- Email: [email protected]
Nasal valve stabilization
Operative Techniques in Otolaryngology (2012) 23, 67-71
Nasal valve stabilization Edward M. Weaver, MD, MPHa,b From the aDepartment of Veterans Affairs Medical Center, Harborview Medical Center, and the b Department of Otolaryngology/Head & Neck Surgery, University of Washington, Seattle, Washington. KEYWORDS Nasal valve; Valve collapse; Valve stabilization
Nasal valve collapse is a challenging, but common, source of nasal obstruction. Many surgical techniques have been described to stabilize the nasal valve, but each has important limitations. Nasal valve stabilization is a new technique that draws on advantages of the nasal valve suspension techniques but minimizes the drawbacks associated with the suspension techniques. The indications, technique, advantages, and disadvantages are described herein. Published by Elsevier Inc.
Nasal valve compromise is a distinct cause of symptomatic nasal airway restriction, but it often remains a challenge to treat effectively.1 The internal nasal valve (“nasal valve”) is the triangular area of the nasal airway bounded by the septum medially, the caudal part of the upper lateral cartilage dorsolaterally, and the head of the inferior turbinate inferiorly (Figure 1). The nasal valve corresponds to the point of greatest resistance in the entire upper airway,2,3 so it is an important area of focus in the setting of nasal obstruction. Dynamic collapse of the upper lateral cartilage during inhalation (Figure 1) is a common cause of nasal valve compromise and symptomatic nasal obstruction. Although there are other important causes and treatments of nasal valve compromise, including mucosal inflammation treated with medication or structural abnormalities treated surgically, this article focuses on the direct treatment of upper lateral cartilage collapse. The direct surgical treatment of nasal valve collapse is aimed at lateralizing or stabilizing the upper lateral cartilage. Numerous techniques are available, including spreader grafts, batten grafts, vestibular skin flaps, implants, and suture dilation techniques.1,4,5 The suture dilation techniques share a common theme of retracting the upper lateral cartilages laterally by anchoring to another structure, such
as the orbital rim,6-8 the contralateral upper lateral cartilage,9 or the dorsal nasal soft tissues.10,11 The existing suture techniques sometimes work very well to open or stabilize the nasal valve, but they have important limitations. Each technique has an expanse of suture to the anchor point, so the optimal tension can be difficult to gauge intraoperatively. If the suture is too tight, it tends to deform the nose visibly, cause severe pain, or cut, like a cheese wire, through the upper lateral cartilage. If the suture is too loose, then there is little or no effect. The valve suspension technique usually requires hardware to anchor the suture, either with a screw or bone anchor.6-8 Each of these techniques also requires an incision outside the nose. These techniques usually are restricted to a single retraction and anchor point per side, and some anchor to soft tissues, which may be less durable than bone anchoring. The nasal valve stabilization is a new suture technique available to stabilize the collapsible nasal valve while addressing some of the aforementioned challenges. It is simple, requires only intranasal incisions, provides secure bony anchor points, easily allows multiple retraction and anchor points, does not change nasal appearance, and leaves no permanent foreign body.
Indications Address reprint requests and correspondence: Edward M. Weaver, MD, MPH, Department of Veterans Affairs Medical Center, Mailstop 112-OTO, 1660 South Columbian Way, Seattle, WA 98108-1957. E-mail address: [email protected]. 1043-1810/$ -see front matter Published by Elsevier Inc. doi:10.1016/j.otot.2011.09.008
The nasal valve stabilization technique can be performed in isolation or in combination with other nasal procedures. Nasal valve stabilization is indicated as a primary procedure
68
Operative Techniques in Otolaryngology, Vol 23, No 1, March 2012 Assessment of nasal valve compromise includes symptomatic and/or audible restriction of airflow on inhalation, especially if the upper lateral cartilage visually collapses (Figure 2).1 Sometimes nasal endoscopy facilitates visualization of collapse by allowing visualization without a speculum, which can inadvertently stabilize the nasal valve. A positive Cottle maneuver can help elucidate potential clinical benefits of dilating the nasal valve. A valve stabilization technique (Figure 2) may be more predictive of the effect of nasal valve stabilization than the Cottle maneuver. For this test, a thin rigid tool (eg, cotton-tip applicator) is positioned to prevent collapse of the upper lateral cartilage without dilating the nasal valve, and the patient is asked to sniff. Audible and/or symptomatic airflow improvement suggests a valve stabilization procedure may be helpful.
Figure 1 Nasal valve anatomy (internal). Speculum examination of the right internal nasal valve (V), the space bounded by the caudal aspect of the upper lateral cartilage (ULC), the anterior part of the inferior turbinate (T), and the septum (S). Nasal valve collapse occurs when the upper lateral cartilage collapses medially (arrow) during nasal inspiration.
in the setting of isolated nasal valve collapse without other nasal deformities. If other structural abnormalities contribute to nasal valve compromise, then valve stabilization can be performed with other nasal procedures (eg, septoplasty), or it can be reserved for a secondary procedure if there is significant residual nasal valve collapse after the primary nasal surgery. This procedure uses an incision similar to inferior turbinate submucous resection, so it is particularly simple to combine that procedure. Nasal valve stabilization is also easily performed in patients who have had previous nasal surgery, even if there were multiple or complex previous surgeries.
Technique The procedure is typically performed in the operating room under general anesthesia; however, it can be performed under local anesthesia. Preoperative topical decongestant is applied to the nasal mucosa. The operative set up is similar to other nasal procedures, such as turbinate submucous resection. Transverse (horizontal) speculum placement easily exposes the piriform rim (Figure 3). A mixture of local anesthetic and vasoconstrictor is injected into the soft tissue overlying the piriform rim while visualizing directly by anterior rhinoscopy (Figure 4). After adequate time for vasoconstrictor effect, a needlepoint electrocautery incision is made over the piriform rim up toward the upper lateral cartilage and nasal bone (Figure 5). Subperiosteal dissection along the medial and lateral aspects of the rim exposes 5 mm of the bony rim up toward the nasal bones and inferiorly toward the attachment of the inferior turbinate bone (Figure 6).
Figure 2 Valve stabilization test. Stabilization of the right upper lateral cartilage with a cotton-tip applicator prevents nasal valve collapse and helps determine the effect of nasal valve stabilization. A, Collapse of right nasal valve during inspiration. B, Improved airflow with nasal valve stabilization confirming nasal valve compromise and possible improvement with nasal valve stabilization procedure.
Weaver
Nasal Valve Stabilization
69
Figure 5 Piriform rim incision. A needlepoint electrocautery incision is made through the intranasal epithelium overlying the piriform rim. Figure 3 Exposure of the piriform rim. While the patient is under anesthesia, lateral orientation of the speculum allows excellent exposure of the piriform rim (dashed line).
A short, small drill bit (eg, 6-mm length, 0.76-mm diameter) is used to drill 3 or 4 holes in the piriform rim 1 to 2 mm from the bony rim (Figure 6). The nasal speculum can be used to protect the nasal soft tissues while drilling, and only a small amount of irrigation is needed. It is preferable to have one or more drill holes superior to the caudal edge of the upper lateral cartilage, if possible. A suture is used to anchor the upper lateral cartilage to the bony rim. The suture is passed through the top drill hole
Figure 4 Piriform rim injection. Local anesthetic and vasoconstrictor are injected along the piriform rim near the upper lateral cartilage.
from lateral to medial, then through the upper lateral cartilage into the nasal cavity (Figure 7). The suture is passed back through the nasal mucosa overlying the upper lateral cartilage, through the cartilage into the surgical wound anterior to the bony rim (Figure 8). This results in a loop of suture through the upper lateral cartilage and around the bony bridge between the drill hole and edge of the piriform rim (Figure 9). There is exposed suture along the mucosa of the upper lateral cartilage. This segment of suture can be buried submucosally by incising the underlying mucosa superficially. The suture is tagged, and another 1 to 3 sutures are passed through the other holes to create multiple anchor points. Usually only the superior 2 sutures are passed
Figure 6 Piriform rim drill holes. After periosteal elevation to expose 5 mm of the piriform rim along the height of the incision, 0.76-mm holes are drilled in 2 to 4 locations along the piriform rim near the upper lateral cartilage.
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Operative Techniques in Otolaryngology, Vol 23, No 1, March 2012
Figure 7 Stabilization suture through the upper lateral cartilage: first throw. A 2-0 polyglycolic (absorbable, synthetic, braided) suture is passed through a drill hole and straight through the upper lateral cartilage into the nasal cavity.
through the upper lateral cartilage, and the inferior 1 to 2 sutures are passed through the lateral nasal mucosa to pin it laterally to the bony aperture. The sutures are tied tightly and cut at the knot. If the patient also has an alar rim collapse (“external nasal valve collapse”), then the suture
Figure 9 Stabilization suture tied (close-up view). The stabilization suture is tied tightly around the bony bridge between the drill hole and the rim edge, retracting and stabilizing the upper lateral cartilage. The visible effect on the upper lateral cartilage is exaggerated in the drawing to demonstrate the effect, but the suture keeps the upper lateral cartilage from collapsing medially. Two to four sutures are passed to provide multisite stabilization of the upper lateral cartilage and lateral nasal tissue (not shown).
can also be passed through alar tissue to help stabilize it, but care must be taken to avoid alar distortion when tightening the suture. The incision is closed with a fine absorbable suture (eg, 5-0 chromic gut suture; Figure 10), and the same procedure is performed on the contralateral side if needed. The author uses a 2-0 polyglycolic acid (absorbable, synthetic, braided) suture on a 17-mm, half-circle, taperpoint needle to stabilize the upper lateral cartilage. Even after the suture eventually reabsorbs, the valve stabilization appears to hold, presumably related to submucosal scar formation along the suture tract and surgical dissection. Alternatively, a permanent suture, such as 3-0 braided polyester suture can be used, but it adds the risk of future granuloma or foreign body reaction.
Complications
Figure 8 Stabilization suture through the upper lateral cartilage: Return throw (close-up view). The suture is passed back through the upper lateral cartilage into the surgical wound and around the piriform rim.
One of the advantages of this technique is the low risk of complications. The most common complication is incomplete treatment effect or persistent nasal valve collapse, but all valve surgery techniques suffer this risk.4 In the author’s experience, this valve stabilization method is more consistent than the valve suspension techniques, and with fewer complications. The temporarily exposed intranasal suture can become crusted, but this problem is managed easily with petrolatum ointment application twice daily until suture is reabsorbed or submucosal placement of this segment of suture. Occasionally granulation tissue will form at the
Weaver
Nasal Valve Stabilization
71 have had multiple prior rhinoplastic procedures when other valve procedures are risky or not possible. Since it leaves no permanent foreign body and requires little dissection, longterm risks are minimal. However, the nasal valve stabilization is not perfect. It only addresses dynamic collapse and not anatomic narrowing of the nasal valve area. It often provides only partial valve stabilization, just like every other nasal valve surgical techniques. Because no valve surgery is uniformly successful, minimization of morbidity is an important goal. This valve stabilization technique achieves that important goal while providing a simple and often useful tool to manage nasal valve collapse.
Acknowledgment This material is the result of work supported by resources from the VA Puget Sound Health Care System, Seattle, Washington.
Figure 10 Wound closed and upper lateral cartilage stabilized. The incision is closed with interrupted 5-0 chromic gut suture. The upper lateral cartilage and lateral nasal tissues are stabilized by multiple sutures.
suture site, but it typically resolves as the suture is reabsorbed. If needed, silver nitrate cautery can be applied to granulation tissue. In more than 50 nasal valve stabilization procedures, the author has not encountered nasal deformities or infections requiring reoperation. One case developed a persistent granuloma at the knot prompting later scar/ granuloma excision intranasally, a minor procedure.
Discussion The nasal valve stabilization technique is a variation of the nasal valve suspension technique, but it offers some potential advantages. The stabilization technique easily allows multiple stabilization points. It does not require an extranasal incision, and it does not change the nasal appearance. It takes guesswork out of how tight to tie the sutures. It anchors strongly to bone without any permanent foreign body. It is a minor procedure requiring a simple intranasal incision. It can be performed in isolation or in combination with other nasal procedures. It can be employed as a primary procedure or as a secondary procedure after prior nasal surgery. It can often be performed in patients who
References 1. Rhee JS, Weaver EM, Park SS, et al: Clinical consensus statement: Diagnosis and management of nasal valve compromise. Otolaryngol Head Neck Surg 143:48-59, 2010 2. Zambetti G, Filiaci F, Romeo R, et al: Assessment of Cottle’s areas through the application of a mathematical model deriving from acoustic rhinometry and rhinomanometric data. Clin Otolaryngol 30:128134, 2005 3. Lenders H, Schaefer J, Pirsig W: Turbinate hypertrophy in habitual snorers and patients with obstructive sleep apnea: findings of acoustic rhinometry. Laryngoscope 101:614-618, 1991 4. Rhee JS, Arganbright JM, McMullin BT, et al: Evidence supporting functional rhinoplasty or nasal valve repair: A 25-year systematic review. Otolaryngol Head Neck Surg 139:10-20, 2008 5. Golde AR: Rhinoplastic techniques for the nasal valve for the patient with sleep apnea. Op Tech Otol 17:242-251, 2006 6. Paniello RC: Nasal valve suspension. An effective treatment for nasal valve collapse. Arch Otolaryngol Head Neck Surg 122:1342-1346, 1996 7. Friedman M, Ibrahim H, Lee G, et al: A simplified technique for airway correction at the nasal valve area. Otolaryngol Head Neck Surg 131:519-524, 2004 8. Friedman M, Ibrahim H, Syed Z: Nasal valve suspension: an improved, simplified technique for nasal valve collapse. Laryngoscope 113:381-385, 2003 9. Park SS: The flaring suture to augment the repair of the dysfunctional nasal valve. Plast Reconstr Surg 101:1120-1122, 1998 10. Rizvi SS, Gauthier MG: Lateralizing the collapsed nasal valve. Laryngoscope 113:2052-2054, 2003 11. Rizvi SS, Gauthier MG: Lateralizing the collapsed nasal valves simplified: 10-year survey of a simple concealed suture technique. Laryngoscope 121:558-561, 2011
Nasal valve stabilization Edward M. Weaver, MD, MPHa,b From the aDepartment of Veterans Affairs Medical Center, Harborview Medical Center, and the b Department of Otolaryngology/Head & Neck Surgery, University of Washington, Seattle, Washington. KEYWORDS Nasal valve; Valve collapse; Valve stabilization
Nasal valve collapse is a challenging, but common, source of nasal obstruction. Many surgical techniques have been described to stabilize the nasal valve, but each has important limitations. Nasal valve stabilization is a new technique that draws on advantages of the nasal valve suspension techniques but minimizes the drawbacks associated with the suspension techniques. The indications, technique, advantages, and disadvantages are described herein. Published by Elsevier Inc.
Nasal valve compromise is a distinct cause of symptomatic nasal airway restriction, but it often remains a challenge to treat effectively.1 The internal nasal valve (“nasal valve”) is the triangular area of the nasal airway bounded by the septum medially, the caudal part of the upper lateral cartilage dorsolaterally, and the head of the inferior turbinate inferiorly (Figure 1). The nasal valve corresponds to the point of greatest resistance in the entire upper airway,2,3 so it is an important area of focus in the setting of nasal obstruction. Dynamic collapse of the upper lateral cartilage during inhalation (Figure 1) is a common cause of nasal valve compromise and symptomatic nasal obstruction. Although there are other important causes and treatments of nasal valve compromise, including mucosal inflammation treated with medication or structural abnormalities treated surgically, this article focuses on the direct treatment of upper lateral cartilage collapse. The direct surgical treatment of nasal valve collapse is aimed at lateralizing or stabilizing the upper lateral cartilage. Numerous techniques are available, including spreader grafts, batten grafts, vestibular skin flaps, implants, and suture dilation techniques.1,4,5 The suture dilation techniques share a common theme of retracting the upper lateral cartilages laterally by anchoring to another structure, such
as the orbital rim,6-8 the contralateral upper lateral cartilage,9 or the dorsal nasal soft tissues.10,11 The existing suture techniques sometimes work very well to open or stabilize the nasal valve, but they have important limitations. Each technique has an expanse of suture to the anchor point, so the optimal tension can be difficult to gauge intraoperatively. If the suture is too tight, it tends to deform the nose visibly, cause severe pain, or cut, like a cheese wire, through the upper lateral cartilage. If the suture is too loose, then there is little or no effect. The valve suspension technique usually requires hardware to anchor the suture, either with a screw or bone anchor.6-8 Each of these techniques also requires an incision outside the nose. These techniques usually are restricted to a single retraction and anchor point per side, and some anchor to soft tissues, which may be less durable than bone anchoring. The nasal valve stabilization is a new suture technique available to stabilize the collapsible nasal valve while addressing some of the aforementioned challenges. It is simple, requires only intranasal incisions, provides secure bony anchor points, easily allows multiple retraction and anchor points, does not change nasal appearance, and leaves no permanent foreign body.
Indications Address reprint requests and correspondence: Edward M. Weaver, MD, MPH, Department of Veterans Affairs Medical Center, Mailstop 112-OTO, 1660 South Columbian Way, Seattle, WA 98108-1957. E-mail address: [email protected]. 1043-1810/$ -see front matter Published by Elsevier Inc. doi:10.1016/j.otot.2011.09.008
The nasal valve stabilization technique can be performed in isolation or in combination with other nasal procedures. Nasal valve stabilization is indicated as a primary procedure
68
Operative Techniques in Otolaryngology, Vol 23, No 1, March 2012 Assessment of nasal valve compromise includes symptomatic and/or audible restriction of airflow on inhalation, especially if the upper lateral cartilage visually collapses (Figure 2).1 Sometimes nasal endoscopy facilitates visualization of collapse by allowing visualization without a speculum, which can inadvertently stabilize the nasal valve. A positive Cottle maneuver can help elucidate potential clinical benefits of dilating the nasal valve. A valve stabilization technique (Figure 2) may be more predictive of the effect of nasal valve stabilization than the Cottle maneuver. For this test, a thin rigid tool (eg, cotton-tip applicator) is positioned to prevent collapse of the upper lateral cartilage without dilating the nasal valve, and the patient is asked to sniff. Audible and/or symptomatic airflow improvement suggests a valve stabilization procedure may be helpful.
Figure 1 Nasal valve anatomy (internal). Speculum examination of the right internal nasal valve (V), the space bounded by the caudal aspect of the upper lateral cartilage (ULC), the anterior part of the inferior turbinate (T), and the septum (S). Nasal valve collapse occurs when the upper lateral cartilage collapses medially (arrow) during nasal inspiration.
in the setting of isolated nasal valve collapse without other nasal deformities. If other structural abnormalities contribute to nasal valve compromise, then valve stabilization can be performed with other nasal procedures (eg, septoplasty), or it can be reserved for a secondary procedure if there is significant residual nasal valve collapse after the primary nasal surgery. This procedure uses an incision similar to inferior turbinate submucous resection, so it is particularly simple to combine that procedure. Nasal valve stabilization is also easily performed in patients who have had previous nasal surgery, even if there were multiple or complex previous surgeries.
Technique The procedure is typically performed in the operating room under general anesthesia; however, it can be performed under local anesthesia. Preoperative topical decongestant is applied to the nasal mucosa. The operative set up is similar to other nasal procedures, such as turbinate submucous resection. Transverse (horizontal) speculum placement easily exposes the piriform rim (Figure 3). A mixture of local anesthetic and vasoconstrictor is injected into the soft tissue overlying the piriform rim while visualizing directly by anterior rhinoscopy (Figure 4). After adequate time for vasoconstrictor effect, a needlepoint electrocautery incision is made over the piriform rim up toward the upper lateral cartilage and nasal bone (Figure 5). Subperiosteal dissection along the medial and lateral aspects of the rim exposes 5 mm of the bony rim up toward the nasal bones and inferiorly toward the attachment of the inferior turbinate bone (Figure 6).
Figure 2 Valve stabilization test. Stabilization of the right upper lateral cartilage with a cotton-tip applicator prevents nasal valve collapse and helps determine the effect of nasal valve stabilization. A, Collapse of right nasal valve during inspiration. B, Improved airflow with nasal valve stabilization confirming nasal valve compromise and possible improvement with nasal valve stabilization procedure.
Weaver
Nasal Valve Stabilization
69
Figure 5 Piriform rim incision. A needlepoint electrocautery incision is made through the intranasal epithelium overlying the piriform rim. Figure 3 Exposure of the piriform rim. While the patient is under anesthesia, lateral orientation of the speculum allows excellent exposure of the piriform rim (dashed line).
A short, small drill bit (eg, 6-mm length, 0.76-mm diameter) is used to drill 3 or 4 holes in the piriform rim 1 to 2 mm from the bony rim (Figure 6). The nasal speculum can be used to protect the nasal soft tissues while drilling, and only a small amount of irrigation is needed. It is preferable to have one or more drill holes superior to the caudal edge of the upper lateral cartilage, if possible. A suture is used to anchor the upper lateral cartilage to the bony rim. The suture is passed through the top drill hole
Figure 4 Piriform rim injection. Local anesthetic and vasoconstrictor are injected along the piriform rim near the upper lateral cartilage.
from lateral to medial, then through the upper lateral cartilage into the nasal cavity (Figure 7). The suture is passed back through the nasal mucosa overlying the upper lateral cartilage, through the cartilage into the surgical wound anterior to the bony rim (Figure 8). This results in a loop of suture through the upper lateral cartilage and around the bony bridge between the drill hole and edge of the piriform rim (Figure 9). There is exposed suture along the mucosa of the upper lateral cartilage. This segment of suture can be buried submucosally by incising the underlying mucosa superficially. The suture is tagged, and another 1 to 3 sutures are passed through the other holes to create multiple anchor points. Usually only the superior 2 sutures are passed
Figure 6 Piriform rim drill holes. After periosteal elevation to expose 5 mm of the piriform rim along the height of the incision, 0.76-mm holes are drilled in 2 to 4 locations along the piriform rim near the upper lateral cartilage.
70
Operative Techniques in Otolaryngology, Vol 23, No 1, March 2012
Figure 7 Stabilization suture through the upper lateral cartilage: first throw. A 2-0 polyglycolic (absorbable, synthetic, braided) suture is passed through a drill hole and straight through the upper lateral cartilage into the nasal cavity.
through the upper lateral cartilage, and the inferior 1 to 2 sutures are passed through the lateral nasal mucosa to pin it laterally to the bony aperture. The sutures are tied tightly and cut at the knot. If the patient also has an alar rim collapse (“external nasal valve collapse”), then the suture
Figure 9 Stabilization suture tied (close-up view). The stabilization suture is tied tightly around the bony bridge between the drill hole and the rim edge, retracting and stabilizing the upper lateral cartilage. The visible effect on the upper lateral cartilage is exaggerated in the drawing to demonstrate the effect, but the suture keeps the upper lateral cartilage from collapsing medially. Two to four sutures are passed to provide multisite stabilization of the upper lateral cartilage and lateral nasal tissue (not shown).
can also be passed through alar tissue to help stabilize it, but care must be taken to avoid alar distortion when tightening the suture. The incision is closed with a fine absorbable suture (eg, 5-0 chromic gut suture; Figure 10), and the same procedure is performed on the contralateral side if needed. The author uses a 2-0 polyglycolic acid (absorbable, synthetic, braided) suture on a 17-mm, half-circle, taperpoint needle to stabilize the upper lateral cartilage. Even after the suture eventually reabsorbs, the valve stabilization appears to hold, presumably related to submucosal scar formation along the suture tract and surgical dissection. Alternatively, a permanent suture, such as 3-0 braided polyester suture can be used, but it adds the risk of future granuloma or foreign body reaction.
Complications
Figure 8 Stabilization suture through the upper lateral cartilage: Return throw (close-up view). The suture is passed back through the upper lateral cartilage into the surgical wound and around the piriform rim.
One of the advantages of this technique is the low risk of complications. The most common complication is incomplete treatment effect or persistent nasal valve collapse, but all valve surgery techniques suffer this risk.4 In the author’s experience, this valve stabilization method is more consistent than the valve suspension techniques, and with fewer complications. The temporarily exposed intranasal suture can become crusted, but this problem is managed easily with petrolatum ointment application twice daily until suture is reabsorbed or submucosal placement of this segment of suture. Occasionally granulation tissue will form at the
Weaver
Nasal Valve Stabilization
71 have had multiple prior rhinoplastic procedures when other valve procedures are risky or not possible. Since it leaves no permanent foreign body and requires little dissection, longterm risks are minimal. However, the nasal valve stabilization is not perfect. It only addresses dynamic collapse and not anatomic narrowing of the nasal valve area. It often provides only partial valve stabilization, just like every other nasal valve surgical techniques. Because no valve surgery is uniformly successful, minimization of morbidity is an important goal. This valve stabilization technique achieves that important goal while providing a simple and often useful tool to manage nasal valve collapse.
Acknowledgment This material is the result of work supported by resources from the VA Puget Sound Health Care System, Seattle, Washington.
Figure 10 Wound closed and upper lateral cartilage stabilized. The incision is closed with interrupted 5-0 chromic gut suture. The upper lateral cartilage and lateral nasal tissues are stabilized by multiple sutures.
suture site, but it typically resolves as the suture is reabsorbed. If needed, silver nitrate cautery can be applied to granulation tissue. In more than 50 nasal valve stabilization procedures, the author has not encountered nasal deformities or infections requiring reoperation. One case developed a persistent granuloma at the knot prompting later scar/ granuloma excision intranasally, a minor procedure.
Discussion The nasal valve stabilization technique is a variation of the nasal valve suspension technique, but it offers some potential advantages. The stabilization technique easily allows multiple stabilization points. It does not require an extranasal incision, and it does not change the nasal appearance. It takes guesswork out of how tight to tie the sutures. It anchors strongly to bone without any permanent foreign body. It is a minor procedure requiring a simple intranasal incision. It can be performed in isolation or in combination with other nasal procedures. It can be employed as a primary procedure or as a secondary procedure after prior nasal surgery. It can often be performed in patients who
References 1. Rhee JS, Weaver EM, Park SS, et al: Clinical consensus statement: Diagnosis and management of nasal valve compromise. Otolaryngol Head Neck Surg 143:48-59, 2010 2. Zambetti G, Filiaci F, Romeo R, et al: Assessment of Cottle’s areas through the application of a mathematical model deriving from acoustic rhinometry and rhinomanometric data. Clin Otolaryngol 30:128134, 2005 3. Lenders H, Schaefer J, Pirsig W: Turbinate hypertrophy in habitual snorers and patients with obstructive sleep apnea: findings of acoustic rhinometry. Laryngoscope 101:614-618, 1991 4. Rhee JS, Arganbright JM, McMullin BT, et al: Evidence supporting functional rhinoplasty or nasal valve repair: A 25-year systematic review. Otolaryngol Head Neck Surg 139:10-20, 2008 5. Golde AR: Rhinoplastic techniques for the nasal valve for the patient with sleep apnea. Op Tech Otol 17:242-251, 2006 6. Paniello RC: Nasal valve suspension. An effective treatment for nasal valve collapse. Arch Otolaryngol Head Neck Surg 122:1342-1346, 1996 7. Friedman M, Ibrahim H, Lee G, et al: A simplified technique for airway correction at the nasal valve area. Otolaryngol Head Neck Surg 131:519-524, 2004 8. Friedman M, Ibrahim H, Syed Z: Nasal valve suspension: an improved, simplified technique for nasal valve collapse. Laryngoscope 113:381-385, 2003 9. Park SS: The flaring suture to augment the repair of the dysfunctional nasal valve. Plast Reconstr Surg 101:1120-1122, 1998 10. Rizvi SS, Gauthier MG: Lateralizing the collapsed nasal valve. Laryngoscope 113:2052-2054, 2003 11. Rizvi SS, Gauthier MG: Lateralizing the collapsed nasal valves simplified: 10-year survey of a simple concealed suture technique. Laryngoscope 121:558-561, 2011