Nasal valve malfunction resulting from resection of cancer

Following cancer resection of the nasal unit, nasal valve malfunction is manifested by the symptoms of nasal stuffiness or difficulty getting air into the nostril. These symptoms occur in cases in which the resection is in the alar crease at the junction with the lateral sidewall of the nose. Wound scar contracture elevates the alar margin and causes the alar and lateral cartilages to move inward forming a visible and palpable shelf on the lateral wall of the nasal vestibule. This displacement of the alar and lateral cartilages and the rigid scar formed between these cartilages render the nasal valve immobile. Since it is easier to prevent nasal valve malfunction than to repair it later, wounds that bridge the alar crease or are located in either the alae or lateral sidewall and come within 1 mm of the alar crease with a total diameter of 1.0 cm should be repaired to prevent nasal valve malfunction. In the process of repairing deep defects, the overlapping region of the lateral crus of the alar cartilage and the lateral cartilage may be stabilized by a conchal cartilage graft. This cartilage graft may be used in combination with reconstruction of the nasal skin with a forehead flap and repair of the nasal lining. In the event that the nasal lining is intact, the cartilage graft may be used with a full-thickness skin graft.     

Histological structure of the nasal cartilages and their perichondrial envelope. II. The perichondrial envelope of the septal and lobular cartilage

The perichondrial envelopes of the septal cartilage and the lateral crus of the lobular cartilage were studied in serial coronal sections of five human noses. To differentiate between the various tissue components, the sections were stained according to Mallory-Cason, Azan, Herovici, Verhoeff-van Gieson, and Lawson. Collagen types I and II were immunohistochemically stained. The results demonstrated that the perichondrium of the septal cartilage and the lateral crus of the lobular cartilage consists of a homogeneous layer of type I collagen fibers and elastic fibers. The elastic fibers have a network-like arrangement and are most numerous in the perichondrium of the lateral crus of the lobular cartilage. Clearly distinguishable zones in the perichondrial envelopes could not be observed. The perichondrium on the outside of the lateral crus of the lobular cartilage and the triangular cartilage is significantly thicker than the inner perichondrium. It is speculated that these morphological characteristics of the perichondrial envelopes are related to functional differences between the cartilages. The mobility of the lateral crus of the lobular cartilage requires a higher content of elastic fibers in its perichondrium than the more rigid septal cartilage. A thicker outer perichondrium of the lateral crus of the lobular cartilage and the triangular cartilage may be related to muscular forces that are exerted on the outer side of the cartilages only.     

Electromyography of the human nasal muscles

Electromyographic (EMG) activity of six nasal muscles was monitored in 17 male volunteers without nasal complaints. Surface electrodes were placed on the nasal skin in such a way that they selectively recorded the activity of these muscles. Recordings were made under different breathing conditions and during voluntary nasal movements. Inspiratory EMG activity was observed during nasal and oral breathing in one or more of the following muscles: dilator naris, nasalis muscle (alar and transverse parts) and apicis nasi. EMG activity increased markedly in response to physical exercise and was more often present in subjects with decreased nasal patency. During voluntary nasal movements a combined activity of the six nasal muscles was consistently found. We conclude that the function of the dilator naris, the nasalis muscle and the apicis nasi strongly relates to respiration. These muscles probably contribute to the prevention of collapse of the nasal valve. The role of the procerus and levator labii superioris alaeque nasi seems to be primarily concerned with facial expression.     

Management of severe bilateral nasal wall collapse

OBJECTIVE: The aim of this study was to examine and analyze the pathology contributing to severe bilateral nasal wall collapse seen in certain revision rhinoplasty patients and identify those surgical maneuvers in the previous nasal surgery, which may have contributed to this complication; suggest alternatives or modifying steps in nasal surgery to prevent lateral wall collapse; analyze consecutive revision rhinoplasties and identify those patients who have complete bilateral nasal collapse at the internal nasal valve; and analyze the results achieved after surgical reconstruction of complete bilateral nasal collapse. PATIENTS: We identified 49 patients, who presented from 1990 to 2000 for revision surgery, who had bilateral collapse of the upper lateral cartilage. All patients had at least one previous rhinoplasty and all but 14 patients had undergone two or more procedures. The patients were reconstructed with a conchal cartilage graft placed through an external rhinoplasty approach. RESULTS: All patients complained of nasal obstruction with forced nasal inspiration. The collapse was visualized on inspiration and when prevented with intranasal positioning of a bayonet, all patients experienced an immediate improvement in nasal breathing. Postoperatively, all patients experienced this same improvement in their nasal airway. Collapse was not identified in any of the patients after surgery. Two patients underwent revision because of cosmetic asymmetries. CONCLUSION: We strongly recommend a cartilage overlay to reconstitute the rigid midline continuity of the upper lateral cartilages. Unfortunately, with any significant hump removal, this structural interruption is, to varying degrees, inevitable in most rhinoplasty techniques. The upper lateral cartilages can be sutured to circumvent some of the inferior drift, but this will not reconstitute the rigid lateral cantilever effect of the intact cartilage.     

Optimizing treatment of nasal fractures

OBJECTIVES/HYPOTHESIS: A graduated protocol involving closed reduction, septoplasty, osteotomies, upper lateral cartilage release, anterior perpendicular plate fracture, and camouflaging cartilage grafts yields a higher percentage of straight noses in cases of acute fracture than treatment with closed reduction alone. STUDY DESIGN: Retrospective chart and literature review followed by a prospective, non-randomized sequential trial. METHODS: Closed reduction was performed on 26 cases of acute nasal fracture and the results were compared with a subsequent series of 79 cases treated using a more complete protocol. RESULTS: The cases treated with the more complete protocol yielded straighter noses. The difference was statistically significant using Wilcoxon rank sum analysis at the P=.028 level. CONCLUSIONS: Treatment of the acutely fractured nose involving an individually tailored protocol of closed reduction, septoplasty, osteotomies, release of the upper lateral cartilages, fracture of the anterior extension of the perpendicular plate of the ethmoid, and camouflaging cartilage grafts yields straighter noses than treatment by closed reduction alone.     

Effect of alar nasal valve stent on nasal breathing

PurposeLateral nasal wall insufficiency has previously been a surgical challenge. In 2018, the Alar Nasal Valve Stent (Medtronic) was taken into use at Helsinki University Hospital. The alar cartilages are repositioned and locked into position with the Alar Nasal Valve Stent on the mucosa. The stent gives support and widens the alar valve while cartilages scar into their new position presumably facilitating breathing after removal of the stent. The aim of this prospective, observational study was to investigate whether the Alar Nasal Valve Stent has an effect on nasal breathing in patients with lateral nasal wall insufficiency.Materials and methodsSymptom questionnaires (Sino-Nasal Outcome Test-22, Nasal Obstruction Symptom Evaluation, five-step symptom score) were analyzed preoperatively and at 3, 6, and 12 months postoperatively. Acoustic rhinometry, rhinomanometry, and peak nasal inspiratory flow were analyzed preoperatively and 3 months postoperatively. The patients performed a stress ergometry preoperatively and 3 months postoperatively, with their noses being photographed and filmed.ResultsIn a series of 18 patients, a significant positive difference was seen in subjective symptom scores preoperatively versus postoperatively. The difference remained stable throughout the follow-up. No difference in objective symptom measurements was observed.ConclusionsPatients suffering from lateral nasal wall insufficiency experience a significant subjective improvement in nasal breathing after Alar Nasal Valve Stent surgery.     

Nasalis myocutaneous flap for nasal reconstruction

Eight patients underwent reconstruction of the nasal supratip using nasalis myocutaneous flaps. This flap's blood supply is an axial blood supply from the nasalis muscle. The muscle originates from the piriform aperature and stretches out into an aponeurosis that attaches into the dermis in the nasal supratip and tip areas. Tumor defects 1 to 2 cm in diameter have been reconstructed using this versatile flap. I have been very impressed with natural alar contour, skin texture, and color matching using these flaps. The nasalis myocutaneous flap can be advanced up to 1.5 cm and can be used for lateral nasal wall and central nasal tip defects.     

The obstructive nasal septum. Effect of simulated deviations on nasal airflow resistance

Effects of simulated septal deviations on nasal airflow resistances were assessed by rhinomanometry in healthy human adults. Obstructions 5 x 15 mm protruding 1 to 5 mm into the nasal lumen were applied to the septum in untreated and decongested nasal cavities. The most resistive septal site was located opposite the caudal edge of the upper lateral cartilage where a 3-mm deviation increased resistance substantially in untreated noses, but produced no resistive effect when the mucosa was decongested, whereas a 4-mm deviation increased resistance severely at this site in untreated and decongested noses. Deviations at the caudal end of the septum that overlapped the upper lateral cartilage were markedly resistive also, while near the cavum they were less resistive. Decongestion reduced resistance and length of this anterior-resistive nasal segment. By contrast, within the cavum neither deviations of 5 mm nor mucosal status affected resistance. It is concluded that airflow resistance of the nasal cavum is unresponsive to septal deviations and mucosal status, but the anterior part of the nose is most susceptible and differences of 1 mm in lumen can be critical.     

Septal cartilage graft for nasal valve incompetence associated with deviated septum

BACKGROUND: The nasal valve is one of the major factors contributing to nasal airflow obstruction. Physiologically, the nasal valve offers the greatest resistance to nasal airflow and generally functions as an inflow device controlling nasal airflow and resistance. Many patients who have complaints of breathing impairment are affected by alterations of the nasal septum, the turbinates, the columellar base, the vestibule floor, or the lateral wall of the nose but may have associated incompetence of the nasal valve, which is too often undervalued by nasal surgeons. The aim of this study was to propose a relatively easy surgical technique to correct most nasal valve impairments associated with nasal septum deviation whether or not there also is inferior turbinate hypertrophy. METHODS: Between May 2004 and September 2006, 68 patients (26 women and 42 men; mean age, 37 years; range, 16-71 years) underwent primary or secondary functional nasal surgery, because of a nasal respiratory obstruction caused by nasal septal deviation eventually associated with inferior turbinates hypertrophy, and also demonstrated nasal valvular incompetence. A septal cartilage graft was used to correct the valvular incompetence. RESULTS: On postoperative visits almost all of the patients (with one exception) showed a remarkable improvement in the stiffening of the valvular region and had only minimal depression of the nostril during deep inspiration. CONCLUSION: This study indicated that septal grafts were useful in the surgical management of nasal respiratory impairment because of nasal valve incompetence, where there had been flaccid mobile collapse of the ala of the nose associated with septal alterations.     

Avulsion of the upper lateral cartilage: Etiology,diagnosis, surgical anatomy and management

Relatively little has been published about upper lateral cartilage abnormalities, trauma, and management in rhinoplastic literature. In this paper we would like to present a relatively common problem seen either by trauma or as a result of rhinoplasty. The upper lateral cartilages are a pair of triangular cartilages, one on each side of the dorsum, which comprise the upper cartilaginous vault with the septum and can be avulsed due to direct trauma. This results in loss of their attachments and resultant healing in a new angulated position. The middle third of the nose, being relatively mobile, is less susceptible to trauma than the upper third which is rigid and comprised of bone, and that frequently is the reason for less incidence of avulsion of the upper lateral cartilages compared to fractured nasal bones. The surgical treatment of the structures adjacent to the upper lateral cartilage during the process of rhinoplasty severs many attachments of these cartilages and frequently causes them to be free floating. This may not be recognized and not treated. Lack of appropriate realignment in the normal anatomical position may heal the cartilage in a distorted angulated position. Irrespective of etiology, when distortions of the upper lateral cartilage occur, they may cause significant concavity and “hollowed out” appearance on the side of the avulsion which functionally may impede the nasal airway by encroachment and/or “flutter valve” effect. During inspiration this unsupported upper lateral cartilage may interfere with anatomy, physiology and efficiency of the internal nasal valve function. Avulsion of the upper lateral cartilage is a definite entity and should be recognized and treated appropriately to realign the lateral cartilage in its normal anatomical position for a functional as well as a good cosmetic result.     

Surgery of the incompetent nasal valve

One of the causes of nasal airway obstruction during inspiration is an incompetent nasal valve. An incompetent valve is one that collapses during quiet normal breathing due to narrowing of the valve area, a loss of upper and/or lower lateral cartilage support, or a combination of these. The most common etiology is a previous rhinoplasty; trauma and aging are other causes. Treatment is surgical and consists of replacing what is missing with similar tissue. If only the vestibular skin is scarred, a skin graft is used. If cartilage alone is missing, a cartilage graft is inserted. If both skin and cartilage are absent, a composite graft from the concha is the best choice.     

Histological structure of the nasal cartilages and their perichondrial envelope. I. The septal and lobular cartilage

The cellular elements and extracellular matrix of the nasal septal cartilage and the lateral crus of the lobular cartilage were studied in serial coronal sections of five human cadaver noses. To discern the various tissue components, the sections were stained according to the methods of Mallory-Cason, Azan, Herovici, Verhoeff-van Gieson, and Lawson as well as by immunohistochemistry to demonstrate the presence of collagen type I and II. A characteristic gradual transition of the chondrocytes was observed in both septal and lobular cartilage: from numerous small flat cells oriented parallel to the surface of the cartilage to less numerous larger ovaloid cells oriented perpendicular to the surface. This difference between the peripheral and central zones of the cartilage was particularly marked in lobular cartilage. Both septal and lobular cartilage have a high density of type II collagen but almost none of type I. The peripheral zones of the matrix showed a higher density of collagen than the central zone. This difference was more pronounced in septal than lobular cartilage. The high density of type II collagen in septal cartilage, particularly in the peripheral zones, suggests that one of the primary tasks of the septum is providing stiffness to the external nose. That idea is consistent with findings from our study of the perichondrial envelope.     

Intranasal electromyography in evaluation of the nasal valve

OBJECTIVES: The present study was performed to investigate the best way of using surface electromyography (sEMG) in evaluation of muscle involvement in nasal valve function. The function of the nasal muscles in nasal valve movements has not been investigated sufficiently and in the present study we tried to improve the way of testing these muscles introducing the intranasal placement of surface EMG electrodes. METHODS: Skin surface electromyography (EMG) and intranasal electrode EMG investigation of nasal muscles was performed in two groups (n = 30 for each Group) of healthy subjects: (1) subjects with extremely effective coordination of nasal muscles and (2) those with extremely poor coordination of nasal muscles. Functions of the nasal muscles were assessed by EMG in response to breathing and voluntary nasal movements. RESULTS: In both Groups, during normal breathing all the tested muscles were not active. During forced nasal inspiration in Group 1 the transverse nasalis, anomalous nasi, alar nasalis and dilator naris anterior were active. In Group 2 during forced nasal inspiration these muscles remained inactive. During rhythmic widening of the nostril, the tested nasal muscles were active in subjects of Group 1 and significantly less active in Group 2 (p = 0.0024). In both Groups the amplitude of muscle activity, recorded from intranasal electrodes was significantly higher that the amplitude recorded from the skin electrodes (p < 0.05). During the tests with two intranasal electrodes, the insignificant difference was detected in amplitude between left and right nostrils in majority of subjects (Group 1 p = 0.15; Group 2 p = 0.1). CONCLUSION: We conclude that in human population the ability to operate nasal muscles is varying from person to person, i.e. the nasal muscles can be either inactive ("relatively rudimentary") or active. This fact should be taken into account before any surgical intervention is planned. The subjects with active nasal muscles can control the function of their nasal valve. The intranasal surface EMG is a more direct and precise EMG method for nasal valve evaluation in comparison to skin surface EMG testing.     

Evaluation of nasal tip surgery.

Nasal tip surgery has been evaluated with respect to correction of the lower lateral cartilages. Indications, techniques, results, and complications related to three generic approaches to the lower lateral cartilages are described. In 673 consecutive rhinoplasties the commonest type of nasal tip surgery was excisional, utilizing either a marginal or cartilage splitting technique. These techniques were utilized: 1. to accomplish debulking, and 2. to accomplish the installation of facets. The excisional technique found its greatest utility in primary rhinoplasties. The version technique, utilizing a change of direction of the thrust of the lower lateral cartilages was utilized in a variety of situations, particularly for the correction of moderately congenitally hypoplastic tip cartilages. It also found great utility in surgery of the Negro or cleft palate nose, increasing tip projection, correcting unacceptable bifidity, and in revision rhinoplasty. Augmentation rhinoplasty, utilizing conchal cartilage as an elastic strut was particularly useful for severe hypoplastic cartilage deficits, the Negro nose, columellar retraction, and alar rim deficits. The overall complication rate of lower lateral rhinoplasty was 17.4 percent. The rate of unacceptable complications related to lower lateral rhinoplasty was 2.7 percent.     

Surgery of the lateral nasal wall and ethmoid: effects on sinonasal growth: an experimental study in rabbits

OBJECTIVE: To assess the impact of lateral nasal wall surgery on sinonasal growth METHODS: Twenty young New Zealand White rabbits, 6 weeks of age, were included in this experimental study. Surgery was performed on two groups of ten animals each (series I and II). Entrance to the left nasal cavity is achieved through the nasal dorsum via mobilization and rotation of the left nasal bone. Series I: partial resection of the lateral nasal wall (including the ostium to the maxillary sinus) on the left side. Series II: partial resection of the lateral nasal wall and anterior ethmoid. Follow-up period was 20 weeks. Twenty rabbits served as controls. RESULTS: In series I, all skulls have grown normally. In series II the nasal dorsum has also developed symmetrically. Snout length and growth of upper jaw are normal; there is no malocclusion. Three skulls show a slight deviation of the nasal dorsum (two to the left, one to the right). Morphometric measurements of 20 points on the skulls show no significant difference between the control group and the experimental series I and II. CONCLUSION: This experimental study demonstrates that visually controlled partial resection of the bony sinonasal wall, with or without resection of the anterior ethmoid does not affect later development of nose and upper jaw on condition that eventually underlying cartilage is preserved. Contradictory results from other experimental studies, previously published and concerning negative effects of sinus surgery, might be attributed to surgical traumatization of intranasal cartilage structures, in particular, the upper lateral cartilages.     

The four components of the nasal valve

The nasal valve consists of four distinct airflow-resistive components. (i) The vestibule terminates in an airflow-resistive aperture between the septum and the caudal end of the upper lateral cartilage. Its cross-sectional area is stabilized by the cartilaginous structures and by inspiratory isometric contractions of alar dilator muscles. Its walls are devoid of erectile tissues that might otherwise affect its cross-sectional area and airflow resistance. By contrast, (ii) the bony entrance to the cavum is occupied by erectile tissues of both (iii) lateral (turbinate) and (iv) septal nasal walls that modulate the cross-sectional area of the airway and airflow resistance. The body of the cavum offers little resistance to airflow. Valve constrictions induce "orifice flow" of inspiratory air as it enters the body of the cavum, disrupting laminar characteristics and thereby enhancing exchanges with the nasal mucosa of heat, water, and contaminants. Acoustic rhinometric and rhinomanometric measurements show the sites, dimensions, and resistances of the valve constrictions and indicate that it is seldom necessary to extend septal and/or turbinate surgery far beyond the piriform aperture in the treatment of nasal obstruction.     

Semilunar conchal cartilage graft in saddle nose reconstruction

IntroductionThe saddle nose deformity is easily recognized by the loss of septal support and nasal dorsal height with adverse functional and aesthetic consequences.TechniqueWe treated a 50-year-old woman and a 54-year old man that presented with a moderate saddle nose deformity following a previous septorhinoplasty (female patient) and a posttraumatic severe saddle nose deformity (male patient). The patients were treated by open approach rhinoplasty under general anesthesia, and the saddle nose deformity was reconstructed with a semilunar conchal cartilage graft. A semilunar part of the conchal cartilage is excised, lending its name to the graft. A smaller leaf shaped cartilage part is excised and sutured upside-down with PDS 5-0 sutures on the opposite of the cartilage, so that the concave surfaces are facing each other. The newly formed graft is then sutured in its place on the nasal dorsum in the supratip saddle area over the triangular cartilages to widen the inner nasal valve angle. The lateral tips of the semilunar graft are placed below the lateral alar crura to improve external nasal valve functionality.DiscussionThis modified conchal cartilage graft presents itself as an excellent reconstructive option, especially considering its low morbidity, availability and ability to retrieve an adequate amount of cartilage in the vast majority of patients. These modifications of the conchal cartilage are previously unreported, and provide the needed height and elasticity in saddle nose reconstruction without the need for additional grafting. It is important to stress that when positioned properly, a beneficial effect in peak nasal inspiratory flow may be observed, adding to its usefulness in repairing both function and aesthetics.     

Techniques for the improvement of the internal nasal valve in functional-cosmetic nasal surgery

The internal nasal valve (INV) refers to the slit-like region between the caudal end of the upper lateral cartilage (ULC) and the nasal septum. It is the narrowest portion and primary regulator of the nasal airway. Reduction rhinoplasty decreases the nasal airway cross-sectional area and may cause symptoms, unless additional surgical measures are taken. Rhinoplasty or septorhinoplasty was performed for 76 patients with a nasal hump, using an external approach. As a consequence of the nasal hump removal, the ULCs were separated from the septal cartilage. All patients underwent one of the three forms of cartilaginous nasal dorsum reconstruction: primary closure (PC) (50 patients); spreader graft (SG) (19 patients); or upper lateral splay graft (ULSG) (7 patients). At least 3 months postoperatively. INV obstruction was evaluated by asking the patients about nasal obstruction symptoms and visually examining the INV with an otoscope. Nasal obstruction complaints and INV constriction found among patients in the PC. SG and ULSG groups were 16 (32%), 2 (10.5%) and none, respectively. The results of the PC group were compared statistically with the combined results of the SG and the ULSG groups. The patients in the combined SG-ULSG group had significantly less nasal obstruction complaints and INV angle constriction compared with the PC group. Due to the higher rate of postoperative INV stenosis. PC should be avoided. The author uses ULSG when the septal cartilage appears straight and sturdy and SGs when the straightened septal cartilage looks weak and vulnerable, since SGs not only improve the INV, but also reinforce the septal cartilage.     

Advances in nasal tip surgery. The lateral crural steal

Increasing nasal tip projection, rotation, and definition have classically been attempted through a variety of lobular cartilage incising or excising techniques. Resultant long-term complications, including bossing, alar notching, pinched tips, and alar collapse, have occasionally resulted from the use of these techniques. The majority of these complications have arisen secondary to a loss of structural support following the interruption of the lower lateral cartilages. This article describes the "lateral crural steal," a method of increasing nasal tip projection and nasal tip rotation while preserving the integrity of the lobular cartilage complex. The procedure uses the external rhinoplasty approach for exposure. By elevating both the dorsal and the vestibular skin from the domes of the lobular cartilages, the lateral crura may be advanced onto the medial crura to further project the nasal tip and to reorient the tip upward. This technique along with its philosophy and long-term follow-up results are presented.