Nasal Valve Collapse and Treatment
Garrett H. Bennett, MD
Introduction
Collapse of the nasal valves – internal and external – is a commonly overlooked cause of breathing obstruction. Common causes include previous trauma to the nose or cosmetic rhinoplasty. Lifting the soft tissue of the cheek on the affected side of the nose or using BreatheRite nasal strips may relieve some symptoms, but surgery is the best option for permanent treatment of nasal valve collapse. Many ENT surgeons are not comfortable with these surgical techniques. It may be necessary to find a surgeon with Facial Plastic Surgery Board certification, as he/she will have the additional training required to perform this corrective surgery.
Internal Valve Collapse
Before and after: Correction of bilateral internal valve collapse due to a previous cosmetic rhinoplasty. Note the ‘inverted-V’ shape of the nasal bones on the left (actual patient).
The intersection of the nasal septum and upper lateral cartilage forms an angle that is usually eight to 15 degrees. Less than this can cause collapse of the internal valve, where much of the sensation of breathing comes from. Internal collapse may also cause narrowing of the middle third of the nose. Visually, the nose may have an ‘inverted-V’ where cartilage has pulled away from the nasal bones. This can be corrected by placing of strips of cartilage at the area of collapse to splint out the valve, or reattaching the cartilage to the nasal septum.
External Valve Collapse
Before and after: correction of right external valve collapse (actual patient).
If the side of the nose collapses inward during inspiration (breathing in), you may have a collapsed external valve. The sidewalls of the nose may look pinched where the cartilage is weak or has collapsed inward. This can also make the nose tip appear larger when it in fact has a normal size. Placing a cartilage graft into the weakest area of the nose can prevent collapse in that area. A deviated nasal septum or enlarged inferior turbinates may further contribute to external valve collapse.
Causes of Valve Collapse
Aging weakens the nasal sidewalls and causes the tip of the nose to sag. These changes can obstruct airflow inside the nose. Weak cartilage or cartilage turned inward can also predispose patients to nasal valve obstruction. The primary cause of nasal valve obstruction requiring surgery is previous nasal surgery. Taking down a large bump or decreasing a large tip can weaken support in the rest of the nose. Dividing the cartilage from the septum can cause scarring in the internal valve area that is very difficult to correct. Cosmetically, the nose may look great, but your breathing is still problematic. This can be avoided by choosing a surgeon trained to avoid and correct this deformity.
Cottle Maneuver: If your breathing improves when holding the cheek outward (as pictured above), you may have a collapsed valve(s).
A “Cottle maneuver” is an invaluable tool for diagnosing nasal valve collapse. The nose’s internal and external valves are elevated outward and the improvement in breathing is scored on a 10 point scale. The doctor should perform an intranasal exam should be performed before and after the nose is decongested. He/she can also perform a nasal endoscopic exam to evaluate structures deeper within the nose. In addition to valve collapse, a complete intranasal exam should look for indications of a deviated nasal septum, inferior turbinate swelling, sinus infection, or adenoid enlargement. A Sinus CT scan may be required for some patients.
Is this considered cosmetic surgery?
No. The ability to breathe through the nose is recognized by insurance companies as important to health and has its own insurance code. The nose shape may be more pleasing aesthetically as a result of correction of the nasal valves. Insurance will cover the functional cost of the surgery.