Vestibular stenosis: nasal valve collapse

The turbulence in the nose causes the air to come in contact with out nasal mucosa in order to warm, humidify, and purifiy the air we breathe before it gets to our lungs. Airflow resistance is therefore extremely important for good pulmonary function. Our nose is where more than half of this resistance occurs when we breathe. The anterior portion of the nose is where most of the resistance occurs. This area is known as the internal and external nasal valves, and they act as a flow limiters.

nasal valves

This diagram pinpoints where both the external and internal nasal valves are located inside the nose.

The external nasal valve is constructed by the nasal floor, the nasal wall, and by the middle of the nose in the front called the columella. The nasalis muscle expands the external valve area during inhalation.

The internal nasal valve is what we normally mean when we are referring to the area called the “nasal valve”. The internal nasal valve is where most of the flow resistance is created. It is in the area between the nasal septum and the mobile side cartilage of the nose. When air comes in the narrow valve, it creates a negative pressure and the valve tends to collapse. After inhale is the exhale, where the negative pressure releases and the passage opens to its original position. Nasal valve collapse can be dynamic, fixed or both.

deviated septum

Causes of vestibular stenosis (nasal valve collapse)

The causes of nasal valve collapse can be aging, iatrogenic causes, congenital or secondary after trauma. Reduction rhinoplasty, can cause a decreased cross-sectional portion of the nasal valve or detach the cartilage in the valve area from the nasal bones creating an inverted-V looking deformity under the nasal bones.. A deviated septum can narrow the valve as well.

Non-surgical vestibular stenosis (nasal valve collapse) treatment

No single approach has been universally corrective when dealing with nasal valve collapse — often this condition requires multiple solutions.

Pulling on your cheeks is something that patients will do to open the valves. Many will do it unconsciously because for that breath it opens the airway. This is also a diagnostic test for valve collapse your doctor may perform called a Cottle maneuver.

Oxymetazoline spray, like Afrin, can temporarily decongest the valves but has the risk of making the valves more congested after a couple of days. Nasal steroid sprays may decrease the valve congestion over time and give some valve area breathing improvement.

Another solution is the use of prosthetic splints such as flat springs taped to the outside of the nose, Breathe-Rite strips, or wire or plastic “cones” placed inside the nostrils. These can be uncomfortable but will provide clear breathing during periods of sleep or exercise, however, they are not an acceptable solution for most social situations.

Nasal valve collapse surgery

If the nasal valve collapse is causing significant symptoms, you may consider to surgically augmenting the internal nasal valve. This requires the use of a cartilage “spreader graft” put between the upper lateral cartilage and the septum. This attaches the upper and lower margin of the collapsed upper lateral cartilage to the septum. It should decrease or eliminate the inverted-V deformity but it may also widen the middle nasal vault.

nasal_collapse

This “Before & After” photo shows one of Dr. Bennett’s patients who underwent a correction of the bilateral internal valve collapse.

Those with severe external valve collapse may need a different cartilage graft to build up the weakened lateral nasal wall. The alar batten graft is commonly used. Alar batten grafts are grafts used to fortify the nasal airway in the collapsing part of the upper nostril. The name alar batten comes from the word alar (the cartilaginous flap on the outer side of each nostril) and batten (which is a nautical term describing: a thin narrow strip of lumber used especially to seal or reinforce a joint. Ex: “Batten down the hatches.”)

Normally alar batten grafts are inserted in surgical subcutaneous pockets at the weakest area of the lower lateral cartilages. Alar batten grafts can be made up of septal, rib, or ear cartilage. However, conchal cartilage or ear cartilage, is often shaped in a curved manner making it and ideal choice for patients with significant collapse.

Nasal valve collapse can be complex and requires the practitioner to be well versed in several procedures in order to be successful in its repair. But, for those suffering with nasal valve collapse the correction can truly be life-changing.

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