Treatment of Nasal Obstruction From Nasal Valve Collapse with Alar Batten Grafts
Daniel G. Becker, MD, FACS¹ & Samuel S. Becker, MD, MFA²
¹Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania
Hospital, Philadelphia, Pennsylvania; ²Department of Otorhinolaryngology-Head and Neck
Surgery, University of Virginia Hospital, Charlottesville, Virginia
Address all correspondence to Dr. Daniel G. Becker, Dept. of Otorhinolaryngology-Head and Neck Surgery, Univ. of Pennsylvania Hospital, 3400 Spruce Street, 7 Silverstein, Philadelphia PA 19104; [email protected]
ABSTRACT: Nasal obstruction may require treatment with rhinoplasty techniques. One cause of nasal obstruction is known as nasal valve colapse. This refers to narrowness and weakness at the nasal valve, the narrowest part of the nasal airway. There are a number of surgical approaches available to treat nasal valve collapse. Selection of the appropriate surgical intervention depends on proper identification of the anatomic cause of the collapse. Alar batten grafts are especially useful for addressing nasal valve collapse caused by a weak nasal sidewall. In this report, we review the senior author’s experience with the use of alar batten grafts for nasal valve collapse.
Twenty-one patients had septoplasty with placement of alar batten grafts; all patients noted improvement in their nasal breathing. Seven patients underwent ear cartilage harvest with alar batten grafts, and five of them noted improvement, one noted partial improvement, one noted no improvement. Six patients underwent revision septorhinoplasty with alar batten grafting, and ten patients underwent revision septorhinoplasty with ear cartilage harvest and alar batten grafting. These patients all reported improvement in their nasal breathing postoperatively. Six patients underwent revision rhinoplasty (no septoplasty) with ear cartilage and battens. These patients hold special interest because no other intranasal procedures were performed that affected nasal breathing. All six of these patients reported significant improvement of their nasal breathing and all patients were satisfied with their postsurgical cosmetic appearance.
The nasal valve area is considered to be the location of the least cross-sectional area in the nose. When narrowing of the nasal valve is a result of collapse of the nasal sidewall, alar batten grafts are a useful technique to address the patient’s nasal obstruction.
KEYWORDS: nasal valve, nasal obstruction, rhinoplasty, septoplasty
Document ID# JLT1303-259-269(192) 2S9 1050-6934/03 $5.00 © 2003 by Begell House, Inc.
A detailed history and physical examination are critical first steps in the evaluation and treatment of every patient presenting with nasal obstruction. Nasal valve collapse is commonly overlooked and must be considered in the complete evaluation of the patient with nasal obstruction. Certain elements of the history may prompt the rhinologist to give special consideration to the possibility of nasal valve collapse.
Patients may describe relief when they lift the soft tissues of the cheek (and thereby the lateral soft tissues of the nose)—which is known as “the Cottle sign.” Also, some patients find relief from prosthetic devices such as the BreatheRite Strips, nasal stents, and other devices that lateralize the nasal soft tissues. This history may suggest the nasal valve as a contributing factor.
A past history of rhinoplasty with gradually worsening nasal obstruction may be seen in patients with nasal valve collapse. Cephalic resection of the lateral crura during rhinoplasty and subsequent postoperative soft tissue contraction may lead to internal and/or external nasal valve compromise. Other commonly performed surgical maneuvers such as dorsal hump reduction can result in loss of support to the middle vault, with narrowing of the middle vault with internal valve collapse.
Some patients have no history of prior surgery but simply have congenitally weak nasal sidewalls or narrow nasal valves. It may be this patient category in which nasal valve collapse is most frequently overlooked.
With age, the nasal sidewalls weaken and sagging of the nasal tip, or tip ptosis, frequently occurs. This changes the nasal airflow pattern and contributes to nasal obstruction.”,’ These patients may have other causes of nasal obstruction such as a deviated septum and rhinitis. Although the other contributing factors may have been of longstanding nature, the gradual addition of nasal valve collapse and tip ptosis in the aging patient may result in a description of recent onset of nasal obstruction.
Physical examination of the nose begins with an external nasal examination. Evaluating the nasal skeleton from the top down assures a stepwise andcomplete examination. A narrow middle third of the nose may be an indication of internal nasal valve compromise. External nasal valve narrowing and collapse also should be recognized when present. A severely deviated caudal septum may contribute to passive narrowing at the external nasal valve, and collapse of the mobile alar sidewall may provide an active component.
Intranasal exam should be performed before and after topicalization with a vasoconstricting agent. When indicated by the patient history or by findings on anterior rhinoscopy, a nasal endoscopic examination is also performed. Examination may reveal a deviated septum, polyps, turbinate hypertrophy, internal and external valve collapse, sinusitis, and other abnormalities. A CT scan may be indicated in some patients.
There are a number of surgical approaches available to treat nasal valve collapse. Selection of the appropriate surgical intervention depends on proper identification of the anatomic cause of the collapse. Alar batten grafts are especially useful in addressing nasal valve collapse caused by a weak nasal sidewall. In this report, we review the senior author’s experience with the use of alar batten grafts for nasal valve collapse.
A retrospective chart review was undertaken of the senior author’s experience. All patients seen by the senior author with a history of nasal obstruction and who underwent surgery between January 1999 and June 2001 were included in this chart review. Findings on history and physical examination, the nature of the surgery performed, and the results of surgery were recorded.
Indications for Alar Batten Grafts
Specific aspects of the patient’s history may be positive factors suggesting the need for alar batten grafts. A history of inspiratory collapse, benefit from using the BreatheRite Strips, and a history of benefit from “lifting the cheek” (Cottle sign) are positive factors. Prior history of rhinoplasty with subsequent gradual onset of nasal obstruction is also suggestive of nasal valve collapse.
On physical examination, inspiratory collapse may be subtle or obvious (Fig. 1). A Cottle test is a critical objective finding and must be performed by an experienced clinician to have positive predictive value. Prior to topicalization of the internal nose, the back end of a Q-tip or some other small instrument is used to elevate the sidewall of the nose approximately 1-2 mm. If the patient reports definite benefit fromthis conservative elevation of the nasal sidewall, then alar batten grafts may be beneficial.
In older patients, elevation or “rotation” of a ptotic tip may also relieve nasal obstruction. In this situation, rhinoplasty with tip projection and rotation are considered in addition to repair on the nasal sidewall collapse..’ If the patient has had prior rhinoplasty and now has excessive collapse, retraction, and weakness of the nasal sidewalls on physical examination, alar batten grafts are indicated. At times the retraction may be so severe that composite grafts of skin and cartilage may be required.
FIGURE 1. This patient had a prior history of septoplasty and rhinoplasty and had obvious inspiratory nasal collapse on mild nasal inspiration. Her septum was straight. Her nasal obstruction was successfully addressed with ear cartilage harvest and alar batten grafts.
FIGURE 1. (c) preoperative nasal inspiratory collapse; (d,e) postoperative. (Diagrams reprinted with permission from revisionrhinoplasty.com.)
IV.A. Cartilage Harvest
If septoplasty has not been performed, septoplasty may be done not only to correct any deviation that exists but also to harvest cartilage for batten grafting. A significant amount of cartilage must be obtained, but great care must be taken to maintain a generous L-strut for continued nasal support. In patients who have not had prior septoplasty, ample septal cartilage is typically available. When septal cartilage is not available, auricular cartilage is obtained. Auricular cartilage has a curvature that makes it ideally suit-able for alar batten grafts.
Although alloplastic material is available for alar batten grafts, the authors do not advocate its routine use because of the risk of infection and extrusion.
IV. B. Alar Batten Graft
Alar batten grafts, typically of curved septal or auricular cartilage, placed to support the alar rim can correct internal or external nasal valve collapse.
Alar batten grafts may be placed via a precise pocket. A graft is fashioned from harvested auricular or septal cartilage. Auricular cartilage has a favorable curvature and in this respect is preferred, but septal cartilage is satisfactory and is used preferentially when it is available. When a cartilage graft has a curvature, the convex side of the graft is oriented laterally to correct the supra-alar pinching.
Through a limited marginal incision, a precise pocket may be fashioned using scissor dissection at the point of maximal supra-alar collapse. Marking the location of the precise pocket on the skin prior to infiltrative anesthesia is helpful. The graft is typically placed caudal to the lateral crura at the point of maximal lateral nasal wall collapse. Suture fixation is not necessary. The pocket is subcutaneous, but if the pocket is too superficial the graft may be palpable or visible (Fig. 2).
The graft is non-anatomic and is typically placed caudal to the lateral crura, where there is maximal collapse of the lateral nasal wall and supra-alar pinch-ing. For maximal support, the alar batten graft should extend over the bone of the pyriform aperture (Fig. 2). If alar batten grafts are placed too far cephalic, excessive fullness over the middle vault will be noted.
Alar batten grafts may also be placed via an external rhinoplasty approach. This approach may be prefer-able when other reconstructive work is required. In this setting the graft is typically secured with a suture applied medially from the graft to adjacent soft tissue or lateral crus.
With 1-30 months of followup, 170 patients had functional endoscopic sinus surgery (FESS) or FESS/ septoplasty. Specifically, 83 patients underwent FESS, and 87 underwent FESS/septoplasty. Three of these patients, or 1.5%, had alar batten grafts. Ten patients also underwent cosmetic rhinoplasty without batten grafting.
One-hundred-ten patients had septoplasty only for nasal obstruction. Sixty-seven of these patients also had cosmetic rhinoplasty, and 43 underwent septoplasty alone.
Twenty-one patients had septoplasty with placement of alar batten grafts, representing 16% of the “septoplasty only” patients. This is a large percentage, but it is notable that 16 of these 21 patients were referred by other otolaryngologists. When these 16 patients are excluded, 3.5% of the “septoplasty only” patients underwent alar batten grafting. This may be more representative of a general otolaryngology practice. Notably, all 21 of these patients noted improvement in their nasal breathing.
Seven patients underwent ear cartilage harvest with alar batten grafts (Fig. 1). This group is of great interest, because the only intervention for nasal obstruction was placement of batten grafts. All had undergone prior septoplasty and four out of the seven had undergone prior FESS and had persistent nasal obstruction. Five noted improvement, one noted partial improvement, and one noted no improvement.
Of the seven patients noted above who underwent alar batten grafting only, five were referred by other otolaryngologists as a result of a suspicion of nasal valve collapse.
FIGURE 2. Precise pocket alar batten graft, surgical technique. (a) The site of the proposed graft may be marked on the skin prior to infiltrative anesthesia. (b) Auricular cartilage is harvested and fashioned into batten grafts. Alar bat-ten grafts are most effective when they extend beyond the pyriform aperture. (c) The grafts are placed through an endonasal approach via a limited marginal incision. (Photographs reprinted with per-mission from revisionrhinoplasty.com).
|Endoscopic sinus surgery patients||83 patients underwent FESS|
|87 patients underwent FESS and septoplasty|
|3 of these patients had alar batten grafts|
|10 of these patients also underwent cosmetic rhinoplasty without batten grafting|
|Septoplasty patients (21 of these 28 were referred by other otolaryngologists)||43 patients underwent septoplasty|
|21 patients underwent septoplasty with repair nasal vestibular stenosis|
|7 patients underwent ear cartilage harvest with repair nasal vestibular stenosis|
|Septorhinoplasty patients||67 patients underwent septorhinoplasty alone without battens|
|1 patient underwent septorhinoplasty with battens|
|6 patients underwent primary rhinoplasty alone|
|2 patients underwent primary rhinoplasty with ear cartilage, no alar battens|
|Revision septorhinoplasty patients||6 patients underwent revision SR with repair nasal vestibular stenosis|
|10 patients underwent revision SR with ear cartilage and repair nasal vestibular stenosis|
|6 patients underwent revision rhinoplasty with ear cartilage with repair nasal vestibular stenosis|
|3 patients underwent revision rhinoplasty with ear cartilage, no alar battens|
Sixty-seven patients underwent primary septorhino plasty without alar batten grafts. Two patients underwent primary rhinoplasty with ear cartilage harvest but no alar battens. In these cases, valve col-lapse was evaluated but not identified.
One patient for primary septorhinoplasty under-went alar batten grafting because of a congenital abnormality of his lateral crura. Two patients had excessively concave lateral crura contributing to nasal obstruction; in these cases alar batten grafts were not placed, but the lateral crus was excised and “flipped” to achieve both aesthetic improvement and improvement in the nasal valve area (Fig. 3).
Six patients underwent revision septorhinoplasty with alar batten grafting, and ten patients underwent revision septorhinoplasty with ear cartilage harvest and alar batten grafting. These patients all reported improvement in their nasal breathing postoperatively.
Six patients underwent revision rhinoplasty (no septoplasty) with ear cartilage and battens (Fig. 4). Again, these patients hold special interest because noseptoplasty was performed. No other intranasal procedures were performed that affected nasal breathing. These patients did undergo tip rotation and projection resulting from the ptotic, droopy tip. Rotation and projection of the nasal tip does affect nasal breathing. All six of these patients reported significant improvement of their nasal breathing.
All patients were informed that the nasal sidewall would have a more full, less “pinched” appearance. All patients who underwent alar batten grafts were satisfi ed with the aesthetic appearance of this area.
Prior rhinoplasty was the number one cause of nasal valve collapse in this series. It is notable that one out of 68 primary septorhinoplasty patients required alar batten grafts, while 22 out of 44 revision rhinoplasty patients required alar batten grafts. Clearly, when history of prior rhinoplasty is elicited in a patient with nasal obstruction, the possibility of nasal valve collapse must be entertained.
FIGURE 3. This patient had a caudal septal deviation causing passive external nasal valve collapse and also had an excessively con-cave lateral crura contributing to nasal obstruction. In this case the caudal septum was straightened and the right lateral crus was excised and “flipped” to achieve both aesthetic improvement and improvement in the nasal valve area. (a,b) preoperative; (c,d) postoperative. (Reprinted with permission from therhinoplastycenter.com.)
FIGURE 4. This patient had a history of prior septorhinoplasty and had nasal obstruction, a straight septum, nasal valve collapse, and tip ptosis. He underwent external rhinoplasty with tip rotation and projection and ear cartilage harvest for alar batten grafts. No intranasal surgery was performed. (a) preoperative; (b) postoperative. (Reprinted with permission from revisionrhinoplasty.com.)
Careful evaluation of patients presenting with nasal obstruction will allow identification of patients with nasal valve collapse. The percentage of patients in this series with nasal valve collapse is probably higher than in a random population because of the nature of the senior author’s referral practice.
Other causes of valve narrowing, such as enlarged inferior turbinates,¹ deviated caudal septum (Fig. 3),¹,¹²-¹³ narrow middle nasal vault, and others must be considered. However, when history and physical examination lead to an anatomic diagnosis of nasal sidewall weakness, strengthening the sidewall withalar batten grafts seems like a direct solution to the problem.
For comfortable nasal respiration, nasal resistance must be produced by intranasal structures. Absence of adequate resistance creates the sensation of nasal obstruction, evident in the over-wide airway produced in patients demonstrating atrophic rhinitis, complete turbinectomy, or total septectomy.
The internal nasal valve and the nasal valve area play a critical role in nasal resistance. In the absence of other causes of nasal obstruction, the internal nasal valve and nasal valve area constitute the flow-limiting segment of the nose. The internal nasal valve refers to the cross-sectional area bordered by the junction of the caudal portion of the upper lateral cartilage and the nasal septum, circumscribing an angle of 9° to 15° in the normal Caucasian nose. The anterior head of the inferior turbinate, the septum, and the tissue surrounding the pyriform aperture also constitute a portion of this so-called “flow-limiting segment.” The nasal valve area includes the cross-sectional area described by the internal nasal valve and is affected by the anterior head of the inferior turbinate, the septum, and the tissues surrounding the pyriform aperture.
The nasal valve area is considered to be the location of the least cross-sectional area in the nose; measurements made from nasal casts and calculated from rhinomanometry measurements indicate an average area of 0.73 cm for the nasal valve area.
The external nasal valve is distinct from the internal nasal valve described above and is composed of the cutaneous and skeletal support of the mobile alar wall up to and including its free edge at the nostril opening.² Overaggressive resection of the lateral crura during rhinoplasty and the subsequent postoperative soft tissue contraction may lead not only to internal but also to external nasal valve compromise. Congenital cephalic position of the lateral crura will also leave suboptimal structural support in the mobile alar wall, with subsequent external valve collapse. External valve narrowing may be active, a result of inspiratory collapse similar to that described above, or passive, resulting from a severely deviated caudal septum causing unilateral obstruction at the external nasal valve. Both active and passive elements may be factors in obstruction at the external nasal valve.
Inspiratory collapse of the lateral nasal sidewalls with normal inspiratory negative pressure suggests inadequate rigidity of nasal supporting structures. Inspiratory collapse at the external valve is visible on examination and is indicative of flaccid soft tissue in this location. Similarly, inspiratory collapse may compromise function at the internal nasal valve. The patient’s nose should be observed for collapse on normal inspiration.
A positive Cottle maneuver, while not alwaysreliable, is consistent with a diagnosis of nasal valve collapse. In the classic description, the patient’s cheek is lateralized; this movement is translated to the nose, where lateralization of soft tissue of the nasal valve occurs. Alternatively, the author prefers to support the nasal sidewalls at the location corresponding to the internal nasal valve area with a small curette or the back end of a Q-tip, lateralizing the lateral nasal sidewall 1-2 mm. When this maneuver relieves nasal obstruction, the diagnosis of functional valve collapse is supported.
Chronic nasal obstruction is the most common presenting symptom of anterior ethmoid sinus disease,¹ 0 so the history should elicit the presence of post-nasal drip and cough, facial pressure or pain, ear pressure or pain, hearing loss, loss of sense of smell or taste, halitosis, and other pertinent fi ndings suggestive of chronic or recurrent sinusitis. The patient should be questioned and, when appropriate, evaluated for allergies. All medications taken should be carefully recorded; a history of topical nasal decongestant abuse may lead to the diagnosis and treatment of rhinitis medicamentosa. It is critical to elicit a history of prior sinus surgery, rhinoplasty, or other nasal surgery.
In patients with a history of prior nasal surgery, special consideration must be given to the possibility of nasal valve collapse. Commonly performed rhinoplastic maneuvers can result in nasal valve col-lapse. Over-resection of lateral crura may be the most common postsurgical cause of nasal valve collapse. When excising the cephalic portion of the lower lateral cartilage (LLC), the surgeon should leave at least 7-9 mm of intact cartilage, preserving an intact strip of cartilage from the feet of the medial crura to the most lateral part of the lateral crus. Overaggressive resection of the lateral crura and the subsequent postoperative soft tissue contraction may lead to nasal valve compromise.
Inadequate support of the upper lateral cartilages after dorsal hump removal can lead to inferomedial collapse of the upper lateral cartilages and internal valve collapse. Externally, this may manifest itself as an “inverted V deformity.” In this deformity, the caudal edge of the nasal bones are visible in broad relief. The inverted V deformity is not always present with nasal valve collapse. Also, it is not always indicative of nasal valve collapse, because it also may be due to inadequate infracture of the nasal bones.
Despite the clearly functional aspect of this surgery, in the United States many insurance companies were reluctant to authorize payment for this surgical treatment. In the past, these procedures were coded using rhinoplasty codes, but insurance carriers often categorized these procedures as cosmetic, even thoughthe procedure was undertaken to improve breathing and the patient may have had no interest in changing the nasal appearance.
Due in part to educational and patient advocacy efforts by physicians and physician groups, a new CPT code, 30465, is now available for repair of vestibular stenosis.¹7 This reflects a recognition by insurance companies of the importance of this procedure for treating nasal obstruction.
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