General Medical Information

Valvular Collapse

Richard L. Mabry

The nasal valve is the narrowest portion of the noses of white persons. When insufficient cartilaginous support is present, negative (inspiratory) pressure within the nasal cavity can collapse soft tissue in this region. The internal nasal valve comprises the caudal end of the upper lateral cartilage and the nasal septum, whereas the internal nasal valve or external nasal valve contains additional anatomic components such as the lower lateral (alar) cartilage, the anterior head of the inferior turbinate, and the inferior rim of the piriform aperture. Extranasally the nasal valve constricts (posterior to the alar cartilage) when there is large negative pressure (inspiration) and expands when there is large positive pressure (expiration) within the nasal passage.

Incompetence of the nasal valve is confirmed with the Cottle test. In this test, with the patient breathing lightly, the examiner pulls the patient’s cheek laterally to increase the nasal valve angle and asks the patient whether the maneuver improves ipsilateral nasal patency. If the maneuver increases patency, the test result is positive; if no improvement is felt, the test result is negative. Normal nasal valves should have a negative result; incompetent nasal valves have a positive result. False-positive result can be caused by alar collapse. False-negative results can be caused by adhesions, stricture of the nasal valve, or surgical or nonsurgical trauma that displaces the frontal process of the maxilla.

Surgical reconstruction of an incompetent nasal valve should be undertaken with an open approach that allows clear assessment of operative augmentations. The most successful operative techniques include systematic alteration of all surrounding internal structures. Surgical methods have included internal valve spreader cartilage grafts (widening the apex of the internal valve); suture repair of drooping upper lateral cartilage (a frequent complication after dorsal hump excision in rhinoplasty); autogenous cartilage grafts, or allografts as needed, to support the columella; and spanning grafts or simple lateral crus onlay grafts to support the lateral crura. Grafts can be composed of cartilage or conchal bone from concurrent inferior turbinectomy. The bony or cartilaginous graft serves as both an inherent structural support and a method for inducing site-specific scarring, which enhances the stiffness of this region.