1. The nasal valve & its management
The external nasal valve is made of the ala, skin of the vestibule, the nasal sill& contour of the
medial crus of the lower lateral cartilage. Dilator muscles are attached to the alar cartilages & when
they contract, these help to flare or support the nostrils.(external nasal valve situated at the
vestibular rim). The external valve has a tendency to collapse at high flow rate even in normal
individuals.
The upper lateral cartilage are in continuity with the superior border of the nasal septum. A valve-like
mechanism exists at the distal end that regulates nasal airflow.
The nasal valve area: the nasal valve area is the narrowest portion of the nasal passage. It is
bounded
- medially by septum & the tuberculum of Zuckerkandel;
- superiorly & laterally by the caudal margin of the upper lateral cartilages;
- its fibro-fatty attachment to the pryiform aperture( first few millimetres);
- the anterior end of the inferior turbinate.
- Inferiorly it is made of the floor of the pyriform aperture.
The entire nasal valve area averages 55& 64mm2
The nasal valve: is the slit-like segment between the caudal margin of the upper lateral cartilage &
the septum(nasal isthmus). It is measured in degrees & normally ranges between 10 -150. The
dialator naris anterior muscle & the alar part of nasalis muscle support the nasal valve.
Physiology
The dynamic of airflow follows a parabolic curve as it passes through the nasal valve. It contributes
to air turbulence. This optimizes contact between the air stream & mucosal surface in order to
obtain maximum air conditioning effects(humidification, filtration& olfaction).
The nasal valve should be considered as an inflow regulator.
The main airflow resistance of the whole respiratory tract is normally confined to the nasal valve
area. Some resistance in the nose is essential to prevent alveolar collapse.
Pathology
Nasal valve problems can be primarily due to inherent problem in this area, such as collapse of weak
or overresected alar cartilage during inspiration or that the upper & lower lateral cartilages do not
overlap.
It is more common for this to occur secondary to a septal deviation, turbinate hypertrophy or
scarring of vestibular skin & this is termed secondary valve collapse.

2. Causes of nasal valve collapse
Primary causes of nasal valve collapse Secondary causes of nasal valve collapse
Excessive resection of the lower lateral
cartilages
Long returning of upper lateral cartilages
A concave lower lateral cartilage
A medially placed upper lateral cartilage
because of a narrow pyriform aperture;
No overlapping between the upper & lower
lateral cartilages;(old age)
Inherently weak upper & lower lateral
cartilages;
Reduced activity of the dilator ala nasi muscles
such as in a facial nerve palsy.
Deviated septum
Wide columella
Turbinate hypertrophy
Scarring of vestibular skin
Slit-like inlet
A wide tuberculum of Zukerkandel.
The nasal valve influenced by the activity of alar muscles that are supplied by facial nerve& these
prevent collapse of the nasal valve during deep inspiration. The nasal resistance during deep
breathing is less than during normal breathing because of the widening of the nasal valve produced
by the alar muscles.
Paralysis of these muscles can result in nasal valve collapse& thus an increase in nasal resistance.
Another factor is mucosal sensation ; a dry lining can paradoxically reduce sensation of airflow
when there is a large patent airway. To compound this problem, the patient may then sniff
vigorously in order to improve the sensation of airflow( produced by a change in the temperature &
humidity of the air)& cause secondary valve collapse when this is not the primary cause of their
symptoms.
Diagnosis
A diagnosis of nasal valve dysfunction can be made by simple inspection by watching the patient
breathe at rest.
Using a Jobson-Horne probe, it is possible to gently support the upper lateral cartilage& ask the
patient if it provides symptomatic benefit. The appearance of an inverted V over the middle third of
the nose is in keeping with collapse of upper lateral cartilages.
Cottle’s sign: distracting the nasal valve by pulling on the soft tissues of the check, often provides
symptomatic improvement in most primary & secondary causes affecting the nasal valve.
Treatment options
The surgical aim is to restore the normal anatomy, maintain the integrity of the framework &
improve nasal ventilation without running the risk of an aesthetic defect.

3. 1)Correction of a deviated septum
A septal deviation can cause narrowing of the nasal valve. SMR or septoplasty can correct the
patency in the valve area.
2)Alar collapse
Corrected by
- The position of a lateral crura spanning graft;
- The position of a lateral crura spanning graft;
- Reefing up of the lower lateral cartilages to be supported by the upper latera cartilages.
3)Upper lateral cartilages
Spreader grafts help to open the nasal valve when resection or lack of support of the upper lateral
cartilage has led them to become medialized. Spreader grafts also help to lateralize not only upper
lateral cartilages but also help the lower lateral cartilages.
Spreader grafts usually placed bilaterally between the septum& upper lateral cartilages but can be
used unilaterally.
Onlay cartilage graft over septum & upper lateral cartilage. Placement of a segment of conchal
cartilage ( kidney shaped or butterfly shaped) to support the upper lateral cartilages in bilateral nasal
valve collapse.
4)Stenosis of nasal valve
Scar formation causing a web in the region of nasal valve can be corrected by a Z-plasty or VY-plasty.
5)Nasal valve suspension
This procedure involves passing sutures from the cartilages to the orbital rim through a
transconjunctival incision where they are fixed.
6)Strengthening of the nasal dilator muscles
The dilator naris anterior & alar part of nasalis muscle act on the nasal valve. These muscles are
strengthening by electrical stimulation, exercises.
Conclusion
Primary & secondary causes of nasal valve collapse should be identified prior to treatment.
Secondary collapse usually gives a poor prognosis.
Primary nasal valve collapse requires some form of support to the lateral wall of the nose. The key
issue is to diagnose what anatomical abnormality is that needs to correcting. A open rhinoplasty is
often helpful to obtain good access & visibility to correct any abnormality of the lower lateral
cartilage & to insert the spreader grafts.