What is nasal valve collapse?

The nasal valve is the space just inside the nose, just over 1cm beyond the front of the nose. In everyone, it is the narrowest point of the inside of the nose. Because of this, it is the most important area in regulating the flow of air through the nose into the lungs. Even small changes in the size or aperture of the nasal valve can affect the flow of air through the nose significantly.

The size of the nasal valve itself does vary from person to person. In fact it is not necessarily the case that someone with a big nose will have a big nasal valve and vice versa. It is possible to have a reasonable sized nose but for the lower half to be ‘pinched’, causing a narrowing at the valve area, which in turn will give a tendency towards having a slightly blocked nose.

Alternatively, the size of the nasal valve may be perfectly adequate, but the strength of the sidewalls of the nose (usually made up of skin, fat and cartilage) may be weaker than normal. This can happen due to the normal ageing process, after an injury or accident or following previous nasal surgery. A weak sidewall will be less able to resist the tendency of the nose to collapse inwards, particularly when breathing hard such as during exertion.

Reasons for and benefits of nasal valve surgery

The surgery is being undertaken to correct a weakness of the nasal valve area, which is causing a reduction of nasal airflow. This can be due to an injury or trauma to the nose, occasionally following previous nasal surgery although in many cases it is a hereditary feature.

Sometimes other surgical procedures may need to be undertaken at the same time, such as to correct a deviated nasal septum, or surgery to trim or reduce the lining of the nose (turbinate cautery or reduction).

Different surgical operations to treat the nasal valve:

  1. Cartilage augmentation: This involves using cartilage to strengthen and rebuild the narrow and weak nasal valve area. The cartilage is usually taken from your own body tissues, usually your own nasal septal cartilage, or if this is not available or sufficient, then it is common to use some ear cartilage. Rarely rib cartilage might be required if you are undergoing a more comprehensive reconstruction of other aspects of the nose at the same time where a larger volume of cartilage might be required.
  2. Intranasal Z-plasty: This procedure involves using stitches and carefully placed skin flaps to widen and stiffen the internal nasal valve area. The flaps are sutured in place using fine absorbable stitches via a keyhole approach through the nostrils without the need for any external cuts.
  3. Titanium Nasal Implant: Titanium BreatheTM Implants are small, carefully fashioned sheets made of the metal titanium, which are used to improve breathing through the nose in people with narrow noses, a narrow nasal valve or nasal valve collapse. Titanium as a metal is quite inert, meaning that the body does not tend to reject titanium. This means that it is generally well tolerated and incorporates well into the existing body tissues, creating stability. It usually requires an external skin incision for placement although it can in some cases be inserted through a closed approach.

Advantages/disadvantages of the different nasal valve surgical techniques:

1. Cartilage augmentation. The main advantage is that your own body tissues are used for reconstruction; the disadvantage is that because cartilage is not as strong as man made materials such as titanium, a larger/thicker piece needs to be used to improve the strength of the nasal valve. Consequently this can result in a broadening of the middle part of the nose and a change in the way it looks.

2. Titanium BreatheTM Nasal Implant. The main advantage is that titanium is inherently stronger than cartilage, therefore the implant can be made to be extremely thin whilst still being strong. Therefore the chance of it showing through the skin or changing the shape of the nose is less than for cartilage. It is also inert and well tolerated so the body does not generate a rejection reaction against it. The disadvantage is that the implant could cause problems such as slipping or movement, although these are extremely unlikely. In any case this complication could also happen with cartilage.

3. Intranasal Z-plasty. By avoiding the need for any cartilage or other implants, there are therefore no material-related complications. This procedure is therefore the one that is associated with the lowest chance of changing the shape of the nose. It does not have the ability to widen the nasal valve area as dramatically as a titanium implant or cartilage grafting; however in most cases the degree of widening is more than sufficient for most patients to achieve an improvement in their nasal airway.

Alternative non-surgical options:

  1. Medical treatment: You may already have tried steroid nasal sprays or drops and this remains an option to treat nasal blockage due to inflammation of the nasal lining. This treatment would however not be expected to improve nasal block due to weakness of the nasal valve, for which surgery is the most effective solution. One alternative is to try an external nasal splint such as a ‘Breathe Right strip’ which is placed on the outside of the nose and has the effect of springing the side walls of the nose outwards, thereby resisting the tendency of the nose to collapse on breathing in. Some people find them quite effective, in some cases sufficiently so that surgery is not required. However the benefit is only realised whilst using the strips, which can cause a problem to some patients who cannot, for work or other reasons, wear them during the day. If the breathing problem is only at night then they are certainly worth a try. Even if surgery is being considered, your surgeon may suggest that you have a trial of the strips. If the strips are not effective then you will be more convinced that surgery is the only way forward. If the strips are effective but you do not like the idea of wearing them all of the time, then again surgery remains a viable way forward. Alternative options include nasal alar dilators that are made of silastic and are inserted into the nostrils at the front of the nose.
  2. Other operations: There are a variety of techniques used to correct nasal valve weakness, as discussed above. Occasionally other procedures may be required in addition to nasal valve surgery such as cautery to the inferior turbinates or septoplasty.
  3. No treatment: You can decide not to have any treatment if you are happy to put up with your symptoms. This is because the proposed operation is elective and is not being undertaken as an emergency; therefore you could elect to live with your symptoms if you prefer not to go through an operation. One consequence of this is that your underlying condition could gradually get worse with time, in which case surgery might need to be considered in the future if medical or other treatments fail.

Details of the operation:

Titanium:

Titanium Breathe Implants are inserted with the patient asleep under a general anaesthetic (GA). An external incision is required in the skin of the tip of the nose, which allows the skin to be carefully raised in order to expose the cartilaginous framework of the nose. In particular, the nasal valve area is meticulously dissected free in order to demonstrate the weak area. At this point, the size of the valve is assessed and the correct titanium implant selected from a range of possible sizes. The titanium implant is then securely sutured in place using non-absorbable material so that there is no movement or slippage of the implant. Any other problems that need to be corrected can now be addressed (e.g. septoplasty, tip refinement) before the external skin incision is closed with fine sutures and a plaster placed on the nose for protection. It is unusual to require any internal nasal dressing unless a septoplasty or sinus surgery has also be conducted simultaneously.

Cartilage Augmentation:

The surgery usually proceeds in exactly the same way as for titanium nasal implant surgery, except for the difference that cartilage is used to rebuild the nose instead of a titanium implant. The cartilage is usually taken from the nasal septum although occasionally ear cartilage (or even rib) can be used. This means that a separate cut or incision will be required either behind the ear or over a rib if required.

Intranasal z-plasty:

The difference here is that this operation is undertaken internally (endonasal approach) with no external skin incision required. Also no cartilage or other material is inserted into the nose.

What to expect after the surgery:

Once the operation has finished, you will be moved into the recovery area where you will wake up. There should be little if any discomfort, although you may feel that your nose is slightly congested and sore, particularly if you accidentally knock it. You will be able to eat and drink soon after you wake up, and you should then be able to go home on the same day.

What can go wrong after nasal valve surgery?

There are some possible risks, side effects and/or complications that can happen after nasal valve surgery. These include:

  • Bleeding: This is an expected side effect following nasal surgery and usually lasts no more than a few days, occasionally lasting up to two weeks in some patients.
  • Infection: This occurs in about 1 in 10 patients and can be treated with antibiotics. Published research and unpublished communications have shown that the Titanium Implant rarely becomes infected. The risk of infection appears if anything to be lower than if the patient’s own cartilage is harvested and implanted. If you suspect an infection such as skin redness or tenderness or a foul smelling discharge from the nose, you are advised to see a doctor as you may require a course of antibiotics.
  • Pain/discomfort: The nose is not usually too painful although it will be sore particularly if you touch, knock or blow the nose hard.
  • Blocked nose: It is expected that the nose will get more and more blocked after the surgery during the first 7-10 days, and then will gradually clear, usually taking 3-4 weeks and sometimes a little longer to clear fully.
  • Swelling: The nose rarely gets swollen after nasal valve although a small amount of swelling can sometimes occur around the tip or columellar.
  • Septal perforation: This can happen with nasal valve surgery when the septum is straightened. Sometimes the layers either side of the cartilage can weaken and cause a small hole. This can occur in around 1 in 25 cases.
  • Dental hypoaesthesiae: Numbness of the upper two front teeth and/or upper lip and tip of nose can occur due to bruising of the small nerves in the area and also due to the prolonged effect of the local anaesthetic injection (which is used to reduce discomfort after the surgery).
  • Persisting nasal block: It is possible that some restriction of nasal breathing may persist after the healing process has taken place. This could be due to a persisting weakness of the nasal valve that has not been possible to address fully, a residual septal deviation, or due to another problem such as inflammation of the nasal lining, which can in some instances get worse after the surgery.
  • Change in shape of nose: Occasionally the shape of the nose can change when nasal valve surgery is carried out, even after the initial swelling has reduced. This is more likely with cartilage or titanium implant surgery where material is added to widen the nose for the purposes of breathing; this can sometimes also widen the nose visually; however it does not happen very often. The change in the shape of the nose seems to be less for titanium implant insertion than cartilage augmentation – this may be because the titanium implant is designed to be extremely thin, which is possible on account of its remarkable strength. Also, once the implant is sutured in place, it is overlapped by the existing nasal valve cartilages, which protect and cover the titanium implant. These two reasons may therefore account for the lack of visibility of the implant. A change in the shape of the nose is the least likely to occur with intranasal z-plasty surgery.

Postoperative advice and preparation

It is advised that you avoid contact with people and dirty/dusty environments for a period of two weeks after the surgery. For most people this means two weeks off work (or work from home if your job allows). This is to reduce your risk of getting an infection or virus.

As with any form of nasal surgery, it is important to minimise the amount of heavy lifting and/or straining in the first few days after the operation otherwise there will be an increased likelihood of a nosebleed. You should also avoid any exercise/gym for two weeks otherwise your blood pressure might go up and cause more bleeding. After two weeks you can resume exercise gently to start with, and avoid any contact sports for 6-8 weeks.

Regarding blowing your nose, try to avoid this for two to three days then you can start blowing your nose gently. During this period, if you feel that you are going to sneeze, keep your mouth open so the pressure does not cause pain in the nose or bleeding.

Also it is important to try not to sustain any injury to the nose as this could disturb the surgical repair.

Further information about Titanium Breathe Implant

This can be obtained from the manufacturer’s website www.breathe-implant.com