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1 Braz J Otorhinolaryngol. 2019;xxx(xx):xxx---xxx
2

3 Brazilian Journal of

OTORHINOLARYNGOLOGY
www.bjorl.org

ORIGINAL ARTICLE

4 Algorithm for the treatment of external nasal valve

5 insufficiency夽
a,b,∗
6 Q1 Eduardo Landini Lutaif Dolci , José Eduardo Lutaif Dolci a

a
7 Santa Casa de São Paulo, Faculdade de Ciências Médicas, São Paulo, SP, Brazil
b
8 Santa Casa de Misericórdia de São Paulo, Departamento de Otorrinolaringologia, São Paulo, SP, Brazil

9 Received 26 August 2018; accepted 22 February 2019

10 KEYWORDS Abstract
11 Nasal obstruction; Introduction: Nasal obstruction is one of the most prevalent complaints in the population.
12 Rhinoplasty; The main causes of nasal obstruction are inflammatory, infectious or anatomical alterations.
13 Nasal surgery Anatomical alterations include nasal septum deviation, turbinate hypertrophy, and nasal valve
14 insufficiency (external and/or internal). The diagnosis of nasal valve insufficiency remains a
15 clinical one and is based on inspection and palpation of the nose, evaluating both its static and
16 dynamic functions. The literature presents several options for the correction of external nasal
17 valve insufficiency. These are chosen according to the choice and experience of each surgeon.
18 Objective: To create a practical algorithm for the treatment of external nasal valve insuffi-
19 ciency that can guide nasal surgeons in their choice of treatment for the different anatomical
20 alterations found in patients with these disorders.
21 Methods: We used the treatment options found in the literature and correlated them with our
22 surgical options for each type of anatomical alteration found. Therefore, we used basically three
23 parameters related to physical examination findings (degree of insufficiency and characteristics
24 of the lower lateral cartilage) and the patient’s complaint (present or absent esthetic complaint
25 regarding the nasal tip).
26 Result: A practical algorithm was developed for the treatment of external nasal valve insuffi-
27 ciency according to the degree of insufficiency (mild-to-moderate or severe), esthetic complaint
28 of the nasal tip (present or absent) and characteristics of the lower lateral cartilage (size and
29 orientation).
30 Conclusion: Through this simple algorithm, one can use each type of graft and/or maneuver
31 according to the patients’ complaints and the anatomical alterations found.
32 © 2019 Published by Elsevier Editora Ltda. on behalf of Associação Brasileira de Otorrino-
33 laringologia e Cirurgia Cérvico-Facial. This is an open access article under the CC BY license
34 (http://creativecommons.org/licenses/by/4.0/).

35 夽 Please cite this article as: Dolci EL, Dolci JE. Algorithm for the treatment of external nasal valve insufficiency. Braz J Otorhinolaryngol.

2019. https://doi.org/10.1016/j.bjorl.2019.02.008
∗ Corresponding author.

E-mail: eduardodolci@hotmail.com (E.L. Dolci).

https://doi.org/10.1016/j.bjorl.2019.02.008
1808-8694/© 2019 Published by Elsevier Editora Ltda. on behalf of Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial.
This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

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36 PALAVRAS-CHAVE Algoritmo para o tratamento da insuficiência de válvula nasal externa

Obstrução nasal;
37 Resumo
Rinoplastia;
38 Introdução: A obstrução nasal é uma das queixas mais prevalentes na população. As principais
Cirurgia nasal
39 causas de obstrução nasal são inflamatórias, infecciosas ou alterações anatômicas. As alterações
40 anatômicas incluem: desvio do septo nasal, hipertrofia de conchas nasais e insuficiência da
41 válvula nasal (externa e/ou interna). O diagnóstico da insuficiência de válvula nasal permanece
42 sendo clínico, e baseado na inspeção e palpação do nariz, avaliado em funções estática e
43 dinâmica. Temos na literatura diversas opções de correção da insuficiência de válvula nasal
44 externa. Estas são escolhidas de acordo com a opção e experiência de cada cirurgião.
45 Objetivo: Criar um prático algoritmo para o tratamento da insuficiência de válvula nasal
46 externa, que oriente os cirurgiões de nariz na escolha do tratamento para as diferentes
47 alterações anatômicas encontradas nos pacientes portadores destas alterações.
48 Método: Utilizamos as opções de tratamento encontradas na literatura, e relacionamos com
49 as nossas opções cirúrgicas para cada tipo de alteração anatômica encontrada. Desta forma,
50 utilizamos basicamente três parâmetros relacionados aos achados de exame físico (grau de
51 insuficiência e características da cartilagem lateral inferior) e à queixa do paciente (queixa
52 estética da ponta nasal presente ou ausente).
53 Resultado: Um algoritmo prático para o tratamento da insuficiência de válvula nasal externa, de
54 acordo com o grau da insuficiência (leve-moderada ou severa), a queixa estética da ponta nasal
55 (presente ou ausente) e as características da cartilagem lateral inferior (tamanho e orientação).
56 Conclusão: Através deste simples algoritmo, podemos utilizar cada tipo de enxerto e/ou
57 manobra de acordo com as queixas dos pacientes e as alterações anatômicas encontradas.
58 © 2019 Publicado por Elsevier Editora Ltda. em nome de Associação Brasileira de Otorrino-
59 laringologia e Cirurgia Cérvico-Facial. Este é um artigo Open Access sob uma licença CC BY
60 (http://creativecommons.org/licenses/by/4.0/).

61 Introduction turbinate.4 In Caucasian noses, this angle varies between 90

10◦ and 15◦ . The external nasal valve is constituted medially 91

62 Q2 Nasal obstruction is one of the most prevalent complaints by the caudal septum and columella, superiorly by the weak 92

63 in the population. The main causes of nasal obstruc- triangle, and laterally by the alar rim (caudal rim of the 93

64 tion are inflammatory conditions, anatomical abnormalities lateral crus of the inferior lateral cartilage) and inferiorly 94

65 and infectious processes. Anatomical alterations include by the nasal vestibule floor.5 95

66 nasal septum deviation, turbinate hypertrophy, and nasal The main complaint of patients with nasal valve insuf- 96

67 valve insufficiency (external and/or internal). In the last ficiency is difficulty in obtaining adequate passage of air 97

68 decades, the improved evaluation of the nose and a better through the nose. In the literature the diagnosis remains 98

69 understanding of nasal anatomy and physiology heightened subjective, and there is no gold standard test for this 99

70 attention to this region during nasal surgeries, both for pre- diagnosis to date. The clinical history associated with otorhi- 100

71 venting these alterations during purely esthetic surgeries nolaryngological physical examination, anterior rhinoscopy, 101

72 and in surgical procedures performed for treatment. Nasal and external inspection/palpation of the nose are impor- 102

73 valve insufficiency has been diagnosed as the cause of nasal tant for this evaluation. Complementary examinations, such 103

74 obstruction in up to 13% of adults.1 Additionally, 95% of as rhinomanometry and nasofibroscopy, are less useful for 104

75 patients with persistent nasal obstruction after septoplasty evaluation and diagnosis of nasal valve insufficiency.6 105

76 have the nasal valve as a responsible factor.2 One study demonstrated that the use of external nasal 106

77 In general, three structures make up the nasal valve dilators may be useful in confirming the diagnosis, allow- 107

78 region: inferior turbinate, nasal septum and lateral nasal ing differentiation of the affected site (lower lateral and/or 108

79 wall. The first two are static and rigid structures, whereas upper lateral cartilages). For this purpose, this device must 109

80 the latter, less rigid, is a variable determinant for nasal valve be positioned over the nasal wing (lateral crus of the lower 110

81 stability. Therefore, it is important to diagnose which of lateral cartilage) or over the cartilaginous nasal dorsum 111

82 these structures are responsible for adversely affecting the (caudal portion of the upper lateral cartilage), and then ver- 112

83 nasal valve function.3 ifying in which situation an improvement in the obstruction 113

84 The nasal valve is comprised of two anatomically close sensation occurs.7 114

85 regions, which can be responsible for nasal valve failure, The performance of the modified Cottle maneuver has 115

86 either alone or together. The internal nasal valve is an angle also been effective in the functional rhinoplasty surgical 116

87 formed medially by the upper portion of the nasal septum, programming, and is more specific than the traditional Cot- 117

88 superiorly and laterally by the caudal portion of the upper tle maneuver. In the traditional maneuver, the cheek region 118

89 lateral cartilage and inferiorly by the head of the inferior is drawn laterally with one or two fingers, checking for 119

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Algorithm for the treatment of external nasal valve insufficiency 3

Degree of
insufficiency
Mild/moderate

Severe

Yes
Aesthetic complaint
of nasal tip
No
> 12mm
Size

< 12mm
Alar cartilage Cephalic
characteristics
Malposition

Orientation Sagittal
Adequate

Figure 1 Initial parameters used to choose the appropriate treatment for the correction of external nasal valve insufficiency.

Mild-to-moderate
insufficiency.

No aesthetic Aesthetic
complaint of complaint of
nasal tip nasal tip

(With or without Batten graft Alar > 12 mm Alar < 12 mm Alar malposition
alar rim graft) (Septo/concha)

Turn in flap Lateral crural strut Oblique

Alar rim graft Lateral crural
(com ou sem alar graft with strut graft turnover flap
rim graft) repositioning

Figure 2 Algorithm for the treatment of mild-to-moderate external nasal valve insufficiency.

Severe
insufficiency

Aesthetic complaint No aesthetic

of nasal tip complaint of
nasal tip

Lateral crural strut

graft (with or without
repositioning) Btten fraft
(auricular concha)
Articulated alar rim
graft
Seagull wing graft
(asa de gaivota)

Figure 3 Algorithm for the treatment of severe external nasal valve insufficiency.

120 obstruction improvement. This maneuver does not allow the External nasal valve 127

121 individual evaluation of the internal or external valves.8

122 In the modified Cottle maneuver, a metal stylus, or even External nasal valve insufficiency is related to either con- 128
123 an otological curette, is used to laterally push the upper genital alterations of the structures that constitute this 129
124 or lower lateral cartilage region, verifying in which situa- region, or alterations that were acquired after a pre- 130
125 tion there is airflow improvement. Therefore, the maneuver vious nasal surgery (iatrogenic). Congenital alterations 131
126 allows the isolated evaluation of each region. related to functional problems are fragile cartilages

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Figure 5 Batten graft created with conchal cartilage. Place

Figure 4 Alar rim graft created from septal cartilage. Place
where the graft will be inserted.
where the graft will be inserted.

132 susceptible to collapse during inspiration or poorly posi- did not find in the literature any articles that addressed 158

133 tioned lower lateral cartilages9 (in an inadequate cephalic this practical implication. We found only one article that 159

134 or sagittal position, in which the caudal rim of the lat- addresses the authors’ treatment protocol.17 However, they 160

135 eral crus is at a different level relative to the cephalic use only one type of graft, the batten graft, for the cor- 161

136 rim). rection of the entire valvular region (internal and external 162

137 The correct definition of the anatomical alteration site valve). 163

138 is essential so that appropriate actions can be undertaken --- Thus, our aim is to allow surgeons who have recently 164

139 columella, caudal septum, alar rim (congenital or iatrogenic started performing nasal surgeries, specifically in func- 165

140 lateral crus fragility), or a combination of these. tional and esthetic rhinoplasties, to have treatment options 166

141 There are no doubts about the treatment when cau- according to the anatomical alterations found, and accord- 167

142 dal septal deviations or a large (obstructive) columella are ing to the availability of grafts for each patient as well. 168

143 found. In these situations, septoplasty and columelloplasty

144 are the treatments of choice. However, when alterations in Results/discussion 169

145 the lower lateral cartilages are found, several options have
146 been described. To choose the type of treatment for nasal valve insufficiency, Q3 170
147 The main surgical options for correction are: Batten we initially used three parameters as reference (Fig. 1): 171
148 graft; Alar rim, Articulated alar rim graft; Lateral crural
149 strut graft; Lateral Crural Turn-in Flap; Seagull wing graft; Esthetic complaint of the nasal tip (present or absent); 172
150 and Lateral crural graft.10---16 Characteristics of alar cartilage (size and orientation); 173

Degree of external nasal valve insufficiency (mild, moder- 174

151 Method ate, severe). 175

152 The choice of the type of graft used in the correction of For surgeons performing rhinoplasty, the esthetic com- 176

153 lateral crus alterations should be defined by the materials plaint of the nasal tip associated with external nasal valve 177

154 available for grafting, the degree of the alteration found insufficiency are important factors when choosing the treat- 178

155 and, especially, by the experience and preference of each ment to be performed. Patients without esthetic complaint 179

156 surgeon. Therefore, we have created a practical algorithm of the nasal tip allow us to perform the treatment with- 180

157 for the treatment of external nasal valve insufficiency. We out the exposure of nasal tip cartilage, which is performed 181

Figure 6 Pre and postoperative (6 months) periods of functional closed rhinoseptoplasty with bilateral alar rim graft, without
access to the nasal tip.

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Figure 7 Intraoperative period. Turn in flap maneuver. Initially marked 8 mm on the lateral crus from the caudal border and then
the cephalic portion is folded under the caudal remnant.

Figure 8 Intraoperative period. Patient with poorly positioned alveolar cartilages in the cephalic orientation. Complete detach-
ment of the lateral crura and lateral crural strut graft fixation under the alar cartilages was performed.

Figure 9 Pre- and postoperative (1 year) periods of functional rhinoseptoplasty and open esthetics, using lateral crural strut graft
and lateral crura repositioning.

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Figure 10 Image of oblique turnover flap for repositioning

and flattening of the lateral crura. Goksel, Vladykina.

182 through open rhinoplasty or closed rhinoplasty with deliv-

183 ery access. In these situations, one can place grafts through
184 small incisions near the alar rim, with its extension being
185 related to the size of the graft to be used. The alar rim
186 grafts and the batten grafts are the available options.
187 Patients with esthetic complaint of the nasal tip asso-
188 ciated with external nasal valve insufficiency should be
Figure 11 Intraoperative period. Articulated alar rim graft
189 submitted to procedures that expose the alar cartilages
was used in primary closed rhinoseptoplasty, with graft fixation
190 through open or delivery access (closed rhinoplasty). Over-
on the lateral crus near the domus.
191 all, these complaints may be associated with the position of
192 the nasal tip (underprojected or overprojected) or its shape
193 (globose and/or asymmetric). and/or poorly positioned cartilages through inspection 229

194 The size of the alar cartilages, specifically of the lateral and palpation of the nose. Severe insufficiency is defined 230

195 crus, is also a condition that is evaluated for the choice of as those patients with collapse of the alar rim at static 231

196 treatment option. We used the following reference parame- inspection of the external nasal valve, or patients with total 232

197 ter for the final configuration of the size of the lower lateral or partial absence of lateral crus caused by iatrogenesis 233

198 cartilages: 5 mm in the dome and 8 mm in the lateral crus or malformation. These situations require more specific 234

199 region.18 Alar cartilages that have a lateral crus > 12 mm choices of graft type to be used. The following are options: 235

200 allow us to perform a maneuver that reinforces this struc- batten graft, lateral crural strut graft, articulated alar rim 236

201 ture without using grafts, by folding the cartilage on itself, graft or butterfly graft, all described in the literature. 237

202 called a ‘‘turn-in flap’’. Cartilages < 12 mm do not allow us Therefore this treatment algorithm was created for 238

203 to perform this maneuver, since we must always maintain external nasal valve insufficiency treatment (Figs. 2 and 3). 239

204 at least 8 mm in the lateral crus portion to prevent alar rim The treatment options for patients with mild-moderate 240

205 fragility. external nasal valve failure without esthetic complaint of 241

206 The lateral crus orientation of the lower lateral carti- the nasal tip are the alar rim graft11 (contour grafting) or 242

207 lage is also essential in the diagnosis of external nasal valve batten graft.10 In these situations, the septal cartilage is the 243

208 insufficiency, since it will define the type of treatment cho- first choice; however, conchal cartilage can also be used. 244

209 sen. Known as a cause of external valvular insufficiency and The alar rim graft should be positioned close to the alar 245

210 sometimes also as a cause of nasal tip esthetic complaint, rim (Fig. 4), whereas the batten graft should be located on 246

211 the cephalically or ‘‘between parenthesis’’ lower lateral the lateral crus (or its remnant) and extend to the piriform 247

212 cartilage requires an adequate therapeutic approach. This opening. For these options, we make a small incision near 248

213 anatomical alteration results in the absence of adequate the caudal margin of the lower lateral cartilage and dissect a 249

214 support for the alar rim region. Among the treatment options narrow space to receive the graft (Fig. 5). It is not necessary 250

215 are repositioning of the lateral crus with or without lat- to fix it with sutures, as we do not perform a wide dissection 251

216 eral crural strut graft,19 and some new options described in of the region. Then, the incision is sutured with 1---2 simple 252

217 the literature as turn over flap.20 Another alteration of the absorbable stitches (Case 1) (Fig. 6). 253

218 lateral crus orientation of the lower lateral cartilage that In patients with mild-to-moderate insufficiency and 254

219 can be found is the sagittal malposition, a condition identi- esthetic complaint of the nasal tip, the treatment options 255

220 fied with the depression of the caudal rim in relation to the will be based on the characteristics of the alar cartilages. 256

221 cephalic rim. In this situation, the anomalous position of the Adequately oriented alveolar cartilages that have a lateral 257

222 caudal rim causes external nasal valve insufficiency. crus size greater than 12 mm, can be treated with turn-in 258

223 The third parameter that was analyzed to define treat- flap14 a maneuver that obviates the need for a graft, and 259

224 ment is the degree of the external nasal valve insufficiency. consists of overlapping at least 4 mm of the lateral crus, 260

225 No classification was found in the literature for this type of thus generating greater stability in this region (Fig. 7). 261

226 alteration. Therefore, we used mild-moderate insufficiency In situations with inadequately orientated lower lat- 262

227 for patients with dynamic alterations of the external nasal eral cartilages, regardless of their size, we must use other 263

228 valve (non-forced inspiration) or with a diagnosis of fragile treatment options for this correction. Cartilages with poor 264

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265 cephalic or sagittal positioning can be treated with lateral

266 crus repositioning, associated with the use of the lateral
267 crural strut graft13 (Fig. 8). In this treatment, we detach
268 the entire lateral crus, since the domus, from the underly-
269 ing mucosa, and remove the lateral crus from the sesamoid
270 cartilages. Next, a graft is fixed (lateral crural strut graft)
271 on this lateral crus and these structures are repositioned to
272 a new, lower position, with the detachment of a narrow tun-
273 nel next to the piriform aperture (Case 2) (Fig. 9). Another
274 option for the correction of cephalic cartilage is the oblique
275 turnover flap,20 described more recently in the literature.
276 This maneuver consists of folding the lateral crus on itself
277 at an oblique axis, changing its position and reinforcing the
278 region of the alar rim (Fig. 10).
279 In patients with severe external nasal valve insuffi-
280 ciency, significant nasal obstruction was found due to this
281 alteration. These situations are very often associated with
282 previous surgeries, with aggressive resection of the lateral
283 crus of the lower lateral cartilage, or malformation of these
284 cartilages. In these cases, the options require a significant
285 strengthening of the external nasal valve area, which will
286 also have as criterion the observed aspect of the lower
Figure 12 Intraoperative period. Articulated alar kidney graft
287 lateral cartilages. Some patients have only a functional com-
used in open revision rhinoseptoplasty for external nasal valve
288 plaint, and in these cases, the use of batten graft with
remodeling. Patient had undergone 2 previous surgical proce-
289 auricular conchal cartilage is an excellent option, without
dures. The graft was attached to the right and, on the left, we
290 the need for a wide access, but only the creation of a narrow
can identify the remnant of the lower lateral cartilage with the
291 area to place the graft.
previously amputated lateral crus. Subsequently, we also fixed
292 However, many patients also have esthetic alterations
the graft to the left.
293 due to deformities in the lateral crus. In these situations,
294 we can also use the previously described lateral crural strut
295 graft. Another increasingly used option, is the articulated near the domus and its most lateral portion is embedded 300

296 alar rim graft12 (Figs. 11 and 12) that can be employed for into a new dissected pouch close to the piriform aperture, 301

297 these more severe situations. It is created preferably with to stabilize this graft and give support to the alar rim (Case 302

298 septal cartilage (or costal cartilage), having its medial por- 3) (Fig. 13). In cases where we find partial or total resection 303

299 tion attached to the lower border of the lateral crus remnant of the lateral crus, we can use the seagull wing graft15 for

Figure 13 Pre- and postoperative (3 months) periods of esthetic and functional revision open rhinoseptoplasty, with the use of
an articulated alar rim graft. Patient had undergone 2 previous nasal surgeries.

Figure 14 Intraoperative period. Seagull wing graft before being fixed (only shown the right graft). Subsequently, the grafts were
positioned bilaterally on the remnants of the alar cartilages.

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304 the reconstruction of this portion of the lower lateral carti- 7. Gruber RP, Lin AY, Richards T. Nasal strips for evaluating and 333

305 lage. In these cases it is necessary to use auricular conchal classifying valvular nasal obstruction. Aesthetic Plast Surg. 334

306 cartilage, as it has intrinsic concavities that are similar to 2011;35:211---5. 335

307 the lateral crus (Fig. 14). 8. Ishii LE, Rhee JS. Are diagnostic tests useful for nasal valve 336
compromise? Laryngoscope. 2013;123:7---8. 337
9. Hamilton GS 3rd. Form and function of the nasal tip: reorienting 338
308 Conclusion and reshaping the lateral crus. Facial Plast Surg. 2016;32:49---58. 339
10. Toriumi DM, Josen J, Weinberger M, Tardy ME Jr. Use of alar 340

309 The use of this simple and practical algorithm allows the batten grafts for correction of nasal valve collapse. Arch Oto- 341

310 use of each type of graft and/or maneuver according to the laryngol Head Neck Surg. 1997;123:802---8. 342

311 patients’ complaints and the anatomical alterations found in 11. Rohrich RJ, Raniere J Jr, HA RY. The alar contour graft: correc- 343
tion and prevention of alar rim deformities in rhinoplasty. Plast 344
312 the inferior lateral cartilages for the correction of external
Reconstr Surg. 2002;109:2495---505. 345
313 nasal valve insufficiency.
12. Ballin AC, Kim H, Chance E, Davis RE. The articulated 346
alar rim graft: reengineering the conventional alar rim 347

314 Conflicts of interest graft for improved contour and support. Facial Plast Surg. 348
2016;32:384---97. 349

315 The authors declare no conflicts of interest. 13. Gunter JP, Friedman RM. Lateral crural strut graft: technique 350
and clinical applications in rhinoplasty. Plast Reconstr Surg. 351
1997;99:943---55. 352
316 References 14. Apaydin F. Lateral crural turn-in flap in functional rhinoplasty. 353
Arch Facial Plast Surg. 2012;14:93---6. 354

317 1. Elwany S, Thabet H. Obstruction of the nasal valve. J Laryngol 15. Pedroza F, Anjos GC, Patrocinio LG, Barreto JM, Cortes J, 355

318 Otol. 1996;110:221---4. Quessep SH. Seagull wing graft: a technique for the replace- 356

319 2. Chambers KJ, Horstkotte KA, Shanley K, Lindsay RW. Evaluation ment of lower lateral cartilages. Arch Facial Plast Surg. 357

320 of improvement in nasal obstruction following nasal valve cor- 2006;8:396---403. 358

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330 6. Rhee JS, Weaver EM, Park SS, Baker SR, Hilger PA, Kriet JD, 20. Goksel A, Vladykina E. Oblique turnover flap for repositioning 368

331 et al. Clinical consensus statement: diagnosis and manage- and flattening of the lateral crura: a novel technique to man- 369

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