Vestibular stenosis: nasal valve collapse

What Are The Nasal Valves?

“Nasal valves” are areas in the nose that are narrow and cause difficulties in breathing. There are 2 nasal valves, an “internal” and an “external” nasal valve. The external nasal valve is the “nostril” of the nose and is made up of the ala, the round fleshy area on the sides of the nose. The ala is supported by cartilages located in the tip of the nose. The internal valve is located inside the nose and is the area between the nasal septum and the lowest portion of the upper lateral cartilage, which are cartilages located on the sides of the nose.

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.

 

What Is A Nasal Valve Collapse?

There are many reasons for a nose to be congested and blocked. These include a deviated septum, enlargement of the natural tissues of the nose (also known as inferior turbinate hypertrophy), nasal polyps, and/or allergies. Another reason is lack of support on either side of the nose when you breathe inward. The “valves” should be strong and resist airflow when breathing in. Weak cartilages can cause the one or both valves of the nose to collapse inward causing blockages and nasal congestion. Sometimes the blockages can be a combination of all of the above-mentioned problems. A thorough evaluation by a specialist is needed to determine the cause of the blockage and the best treatment options for nasal valve collapse.

 

deviated septum

What Causes External Nasal Valve Collapse?

Weakness or upward orientation of the cartilages in the tip of your nose can cause the external valves to narrow with inspiration. If you have had a previous rhinoplasty, then the lower lateral cartilages may have been partially removed which will also weaken the external valves. Having widening of the skin and cartilage between your nostrils or a septum that you see deviated into one nostril will contribute to external valve narrowing.

 

What Causes Internal Nasal Valve Collapse?

For the internal valves, the upper lateral cartilages can be weak or very narrow causing collapse when breathing inward. A bump removal can cause the upper lateral cartilages to become disconnected from the midline septum and causing them to fall against the nasal septum. If the septum in the area of the internal valve deviates toward the valve then this will also cause valve narrowing.

 

What Are The Symptoms Of A Nasal Valve Collapse?

Symptoms of a nasal valve collapse are as followed:

  • Nasal obstruction
  • Congestion and difficulty breathing from the nose
  • Bloody nose
  • Crusting around the nostrils

 

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 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 an 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 from nasal valve collapse, the correction can truly be life-changing.

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Meet Dr. Garrett Bennett

Dr. Bennett is a New York City sinus surgery and rhinoplasty specialist. He is double board-certified with board certifications in Otolaryngology by the American Board of Otolaryngology, and Facial Plastic Surgery by the American Board of Facial and Reconstructive Surgery. He operates and has privileges at Lenox Hill Hospital, a signature acute care facility part of the Northwell Health System, and Gramercy Medical Center located in Manhattan, New York. Learn More »