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Hyaluronic acid spreader-graft injection for internal nasal valve collapse.

A 50-year-old man presented with a long history of left nasal obstruction. He had no history of rhinoplasty, relevant trauma, or infection. Endoscopic examination revealed that the left upper lateral cartilage had completely collapsed into the septum at rest (with quiet, not forced, inspiration) (figure, A). The patient elected to undergo a nonsurgical procedure in which hyaluronic acid (Restylane) is injected to form a spreader graft. Previously, the viability of using calcium hydroxyapatite (Radiesse) as a spreader graft has been documented as a treatment for internal nasal valve collapse. (1)

[FIGURE OMITTED]

In the office, a topical anesthetic/decongestant pledget was placed into the apex of the left internal nasal valve for 10 minutes. Then a medium speculum was introduced to isolate the junction of the upper lateral cartilage and the septum. A syringe of hyaluronic acid with an attached angled spreader-graft injection needle was directed to an area 1 to 2 mm posterior and inferior to the apex on the medial surface of the upper lateral cartilage (figure, B). Another injection was placed 3 to 4 mm inferior to the apex on the caudal-medial surface of the upper lateral cartilage (figure, C). A total of 0.15 ml of hyaluronic acid was injected until a visible increase in the internal nasal valve angle was evident and maintained with nasal inspiration (figure, D). The patient noticed immediate improvement in his perceived nasal patency on that side, and he experienced no pain with the injections. He had only minor middle vault discomfort and swelling for 2 days post-treatment.

To date, the author has treated 5 patients with hyaluronic acid injections into the internal nasal valve. Patients have reported no adverse effects, no external contour deformity, and continued perceived improvement in nasal patency at 6 months post-treatment. Three patients also reported alleviation of snoring.

Nasal obstruction secondary to inspiratory collapse of flaccid upper lateral cartilage into the septum is not uncommon. Compromise of this anatomic region is often caused by upper lateral cartilage insufficiency following rhinoplasty or by an inherent weakness of the cartilages. Traditionally, internal nasal valve collapse has been treated with autologous cartilage. (2) Spreader-graft injection appears to be a viable, nonsurgical option for relieving nasal obstruction secondary to internal nasal valve collapse. Studies are in progress to determine the longevity and continued efficacy of hyaluronic acid as an injected spreader-graft material.

References

(1.) Mangubat EA, Nyte CP. Treatment of internal nasal valve collapse with Radiesse (CaHA) spreader grafting. Presented at the fall meeting of the American Academy of Facial Plastic and Reconstructive Surgery; Sept. 24, 2005; Los Angeles.

(2.) Sheen JH. Spreader graft: A method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plast Reconstr Surg 1984;73(2):230-9.

Christopher P. Nyte, DO

From Nyte Surgical Care, LLC, Maple Valley, Wash., and the Department of Otolaryngology, Snoqualmie Valley Hospital, Snoqualmie, Wash.
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Title Annotation:SPECIAL TOPICS CLINIC
Author:Nyte, Christopher P.
Publication:Ear, Nose and Throat Journal
Date:May 1, 2007
Words:476
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