Eur J Plast Surg DOI 10.

1007/s00238-011-0634-6

ORIGINAL PAPER

Triple-procedure technique in internal nasal valve surgery

Shahram Anari & Mohamed R. El Badawey

Received: 11 May 2011 / Accepted: 20 July 2011 # Springer-V erlag 2011

Abstract In cases of narrowing of the internal nasal valve angle, we address all structures that commonly contribute to the internal valve area obstruction. We term this the tripleprocedure technique. The aim of this study was to assess the efficacy of this technique in improving patients' subjective nasal patency. A prospective longitudinal case study was conducted in a tertiary hospital in northeast of England. All consecutive patients who complained of nasal obstruction and were diagnosed with the internal nasal valve angle narrowing due to septal deviation were offered to have a triple-procedure operation (septoplasty, turbinate surgery and internal nasal valve surgery). Patients completed a validated nose-related questionnaire (Nasal Obstruction Symptom Evaluation (NOSE)) preoperatively, which was repeated 3 months after the operation. The change in NOSE score was the outcome measure. Eight of the nine patients recruited to the study completed the questionnaires (88% response rate). The total and the domain scores improved after the operation, which were clinically and statistically significant. The effect size proved to be very large (total NOSE score effect size, 4.0). Our study shows that addressing all three structures commonly affecting the

internal valve area is an effective technique in improving the obstruction caused by the narrow internal nasal valve angle. Keywords Nasal valve surgery . Rhinoplasty . Nasal airway . M-Plasty . Nasal obstruction . Internal nasal valve

Introduction It has been shown that a significant number of failed septoplasty operations were performed on patients whose nasal valve incompetency were missed preoperatively [1]. Nasal valve has traditionally been divided into the internal and the external segments. The internal valve area is a teardrop-shaped three-dimensional area surrounded by nasal septum, caudal end of the upper lateral cartilage, floor of the nasal cavity and the anterior head of inferior turbinate. Needless to say that any deformity of the said structures along with abnormalities of the mucosal lining (e.g. scars and inflammation) can lead to the narrowing of the internal valve area. Nasal valve surgery is a general term for a variety of surgical techniques employed for correcting the anatomical structures in the nasal valve area [2]. Most of these techniques have the side effects of broadening the midnasal vault or the nasal tip. Some of these techniques can be easily performed through an endonasal route; however, an open approach is required for others. A narrow internal valve angle is a well-known factor in nasal obstruction, and it can be caused by high septal deviation at the internal valve level or by the deformities of the caudal end of upper lateral cartilage. Most cases of severe high septal deviation causing narrowing of the internal nasal valve angle require major septal surgery such as extracorporeal septoplasty which, in our hands, needs an

Electronic supplementary material The online version of this article (doi:10.1007/s00238-011-0634-6) contains supplementary material, which is available to authorized users. S. Anari (*) Department of Otolaryngology/Head and Neck Surgery, ENT Department, Heartlands Hospital, Birmingham, UK e-mail: sssanari@yahoo.co.uk M. R. El Badawey Department of Otolaryngology/Head and Neck Surgery, Freeman Hospital, Newcastle upon Tyne, UK

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open approach. We consider septum, inferior turbinate and lower end of the upper lateral cartilage as one functioning unit within the internal valve area. We have used a combination of three separate procedures to address the structures commonly responsible for the narrowing of the internal nasal valve area (i.e. nasal septum, caudal end of the upper lateral cartilage and the head of the inferior turbinate). We have termed this triple-procedure technique. Along with septoplasty and diathermy to inferior turbinates in our patients with internal valve obstruction, we have used M-plasty, which is an endonasal method designed by Fausto Lpez Infante and popularised by Eugene Kern to address the narrow internal valve angle. The term arises from the shape of the letter M reproduced by mucosal flaps [3] (Fig. 1). This way we have managed to address these difficult cases by an endonasal route with minimal morbidity. Improvement in the nose-related quality of life has been shown in different methods of nasal valve surgery, but our literature search (Medline, 1966 to July 2010) did not reveal any study on efficacy of M-plasty on internal nasal valve obstruction [4, 5]. The aim of this study was to assess the efficacy of triple-procedure technique on improving the subjective nasal patency and patients' quality of life and to compare its effect size to previously published data.

Methods A prospective longitudinal case study was performed in our otolaryngology department in northeast of England in a 6month period in 2009. The study was registered with the local clinical governance department. All consecutive patients with the complaint of nasal obstruction and the clinical diagnosis of internal nasal valve obstruction due to a narrow internal valve angle were offered to take part in the study. We employed modified Cottle's manoeuvre and direct examination of the internal valve angle, including endoscopic examination, to diagnose the problem. All patients had deflected nasal septum to one side at the level of the caudal end of the upper lateral cartilage, leading to narrowing of the internal valve angle and subsequent reduction in the internal valve cross-sectional area. Compensatory hypertrophic inferior turbinate was present on the opposite side. Patients with allergic rhinitis and those with straight septum who did not require septoplasty or turbinate surgery were excluded from the study. The patients completed a Nasal Obstruction Symptom Evaluation (NOSE) questionnaire. NOSE is a validated questionnaire that contains five items on nasal obstruction and its effect on patients' quality of life: (1) nasal congestion or stuffiness, (2) nasal blockage or obstruction, (3) trouble breathing through the nose, (4) trouble sleeping

and (5) trouble breathing through the nose during exertion. Patients are asked to rate their nasal breathing problem on a five-level Likert scale from 0 to 4 where 0 equals no problem and 4 represents a severe problem. The scores are multiplied by 5 to give a scale of 0 to 20 for each domain and a scale of 0 to 100 for the total score [6]. All patients received septoplasty, linear diathermy to inferior turbinate mucosa and M-plasty to address their internal valve obstruction (Figs. 2, 3, 4 and 5). The tripleprocedure technique was performed on both sides of the nose. The main purpose of the triple procedure technique on the symptomatic side was to increase the cross-sectional surface of the internal nasal valve area. This was achieved by increasing the internal nasal valve angle through performing M-plasty, by correcting the deviated septum through septoplasty and by reducing the obstructive effects of engorged anterior head of the inferior turbinate through turbinate surgery. The triple-procedure technique was performed on the other side as well even if the patient did not have nasal obstruction on that side. This was done as a pre-emptive measure to prevent newly onset post-operative nasal obstruction (due to pre-existing hypertrophied inferior turbinate and effects of septal movement after septoplasty). M-Plasty was performed on both sides as well; M-plasty leads to slight nasal tip cephalic rotation, and therefore, unilateral M-plasty could result in a skewed nasal tip in the long run. All patients received the same post-operative treatment including analgesia, normal saline nasal irrigation and Naseptin cream (Naseptin cream contains chlorhexidine hydrochloride, neomycin sulphate, arachis oil and cetostearyl alcohol). Three months after the operation, they completed the same NOSE questionnaire by post or in the outpatient clinic. The outcome measure was the numeric changes in the NOSE score.

Results Nine patients were recruited for this study, but only eight of them completed both sets of questionnaires (response rate, 88%). There were six males and two females with an age range of 1669 years (median, 48 years; mean, 43.3 years). All patients noted improvement in their subjective nasal patency and their associated quality of life (Table 1). Effect size showed very large changes in post-operative scores emphasizing the high magnitude of improvement in all domains (Table 1). The effect size for the total NOSE score in our study was larger compared to other techniques used in nasal obstruction surgery (excluding external valve incompetency; Table 2). It is apparent from the data in Table 2 that internal valve surgery has a great impact on improving patients' nasal obstruction. The techniques

Eur J Plast Surg Fig. 1 Operative steps in M-plasty. a Intercartilaginous incision. b Hook is applied to upper lateral cartilage for counter-traction, and dissection was performed down to perichondrium. c The undersurface of upper lateral cartilage is exposed, preserving the mucosa. d Resection of the caudal end of the upper lateral cartilage (a few millimetres). e Upper lateral cartilage separated from nasal septum medially. f Medial triangle of upper lateral cartilage excised. g Mucocutaneous tissue separated from the septum (an M is formed by the mucosa; hence M-plasty). h Excess mucosal tissue is trimmed, and the intercartilaginous incision is closed. i Widening of the internal valve angle is noted. Reproduced with permission from Kasperbauer and Kern [16]

addressing the septum, turbinates and the internal valve angle in both our study and that of Most's [5] produce the highest impact.

Discussions Our study showed that the triple-procedure technique is an effective method to address the nasal obstruction due to a narrow internal nasal valve angle by addressing all the structures involved in the internal nasal valve area. Improvement in subjective assessment of nasal patency

and its related quality of life was noted in all our patients. The results of this study need to be interpreted with caution due to small number of participants recruited in this study. The sample size calculation was based on a previous study of nasal valve surgery using the NOSE questionnaire. The anticipated difference in means was set at 50, and anticipated standard deviation was set at 20 (power=80%; =0.05). The required sample size was calculated to be four subjects, although eight cases were required to achieve 99% power with =0.01 [5]. This small sample size was due to large size of change noticed in the previous study. We calculated the changes in NOSE scores

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Fig. 2 Endonasal view of the narrow right internal valve angle. Note the high septal deviation

Fig. 4 Endonasal view of the narrow left internal nasal valve angle

by paired Student's t test and calculated the effect size by the Kazis method. The effect size in Kazis method is the mean difference of the pre- and post-intervention for each domain divided by the standard deviation of the preintervention [7]. The interpretation of the magnitude of effect has been described differently by different authors but, in general, any effect size above 0.81.2 is considered as a large effect [7, 8]. The data from a previous study by Sam Most on surgical techniques for nasal obstruction was used for comparison to our results; however, Most's data on surgical techniques addressing the external valve incompetency were excluded in the comparison, as our study did not include this category of patients [5]. It has been shown that septoplasty together with internal valve surgery improves the nasal airway more than septoplasty alone [9]. We consider septum, inferior turbinate and the caudal end of the upper lateral cartilage as one functioning unit within the internal valve area, and we therefore use a triple-procedure technique (combination of septoplasty, turbinate surgery and M-plasty) to address these structures that commonly cause the narrowing. Nasal valve obstruction is generally divided into two main categories: static or dynamic. Static valve obstructions

occur due to the abnormal anatomy (e.g. deflected nasal septum or deformed upper lateral cartilage); however, dynamic obstructions occur due to the mucosal changes (rhinitis or inferior turbinate hypertrophy) or collapse of the nasal valve mobile components secondary to negative intraluminal pressure (Bernoulli's principle). Nasal flow resistance is highest at the nasal valve level. The normal cross-section surface of the nasal valve area is approximately 5583 mm2 [3, 10]. This figure differs between individuals, but the nasal flow becomes turbulent below a certain threshold. This turbulent flow will cause negative intraluminal pressure explained by the Bernoulli principle, and it will lead to collapse of the mobile segments of the valve area and result in nasal obstruction. Also, the narrowing of the internal nasal valve could result in dynamic collapse of the external nasal valve during inspiration. Multiple surgical techniques are available to address the incompetent nasal valve: spreader grafts, alar batten grafts, crural strut grafts, suturing techniques including flaring sutures to the upper lateral cartilages, suspension sutures of the lateral crus to a bony base, thinning of the swollen

Fig. 3 Immediate post M-plasty endonasal view of the patient in Fig. 2. Note how much the caudal end of the upper lateral cartilage has moved away from the deviated septum

Fig. 5 Immediate post M-plasty view of the patient in Fig. 4. Note the cephalic displacement of the caudal end of the upper lateral cartilage opening up the narrow internal valve angle

Eur J Plast Surg Table 1 Pre-operative and post-operative NOSE scores in our study (n =8) Minimum Nasal congestion (pre-op) Nasal congestion (post-op) Nasal blockage (pre-op) Nasal blockage (post-op) Trouble breathing (pre-op) Trouble breathing (post-op) Trouble sleeping (pre-op) Trouble sleeping (post-op) Trouble during exercise (pre-op) Trouble during exercise (post-op) Total NOSE score (pre-op) Total NOSE score (post-op) 10 0 10 0 10 0 5 0 15 0 55 0 Maximum 20 10 20 10 20 10 20 5 20 5 100 35 Mean 14.3 3.7 13.7 4.3 16.2 2.5 15.0 0.6 17.5 1.8 76.8 13.1 SD 4.1 3.5 4.4 4.1 3.5 3.7 5.9 1.7 2.6 2.5 15.7 12.5 P valuea 0.002 0.006 0.001 0.000 0.000 0.000 ES 2.5 2.1 3.8 2.4 5.8 4.0

SD standard deviation, ES effect size (mean difference divided by pre-intervention standard deviation), NOSE Nasal Obstruction Symptom Evaluation
a

Paired sample t test

septal body and the different methods of turbinate surgery [2, 1014]. The aim of these surgical treatments is not simply to widen the airway but also to preserve the anatomy as much as possible and to preserve the laminar and parabolic airflow through the nasal valve area. We have all experienced patients who breathe better through the side that the septum is deflected to, and we have all witnessed patients dissatisfied with their nasal airway that on clinical examination seems patent [15]. Some of the above techniques are more effective cosmetically than functionally (e.g. spreader grafts); in others, an open approach is required to perform them with accuracy and ease (e.g. upper lateral flaring sutures) [11, 13]. M-Plasty was popularised by Kern, and it is a simple procedure that can be performed through a closed approach [3]. This procedure re-arranges the level of the caudal end of the upper lateral cartilages in a slightly more cephalic direction; this will result in a wider internal valve angle and improve the cross-sectional area of the internal nasal valve area. We have found that performing septoplasty at the same time as M-plasty is beneficial, as it mobilises the septal mucosal flaps needed

for the M-plasty. The partial trimming of the septal mucosa is an essential part of M-plasty in order to prevent any nasal valve obstruction by the redundant mucosa. M-Plasty is performed through an endonasal approach, which reduces the operative time and its morbidity. It also has little effect on the nasal shape and does not broaden the dorsum or the tip [3]. Although global quality-of-life and health status instruments are important parts of health status assessments, for many conditions, the changes in health status are too subtle or disease specific to be assessed using the content of a global instrument. Therefore, disease-specific health status instruments are required [6]. Objective assessment of nasal obstruction is controversial, and there is no agreement on an accepted objective measurement tool [6]. For these reasons, we employed a validated disease-specific questionnaire (NOSE questionnaire) to assess the subjective response to our treatment. Improvement in nose-related quality of life has been shown in different methods of nasal valve surgery [4, 5]. We required comparison of our results to other techniques of internal valve surgery published in literature. Most [5]

Table 2 Comparison of the effect size between different surgical techniques Our study Septoplasty, turbinate surgery and M-plasty Study population Total NOSE pre-op score (SD) Total NOSE post-op score (SD) Effect size n =8 76.8 (15.7) 13.1 (12.5) 4.0 Most's studya Septoplasty, turbinate surgery and spreader graft n =24 57.8 (11.9) 13.8 (14.3) 3.7 Spreader graft without turbinate surgery n =7 62.3 (12.0) 24.3 (17.8) 3.1 Septoplasty and turbinate surgery n =5 44.0 (17.2) 16.8 (24.1) 1.6

SD standard deviation, ES effect size (mean difference divided by pre-intervention standard deviation), NOSE Nasal Obstruction Symptom Evaluation
a

Data from Most [5]

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published results of his surgical operations aimed at improving nasal obstruction, and he measured the changes by using the NOSE questionnaire. The surgical techniques in his study included septoplasty and turbinate surgery along with certain nasal valve procedures such as spreader grafts and valve suspension. We calculated the effect size of the change noticed in the NOSE scores in his study for septoplasty, turbinate surgery and spreader grafts at 3.7 (Kazis method), whereas the effect size of our tripleprocedure technique was measured at 4.0 (Table 2). This demonstrates that both methods have achieved high score changes; however, the advantage of our technique is that it addresses all aspects of the narrow internal valve through an endonasal route; there is no donor site morbidity with our technique, and unlike other nasal valve surgical procedures (e.g. spreader grafts), M-plasty does not broaden the nasal vault or the tip.

References
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Conclusions In our hands, triple-procedure technique (i.e. M-plasty along with septoplasty and turbinate surgery) seems as effective as other surgical procedures aimed at treating the narrow internal valve angle. The result of this study needs to be interpreted with care taking into account the low number of participants and the short period of follow-up.

Conflicts of interest The authors are not aware of any conflicts of interest and have not received any financial help in conducting this study.