Algoritmo para o tratamento da insuficiência de válvula nasal externa

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www.bjorl.org

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

ORIGINAL

ARTICLE

Algorithm

for

the

treatment

of

external

nasal

valve

insufﬁciency

夽

Eduardo

Landini

Lutaif

Dolci

a_,b_,_∗

_,

_José

_Eduardo

_Lutaif

_Dolci

a

a_Santa_Casa_de_São_Paulo,_Faculdade_de_Ciências_Médicas,_São_Paulo,_SP,_Brazil

b_Santa_Casa_de_{Misericórdia}_de_São_Paulo,_Departamento_de_{Otorrinolaringologia,}_São_Paulo,_SP,_Brazil

Received26August2018;accepted22February2019 Availableonline23April2019

KEYWORDS Nasalobstruction; Rhinoplasty; Nasalsurgery

Abstract

Introduction:Nasal obstruction isone ofthe mostprevalent complaints inthe population. Themaincausesofnasalobstructionareinflammatory,infectiousoranatomicalalterations. Anatomicalalterationsincludenasalseptumdeviation,turbinatehypertrophy,andnasalvalve insufficiency(external and/orinternal).Thediagnosis ofnasalvalveinsufficiencyremainsa clinicaloneandisbasedoninspectionandpalpationofthenose,evaluatingbothitsstaticand dynamicfunctions.Theliteraturepresentsseveraloptionsforthecorrectionofexternalnasal valveinsufficiency.Thesearechosenaccordingtothechoiceandexperienceofeachsurgeon. Objective: Tocreateapracticalalgorithmfor thetreatmentofexternalnasalvalve insuffi-ciencythatcanguidenasalsurgeonsintheirchoiceoftreatmentforthedifferentanatomical alterationsfoundinpatientswiththesedisorders.

Methods:Weusedthetreatmentoptionsfoundintheliteratureandcorrelatedthemwithour surgicaloptionsforeachtypeofanatomicalalterationfound.Therefore,weusedbasicallythree parametersrelatedtophysicalexaminationﬁndings(degreeofinsufﬁciencyandcharacteristics ofthelowerlateralcartilage)andthepatient’scomplaintpresentorabsentaestheticcomplaint regardingthenasaltip).

Result: Apracticalalgorithmwasdevelopedforthetreatmentofexternalnasalvalve insuf-ﬁciency according to the degree of insufﬁciency (mild-to-moderate or severe), aesthetic complaintofthenasaltip(presentorabsent)andcharacteristicsofthelowerlateralcartilage (sizeandorientation).

Conclusion: Throughthissimplealgorithm,onecanuseeachtypeofgraftand/ormaneuver accordingtothepatients’complaintsandtheanatomicalalterationsfound.

© 2019 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).

夽 _Please_cite_this_article_as:_Dolci_EL,_Dolci_JE._Algorithm_for_the_treatment_of_external_nasal_valve_{insufﬁciency.}_Braz_J_{Otorhinolaryngol.}

2020;86:579---86.

∗_{Corresponding}_author.

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

PeerReviewundertheresponsibilityofAssociac¸ãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial. https://doi.org/10.1016/j.bjorl.2019.02.008

1808-8694/©2019AssociaçãoBrasileiradeOtorrinolaringologiaeCirurgiaCérvico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBYlicense(http://creativecommons.org/licenses/by/4.0/).

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PALAVRAS-CHAVE Obstruc¸ãonasal; Rinoplastia; Cirurgianasal

Algoritmoparaotratamentodainsuﬁciênciadeválvulanasalexterna

Resumo

Introdução: Aobstruçãonasaléumadasqueixasmaisprevalentesnapopulação.Asprincipais causasdeobstruçãonasalsãoinflamatórias,infecciosasoualteraçõesanatômicas.Asalterações anatômicas incluem:desviodosepto nasal,hipertrofia deconchas nasaise insuficiênciada válvulanasal(externae/ouinterna).Odiagnósticodainsuficiênciadeválvulanasalpermanece clínicoebaseadonainspeçãoepalpaçãodonariz,avaliadoemfunçõesestáticaedinâmica. Temosnaliteraturadiversasopçõesdecorreçãodainsuficiênciadeválvulanasalexterna.Essas sãoescolhidasdeacordocomaopçãoeexperiênciadecadacirurgião.

Objetivo:Criar um prático algoritmo para o tratamento da insuficiência de válvula nasal externa, que oriente os cirurgiões de nariz na escolha do tratamento para as diferentes alteraçõesanatômicasencontradasnospacientesportadoresdessasalterações.

Método: Utilizamosas opções detratamentoencontradas naliteraturaerelacionamoscom asnossasopçõescirúrgicasparacadatipodealteraçãoanatômicaencontrada.Dessaforma, utilizamos basicamentetrêsparâmetros relacionadosaosachadosdeexame físico (graude insuficiênciaecaracterísticas dacartilagemlateralinferior) eàqueixadopaciente (queixa estéticadapontanasalpresenteouausente).

Resultado:Umalgoritmopráticoparaotratamentodainsuficiênciadeválvulanasalexterna,de acordocomograudainsuficiência(leve-moderadaousevera),aqueixaestéticadapontanasal (presenteouausente)eascaracterísticasdacartilagemlateralinferior(tamanhoeorientação). Conclusão:Através desse simples algoritmo, podemos utilizar cada tipo de enxerto e/ou manobradeacordocomasqueixasdospacienteseasalteraçõesanatômicasencontradas. © 2019 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Publicado por Elsevier Editora Ltda. Este é um artigo Open Access sob uma licença CC BY (http:// creativecommons.org/licenses/by/4.0/).

Introduction

Nasalobstruction isone ofthemost prevalentcomplaints

in the population. The main causes of nasal

obstruc-tionareinﬂammatoryconditions,anatomicalabnormalities

and infectious processes. Anatomical alterations include

nasal septum deviation, turbinate hypertrophy,and nasal

valve insufﬁciency (external and/or internal). In the last

decades,theimprovedevaluationofthenoseandabetter

understandingofnasalanatomyandphysiologyheightened

attentiontothisregionduringnasalsurgeries,bothfor

pre-ventingthese alterations during purely esthetic surgeries

andinsurgicalproceduresperformedfortreatment.Nasal

valveinsufﬁciencyhasbeendiagnosedasthecauseofnasal

obstruction in up to 13% of adults.1 _{Additionally,} _95% _of

patientswithpersistentnasalobstructionafterseptoplasty

havethenasalvalveasaresponsiblefactor.2

In general, three structures make up the nasal valve

region:inferior turbinate, nasalseptum andlateral nasal

wall.Theﬁrsttwoarestaticandrigidstructures,whereas

thelatter,lessrigid,isavariabledeterminantfornasalvalve

stability. Therefore, it is important to diagnose which of

thesestructuresareresponsibleforadverselyaffectingthe

nasalvalvefunction.3

The nasalvalveis comprisedoftwoanatomically close

regions, which canbe responsible for nasal valve failure,

eitheraloneortogether.Theinternalnasalvalveisanangle

formedmediallybytheupperportionofthenasalseptum,

superiorlyandlaterallybythecaudalportionoftheupper

lateralcartilageandinferiorlyby thehead oftheinferior

turbinate.4 _In _Caucasian_noses, _this _angle _varies _between

10◦and15◦.Theexternalnasalvalveisconstitutedmedially

bythecaudalseptumandcolumella,superiorlybytheweak

triangle, and laterallyby the alar rim (caudalrim of the

lateralcrusofthe inferiorlateralcartilage)andinferiorly

bythenasalvestibuleﬂoor.5

The maincomplaint of patientswithnasal valve

insuf-ﬁciency is difﬁculty in obtaining adequate passage of air

through the nose. In the literature the diagnosis remains

subjective, and there is no gold standard test for this

diagnosistodate.Theclinicalhistoryassociatedwith

otorhi-nolaryngologicalphysicalexamination,anteriorrhinoscopy,

and external inspection/palpation of the nose are

impor-tantforthisevaluation.Complementaryexaminations,such

asrhinomanometry andnasoﬁbroscopy,areless usefulfor

evaluationanddiagnosisofnasalvalveinsufﬁciency.6

Onestudydemonstratedthatthe useofexternal nasal

dilatorsmay be useful in conﬁrming the diagnosis,

allow-ingdifferentiationoftheaffectedsite(lowerlateraland/or

upperlateralcartilages).Forthispurpose,thisdevicemust

bepositionedoverthenasalwing(lateralcrusofthelower

lateral cartilage) or over the cartilaginous nasal dorsum

(caudalportionoftheupperlateralcartilage),andthen

ver-ifyinginwhichsituationanimprovementintheobstruction

sensationoccurs.7

The performanceof the modiﬁed Cottle maneuver has

also been effective in the functional rhinoplasty surgical

programming,andismorespeciﬁcthanthetraditional

Cot-tlemaneuver.Inthetraditionalmaneuver,thecheekregion

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Degree of insufficiency Alar cartilage characteristics Aesthetic complaint of nasal tip Mild/moderate Severe Yes No Size Orientation > 12mm < 12mm Malposition Adequate Cephalic Sagittal

Figure1 Initialparametersusedtochoosetheappropriatetreatmentforthecorrectionofexternalnasalvalveinsufﬁciency.

Mild-to-moderate insufficiency. Aesthetic complaint of nasal tip Alar > 12 mm Turn in flap (com ou sem alar

rim graft)

Alar < 12 mm

Lateral crural strut graft with repositioning

Alar rim graft

Alar malposition Lateral crural strut graft Oblique turnover flap (With or without

alar rim graft)

Batten graft (Septo/concha) No aesthetic complaint of nasal tip

Figure2 Algorithmforthetreatmentofmild-to-moderateexternalnasalvalveinsufﬁciency.

Severe insufficiency Aesthetic complaint of nasal tip No aesthetic 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)

Figure3 Algorithmforthetreatmentofsevereexternalnasalvalveinsufﬁciency.

obstructionimprovement.Thismaneuverdoesnotallowthe

individual evaluation of the internal or external valves.8

In the modiﬁed Cottle maneuver, a metal stylus, or even

an otological curette, is usedto laterallypush the upper

or lowerlateral cartilageregion,verifyingin which

situa-tionthereisairﬂowimprovement.Therefore,themaneuver

allowstheisolatedevaluationofeachregion.

Externalnasalvalve

Externalnasalvalveinsufﬁciency isrelatedtoeither

con-genital alterations of the structures that constitute this

region,oralterations that wereacquired aftera previous

nasal surgery (iatrogenic). Congenital alterations related

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Figure4 Alarrimgraftcreatedfromseptalcartilage.Place wherethegraftwillbeinserted.

Figure5 Battengraftcreatedwithconchalcartilage.Place wherethegraftwillbeinserted.

collapseduringinspirationorpoorlypositionedlowerlateral

cartilages9_(in_an_inadequate_cephalic_or_sagittal_position,_in

whichthecaudalrimofthelateralcrusisatadifferentlevel

relativetothecephalicrim).

The correctdeﬁnitionofthe anatomicalalterationsite

isessentialsothatappropriateactionscanbeundertaken

---columella,caudalseptum,alarrim(congenitaloriatrogenic

lateralcrusfragility),oracombinationofthese.

There are no doubts about the treatment when

cau-dalseptaldeviationsoralarge(obstructive)columellaare

found.Inthesesituations,septoplastyandcolumelloplasty

arethetreatmentsofchoice.However,whenalterationsin

thelowerlateralcartilagesarefound,severaloptionshave

beendescribed.

The main surgical options for correction are: Batten

graft; Alar rim, Articulated alar rim graft; Lateral crural

strutgraft;LateralCruralTurn-inFlap;Seagullwinggraft;

andLateralcruralgraft.10---16

Methods

The choice of the type of graft usedin the correction of

lateralcrusalterationsshouldbedeﬁnedbythematerials

available for grafting, the degree of the alterationfound

and,especially,bytheexperienceandpreferenceofeach

surgeon.Therefore,wehavecreatedapracticalalgorithm

forthetreatmentofexternalnasalvalveinsufﬁciency. We

did not ﬁnd in the literature any articles that addressed

this practical implication. We found only one article that

addressestheauthors’treatmentprotocol.17_However,_they

use only onetype of graft, thebatten graft, for the

cor-rectionoftheentirevalvularregion(internalandexternal

valve).

Thus, our aim is to allow surgeons whohave recently

started performing nasal surgeries, speciﬁcally in

func-tionalandestheticrhinoplasties,tohavetreatmentoptions

accordingtotheanatomicalalterationsfound,and

accord-ingtotheavailabilityofgraftsforeachpatientaswell.

Results/discussion

Tochoosethetypeoftreatmentfornasalvalveinsufﬁciency,

weinitiallyusedthreeparametersasreference(Fig.1):

Estheticcomplaintofthenasaltip(presentorabsent);

Characteristicsofalarcartilage(sizeandorientation);

Degreeofexternalnasalvalveinsufﬁciency(mild,

moder-ate,severe).

Forsurgeonsperformingrhinoplasty, the esthetic

com-plaintofthenasaltipassociatedwithexternalnasalvalve

insufﬁciencyareimportantfactorswhenchoosingthe

treat-menttobeperformed.Patientswithoutestheticcomplaint

of the nasal tip allow us toperform the treatment

with-outtheexposureofnasaltipcartilage,whichisperformed

throughopen rhinoplastyor closedrhinoplasty with

deliv-eryaccess.Inthesesituations,onecanplacegraftsthrough

Figure6 Preandpostoperative(6months)periodsoffunctionalclosedrhinoseptoplastywithbilateral alarrimgraft,without accesstothenasaltip.

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Figure7 Intraoperativeperiod.Turninﬂapmaneuver.Initiallymarked8mmonthelateralcrusfromthecaudalborderandthen thecephalicportionisfoldedunderthecaudalremnant.

Figure8 Intraoperativeperiod.Patientwithpoorlypositionedalveolarcartilagesinthecephalicorientation.Complete detach-mentofthelateralcruraandlateralcruralstrutgraftﬁxationunderthealarcartilageswasperformed.

Figure9 Pre-andpostoperative(1year)periodsoffunctionalrhinoseptoplastyandopenesthetics,usinglateralcruralstrutgraft andlateralcrurarepositioning.

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Figure10 Image ofoblique turnoverﬂap for repositioning andﬂatteningofthelateralcrura.Goksel,Vladykina.

smallincisionsnearthe alar rim,withitsextension being

relatedto the size of the graft to be used.The alar rim

graftsandthebattengraftsaretheavailableoptions.

Patientswith estheticcomplaint of the nasal tip

asso-ciated with external nasal valve insufﬁciency should be

submitted to procedures that expose the alar cartilages

throughopenordeliveryaccess(closedrhinoplasty).

Over-all,thesecomplaintsmaybeassociatedwiththepositionof

thenasaltip(underprojectedoroverprojected)oritsshape

(globoseand/orasymmetric).

Thesizeofthealarcartilages,speciﬁcallyofthelateral

crus,isalsoaconditionthatisevaluatedforthechoiceof

treatmentoption.Weusedthefollowingreference

parame-terfortheﬁnalconﬁgurationofthesizeofthelowerlateral

cartilages:5mm inthedomeand8mm inthelateralcrus

region.18 _Alar _cartilages _that _have _a _lateral _crus_>₁₂_mm

allowustoperformamaneuverthatreinforcesthis

struc-turewithoutusinggrafts,byfoldingthecartilageonitself,

calleda‘‘turn-inﬂap’’.Cartilages<12mmdonotallowus

toperformthis maneuver, sincewe must alwaysmaintain

atleast8mminthelateralcrusportiontopreventalarrim

fragility.

The lateral crus orientation of the lowerlateral

carti-lageisalsoessentialinthediagnosisofexternalnasalvalve

insufﬁciency,sinceitwilldeﬁnethetypeoftreatment

cho-sen.Knownasacauseofexternalvalvularinsufﬁciencyand

sometimesalsoasacauseofnasaltipestheticcomplaint,

the cephalically or ‘‘between parenthesis’’ lower lateral

cartilagerequiresan adequatetherapeuticapproach. This

anatomical alterationresults in the absence of adequate

supportforthealarrimregion.Amongthetreatmentoptions

are repositioning of the lateral crus with or without

lat-eralcruralstrutgraft,19_and_some_new_options_described_in

theliteratureasturnoverﬂap.20 _Another_alteration_of_the

lateralcrusorientationof thelowerlateral cartilagethat

canbefoundisthesagittalmalposition,acondition

identi-ﬁedwiththedepressionofthecaudalriminrelationtothe

cephalicrim.Inthissituation,theanomalouspositionofthe

caudalrimcausesexternalnasalvalveinsufﬁciency.

Thethird parameterthatwasanalyzedtodeﬁne

treat-mentisthedegreeoftheexternalnasalvalveinsufﬁciency.

Noclassiﬁcationwasfoundintheliteratureforthistypeof

alteration.Therefore,weusedmild-moderateinsufﬁciency

forpatientswithdynamicalterationsoftheexternalnasal

valve(non-forcedinspiration) or witha diagnosis of

frag-ile and/or poorlypositioned cartilagesthroughinspection

andpalpationofthenose.Severeinsufﬁciencyisdeﬁnedas

Figure11 Intraoperative period. Articulatedalarrim graft wasusedinprimaryclosedrhinoseptoplasty,withgraftﬁxation onthelateralcrusnearthedomus.

Figure12 Intraoperativeperiod.Articulatedalarkidneygraft usedinopenrevisionrhinoseptoplastyforexternalnasalvalve remodeling.Patienthadundergone2previoussurgical proce-dures.Thegraftwasattachedtotherightand,ontheleft,we canidentifytheremnantofthelowerlateralcartilagewiththe previouslyamputatedlateralcrus.Subsequently,wealsoﬁxed thegrafttotheleft.

thosepatientswithcollapseofthealarrimatstatic

inspec-tionof the external nasalvalve, or patients withtotalor

partialabsenceoflateralcruscausedbyiatrogenesisor

mal-formation. These situations require more speciﬁc choices

ofgrafttypetobeused.Thefollowingareoptions:batten

graft,lateralcruralstrutgraft,articulatedalarrimgraftor

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Figure13 Pre-andpostoperative(3months)periodsofestheticandfunctionalrevisionopenrhinoseptoplasty,withtheuseof anarticulatedalarrimgraft.Patienthadundergone2previousnasalsurgeries.

Figure14 Intraoperativeperiod.Seagullwinggraftbeforebeingﬁxed(onlyshowntherightgraft).Subsequently,thegraftswere positionedbilaterallyontheremnantsofthealarcartilages.

Therefore this treatment algorithm was created for

externalnasalvalveinsufﬁciencytreatment(Figs.2and3).

The treatmentoptionsforpatients withmild-moderate

external nasalvalvefailure without estheticcomplaintof

thenasaltiparethealar rimgraft11 _(contour _grafting)_or

battengraft.10_In_these_situations,_the_septal_cartilage_is_the

ﬁrstchoice; however, conchal cartilage canalso beused.

The alar rim graft shouldbe positioned close tothe alar

rim(Fig.4),whereasthebattengraftshouldbelocatedon

thelateralcrus(oritsremnant)andextendtothepiriform

opening.Fortheseoptions,wemake asmallincisionnear

thecaudalmarginofthelowerlateralcartilageanddissecta

narrowspacetoreceivethegraft(Fig.5).Itisnotnecessary

toﬁxitwithsutures,aswedonotperformawidedissection

oftheregion.Then,theincisionissuturedwith1---2simple

absorbablestitches(Case1)(Fig.6).

In patients with mild-to-moderate insufﬁciency and

estheticcomplaintofthenasaltip,thetreatment options

willbebasedonthecharacteristicsof thealarcartilages.

Adequatelyorientedalveolarcartilagesthathavealateral

crussizegreater than12mm, canbetreated withturn-in

ﬂap14 _a _maneuver_that _obviates_the _need _for _a_graft, _and

consists of overlapping at least 4mm of the lateral crus,

thusgeneratinggreaterstabilityinthisregion(Fig.7).

In situations with inadequately orientated lower

lat-eralcartilages,regardlessoftheirsize,wemustuseother

treatmentoptionsforthiscorrection.Cartilageswithpoor

cephalicorsagittalpositioningcanbetreatedwithlateral

crus repositioning, associated with the use of the lateral

crural strut graft13 ₍_Fig. ₈_)._In _this _treatment, _we _detach

theentirelateralcrus,sincethedomus,fromthe

underly-ingmucosa,andremovethelateralcrusfromthesesamoid

cartilages.Next,agraftisﬁxed (lateralcrural strutgraft)

onthislateralcrusandthesestructuresarerepositionedto

anew,lowerposition,withthedetachmentofanarrow

tun-nelnexttothepiriformaperture(Case2)(Fig.9).Another

optionforthecorrectionofcephaliccartilageistheoblique

turnoverﬂap,20 _described _more_recently_in_the_literature.

Thismaneuverconsistsoffoldingthelateralcrusonitself

atanobliqueaxis,changingitspositionandreinforcingthe

regionofthealarrim(Fig.10).

In patients with severe external nasal valve

insufﬁ-ciency,signiﬁcantnasal obstructionwasfound duetothis

alteration.Thesesituationsareveryoftenassociatedwith

previoussurgeries,withaggressiveresectionofthelateral

crusofthelowerlateralcartilage,ormalformationofthese

cartilages.Inthesecases,theoptionsrequireasigniﬁcant

strengtheningoftheexternal nasalvalvearea,whichwill

also have as criterion the observed aspect of the lower

lateralcartilages.Somepatientshaveonlyafunctional

com-plaint, and in these cases, the use of batten graft with

auricularconchal cartilageis anexcellentoption, without

theneedforawideaccess,butonlythecreationofanarrow

areatoplacethegraft.

However, many patients also have esthetic alterations

duetodeformitiesinthe lateralcrus.Inthesesituations,

wecanalsousethepreviouslydescribedlateralcruralstrut

graft.Anotherincreasingly usedoption, is the articulated

alarrimgraft12₍_Figs.₁₁_and₁₂₎_that_can_be_employed_for

thesemoreseveresituations.Itiscreatedpreferablywith

septalcartilage(orcostalcartilage),havingitsmedial

por-tionattachedtothelowerborderofthelateralcrusremnant

nearthe domusand itsmost lateral portionis embedded

intoanewdissectedpouchclosetothepiriformaperture,

tostabilizethisgraftandgivesupporttothealarrim(Case

3)(Fig.13).In caseswherewe ﬁndpartial ortotal

resec-tionofthelateralcrus,wecanusetheseagullwinggraft15

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cartilage.Inthesecasesitisnecessarytouseauricular

con-chalcartilage,asithasintrinsicconcavitiesthataresimilar

tothelateralcrus(Fig.14).

Conclusion

The use of thissimple and practical algorithm allowsthe

useofeachtypeofgraftand/ormaneuveraccordingtothe

patients’complaintsandtheanatomicalalterationsfoundin

theinferiorlateralcartilagesforthecorrectionofexternal

nasalvalveinsufﬁciency.

Conﬂicts

of

interest

Theauthorsdeclarenoconﬂictsofinterest.

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