty, other nasal surgery, facial paralysis, congenital defects, trauma and ageing. In 1393 consecutive patients assessed for chronic orofacial pain with cone beam computed tomography, nasal valve compromise was the most prevalent type of nasal airway obstruction found, present in 1006 patients, 72.2%.

Rests on: Sinkler et al., surgical approaches review · Olmos, multicentre analysis · and nasal airway obstruction.

A valve that falls in is a different problem from a valve that is too narrow

Dynamic obstruction is inspiratory collapse of the valve. Static obstruction is stenosis, a valve that is narrow whether or not the patient is breathing in. Identifying which one is present, and where, decides the operation. The external valve divides further into an alar and a rim component, and naming the component tells the surgeon which graft to use.

Rests on: Lee and Won, management of nasal valve dysfunction · Samra et al., surgical management of collapse.

The absorbable lateral wall implant beat a sham procedure in a randomised trial

One hundred and thirty-seven patients at 10 clinics were randomised, 70 to an in-office bioabsorbable implant supporting the lateral nasal wall and 67 to a sham procedure. At three months the responder rate was 82.5% in the treatment arm against 54.7% in the sham arm. NOSE scores fell by 42.4 points against 22.7, and visual analogue scores by 39.0 against 13.3. Seventeen patients reported 19 procedure or implant related adverse events, all of which resolved. A meta-analysis of five studies covering 396 patients found reduced lateral wall motion and improved quality of life at 12 months, with adverse effects reported at around a 5% incidence.

Rests on: Stolovitzky et al., sham-controlled trial · Kim et al., implant meta-analysis.

The graft techniques all report gains, and none is shown to be the best

Ten studies covering 567 cases compared the spreader graft with the spreader flap and found no statistically significant difference in restoration of dorsal aesthetic lines, in valve angle improvement, in NOSE score or on anterior rhinomanometry. The spreader graft had the significantly better satisfaction rate. Fifteen studies covering 1052 patients compared alar batten grafts with lateral crural strut grafts: NOSE improvements ran 15.8 to 65.6 points for the strut graft and 25.6 to 69.0 points for the batten graft, and heterogeneity was too great to pool.

Rests on: Keyhan et al., spreader graft versus flap · Jackson et al., batten versus strut.

By how the valve is opened

The named techniques, and what each is measured to do.

Spreader grafts and spreader flaps

A strip of cartilage set between the septum and the upper lateral cartilage widens the angle. The flap version rolls the surgeon's own upper lateral cartilage inward instead of adding a graft. Adding a triangular graft to a spreader flap in three groups of 12, 14 and 10 patients raised the internal valve angle significantly in all three, and significantly more in the triangular group, with NOSE and appearance scores the same across groups.

Rests on: Keyhan et al. · Kocak and Düzenli, triangular spreader graft · and the middle vault.

The T-splay graft

Sixty rhinoplasty patients were randomly assigned to spreader graft or T-splay graft for the same problem. Both groups had significantly better visual analogue, NOSE and modified Glatzel mirror scores at three and six months than before surgery.

Rests on: Kapı et al., spreader versus T-splay.

Alar batten and lateral crural strut grafts

Both stiffen the lateral wall rather than the valve angle. In the pooled review, cosmetic outcomes measured with validated instruments were reported for the strut graft and not for the batten graft. In revision surgery the lateral crural strut graft is described as the stronger option, without needing other techniques to reinforce the lateral crus.

Rests on: Jackson et al. · Parikh and Lighthall, revision surgery · and pinched tip.

Endonasal options that do not open the nose

Spreader, butterfly and alar batten grafts, suspension and flaring sutures and Z-plasty for scarring can all be placed through the nostrils. The trade is less surrounding trauma and shorter operative time against limited visibility and the need for precise graft placement.

Rests on: Boyce et al., closed treatment · Apaydin, nasal valve surgery · and the butterfly graft.

Suspension and implant techniques

Suture suspension pulls the lateral wall outward and anchors it. The reviewed methods include the transconjunctival approach, a bone anchor, the flaring suture, the lateral pull-up and piriform rim suspension, alongside a titanium butterfly implant. Newer methods described in the literature include radiofrequency-induced thermotherapy, the upper lateral strut graft, the stairstep graft and the nasal valve lift.

Rests on: Sinkler et al. · Motamedi et al., innovations.

Enlarging the bony opening

Pyriform aperture enlargement removes bone at the edge of the nasal opening. Eight articles describe three types by the level of bone resected: low-level through a sublabial approach, mid-level through an endonasal approach and an extended version through either. Indications were a narrow pyriform aperture, previously unsuccessful valve surgery, lateral wall collapse and hypertrophy of the head of the inferior turbinate. Subjective improvement was reported for all four and no major complication was encountered.

Rests on: Hajem et al., pyriform aperture enlargement · and turbinate surgery.

What to ask about internal nasal valve surgery

Questions the evidence supports asking.

Which valve is the problem, and does it collapse or is it just narrow

The two mechanisms are treated differently and can coexist. Ask the surgeon to name the site and say whether the obstruction is static or dynamic before naming an operation.

Rests on: Lee and Won · Samra et al..

What is going in, and where does it come from

Septal cartilage, ear cartilage, rib, the patient's own upper lateral cartilage rolled inward, or a manufactured implant. Ask which, and ask about the donor site.

Rests on: Sinkler et al. · Keyhan et al. · and rib cartilage grafts.

Will the outside of my nose change

Widening the valve widens the middle of the nose. The spreader graft carried the better satisfaction score in the pooled comparison, and cosmetic outcomes after batten grafts have not been measured with a validated instrument in any published study.

Rests on: Keyhan et al. · Jackson et al. · and the inverted-V deformity.

Is an office procedure an option for me

The bioabsorbable implant is placed in clinic and has the only sham-controlled randomised evidence in this field. Ask whether lateral wall insufficiency is the main contributor, since that is the population it was tested in.

Rests on: Stolovitzky et al. · Kim et al. · and cost.

What happens if this operation does not work

Repeat valve surgery is its own subject, and prior rhinoplasty is one of the listed causes of valve collapse in the first place. Ask what the surgeon does second.

Rests on: Parikh and Lighthall · Sinkler et al. · and revision rhinoplasty.

The terms, defined

The words used about this part of the nose.

• Internal nasal valve: the slot bounded by the septum, the caudal margin of the upper lateral cartilage and the inferior turbinate, about 1.3 cm inside the nose. [39426874]
• Internal nasal valve angle: the angle between upper lateral cartilage and septum, 10 to 15 degrees in the Caucasian population. [39426874]
• External nasal valve: the nostril opening, subdivided into an alar and a rim component. [39111772]
• Static obstruction: a valve that is narrow at rest, also called stenosis. [39111772]
• Dynamic obstruction: a valve that falls inward on breathing in. [39111772]
• Lateral wall insufficiency: weakness of the side wall of the nose, the anatomic target of the bioabsorbable implant. [32282129]
• Spreader graft: a strip of cartilage placed between septum and upper lateral cartilage. [34864854]
• Spreader flap: the upper lateral cartilage folded in on itself to do the same job. [34864854]
• Alar batten graft: a graft laid over the weak part of the lateral wall to stop it collapsing. [40922497]
• Lateral crural strut graft: a graft placed under the lateral crus of the tip cartilage to stiffen and reposition it. [39765368]
• Flaring suture: a suture that pulls the upper lateral cartilage outward to open the angle. [21404160]
• Pyriplasty: enlargement of the bony pyriform aperture at the edge of the nasal opening. [33648407]
• NOSE scale: the Nasal Obstruction Symptom Evaluation, the endpoint in nearly all of these studies. [31226238]

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology published a clinical practice guideline on nasal form and function after rhinoplasty, with a plain language summary written for patients. It sets what the surgeon should assess and record before operating on the airway.

Rests on: the clinical practice guideline · the plain language summary.

The surgeons' own textbook chapters

Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, carries chapters on the valve, on the grafts used to open it and on the tests used to measure the airway. They are written for surgeons and go further into technique than a patient page should.

• Management of the Internal Nasal Valve
• Treatment of Nasal Obstruction
• Endonasal Spreader Grafts
• Functional grafts in rhinoplasty
• Objective Measures of Nasal Airway Obstruction

The reference summary

Anatomy, Head and Neck, Nose in StatPearls and Rhinoplasty in StatPearls, on the National Library of Medicine's Bookshelf, give the anatomy, the indications and the complication list in full text at no charge.

The device records

The lateral nasal wall implant is a regulated medical device. The Food and Drug Administration runs the public databases that hold its premarket notification and the adverse events reported after use.

• Medical device databases, the index to all of them.
• Premarket notification database, searchable by device and manufacturer.
• MAUDE, the reported device adverse events.

The societies

• American Society of Plastic Surgeons, patient information.
• American Academy of Facial Plastic and Reconstructive Surgery, patient information.
• The Rhinoplasty Society, the surgeons' body, with its member directory. See associations.

The trials in progress

Valve surgery and the implants used in it are registered on ClinicalTrials.gov, so the evidence base moves.

• Latera RCT - Latera vs. Sham Control for Lateral Nasal Valve Collapse, completed, 137 participants.
• LATERA-OFFICE Study, completed, 166 participants.
• Evaluation of an Absorbable Implant for the Treatment of Nasal Valve Collapse, completed, 30 participants.
• Cartilage Remodeling Using Low-Temperature Radiofrequency for Nasal Airway Reconstruction, recruiting, 20 participants.

What is not settled

• The anatomy, terminology, evaluation and management of the nasal valve are all described as contested, with evidence that is plentiful and often low in quality. [27400837]
• The historic definition treats the valve as a two-dimensional cross-section. It is a three-dimensional collapsible structure, and the authors call for a new conceptual framework to guide surgical decisions. [39426874]
• The randomised implant trial followed patients to three months, and the supporting meta-analysis covers five studies and 396 patients. [31226238] [32282129]
• Batten grafts and lateral crural strut grafts could not be pooled because of heterogeneity, and no batten graft study used a standardised cosmetic outcome measure. [40922497]
• There is no agreed definition of normal pyriform aperture dimensions, so the indication for enlarging it rests on the individual surgeon's judgement. [33648407]
• Standardised definitions, consistent methods and validated outcome measures are named by reviewers as the missing pieces before any technique can be ranked against another. [27400837]