VI. DISCUSSION (cont'd)

The nasal valve area is considered to be the location of the least cross-sectional area in the nose; measure­ments made from nasal casts and calculated from rhinomanometry measurements indicate an average area of 0.73 cm for the nasal valve area.

The external nasal valve is distinct from the in­ternal nasal valve described above and is composed of the cutaneous and skeletal support of the mobile alar wall up to and including its free edge at the nostril opening.² Overaggressive resection of the lateral crura during rhinoplasty and the subsequent postoperative soft tissue contraction may lead not only to internal but also to external nasal valve compromise. Congenital cephalic position of the lateral crura will also leave suboptimal structural support in the mobile alar wall, with subsequent external valve collapse. External valve narrowing may be active, a result of inspiratory collapse similar to that described above, or passive, resulting from a severely deviated caudal septum causing unilateral obstruction at the external nasal valve. Both active and passive elements may be factors in obstruction at the external nasal valve.

Inspiratory collapse of the lateral nasal sidewalls with normal inspiratory negative pressure suggests inadequate rigidity of nasal supporting structures. Inspiratory collapse at the external valve is visible on examination and is indicative of flaccid soft tissue in this location. Similarly, inspiratory collapse may compromise function at the internal nasal valve. The patient's nose should be observed for collapse on normal inspiration.

A positive Cottle maneuver, while not alwaysreliable, is consistent with a diagnosis of nasal valve collapse. In the classic description, the patient's cheek is lateralized; this movement is translated to the nose, where lateralization of soft tissue of the nasal valve occurs. Alternatively, the author prefers to support the nasal sidewalls at the location corresponding to the internal nasal valve area with a small curette or the back end of a Q-tip, lateralizing the lateral nasal sidewall 1-2 mm. When this maneuver relieves nasal obstruction, the diagnosis of functional valve collapse is supported.

Chronic nasal obstruction is the most common presenting symptom of anterior ethmoid sinus dis­ease,¹ 0 so the history should elicit the presence of post-nasal drip and cough, facial pressure or pain, ear pressure or pain, hearing loss, loss of sense of smell or taste, halitosis, and other pertinent fi nd­ings suggestive of chronic or recurrent sinusitis. The patient should be questioned and, when appropri­ate, evaluated for allergies. All medications taken should be carefully recorded; a history of topical nasal decongestant abuse may lead to the diagnosis and treatment of rhinitis medicamentosa. It is critical to elicit a history of prior sinus surgery, rhinoplasty, or other nasal surgery.

In patients with a history of prior nasal surgery, special consideration must be given to the possibil­ity of nasal valve collapse. Commonly performed rhinoplastic maneuvers can result in nasal valve col-lapse. Over-resection of lateral crura may be the most common postsurgical cause of nasal valve collapse. When excising the cephalic portion of the lower lateral cartilage (LLC), the surgeon should leave at least 7-9 mm of intact cartilage, preserving an intact strip of cartilage from the feet of the medial crura to the most lateral part of the lateral crus. Overaggres­sive resection of the lateral crura and the subsequent postoperative soft tissue contraction may lead to nasal valve compromise.

Inadequate support of the upper lateral cartilages after dorsal hump removal can lead to inferomedial collapse of the upper lateral cartilages and internal valve collapse. Externally, this may manifest itself as an "inverted V deformity." In this deformity, the cau­dal edge of the nasal bones are visible in broad relief. The inverted V deformity is not always present with nasal valve collapse. Also, it is not always indicative of nasal valve collapse, because it also may be due to inadequate infracture of the nasal bones.

Despite the clearly functional aspect of this sur­gery, in the United States many insurance companies were reluctant to authorize payment for this surgical treatment. In the past, these procedures were coded using rhinoplasty codes, but insurance carriers often categorized these procedures as cosmetic, even thoughthe procedure was undertaken to improve breathing and the patient may have had no interest in changing the nasal appearance.

Due in part to educational and patient advocacy ef­forts by physicians and physician groups, a new CPT code, 30465, is now available for repair of vestibular stenosis.¹7 This reflects a recognition by insurance companies of the importance of this procedure for treating nasal obstruction.

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Ask Dr. Becker a question about revision rhinoplasty or make an appointment for a consultation, by calling 856-589-NOSE (6673) or emailing us at info@revisionrhinoplasty.com.