الفهرس 
Nasal embryologyOnly 14 pages are availabe for public view
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Abstract
Conclusion and Recommendation
The role of the INV the nasal obstruction is frequently missed in the usual evaluation of nasal airway obstruction, so we advise to assess the INV separately before the progress in the internal nasal cavity examination as the speculum will distort the valve area and also apply the Cottle test in every patient.
Primary goals of the spreader graft (SG) and the conchal splay graft (CSG) applications are to reconstruct the normal anatomy of the internal nasal valve and to improve the airflow at this area. The spreader grafts are designed to lateralize the upper lateral cartilages by the width of the graft and thereby, increase the cross-sectional area, restore or maintain the internal nasal valve , strengthen the weakened septal L-strut, recreate the dorsal aesthetic lines, maintain straight dorsal alignment and widen narrow middle vault, therefore, spreader grafts should be applied when the nasal septum is weak and in need of reinforcement .
from our results as regarding the dislodgement of the SG can be avoided through meticulous securing the graft in the septum and ULCs through mattress sutures and test fixation of the graft well in place before closing the surgical field.
In the normal individuals the 2 upper lateral cartilages (ULCs) fused to the septal cartilage in a ―T‖. The stability between the septal and the upper lateral cartilage arises from this configuration that can be maintained by the application of the splay conchal graft. This graft can opens the internal nasal valve angle by its power of recoil and also increases the strength of the lateral nasal wall to resist the inward bowing (collapse) with intranasal negative pressure during inspiration. The intrinsic spring or recoil in the splay conchal graft elevates each upper
lateral cartilage with septum as the fulcrum, thus correcting the middle vault collapse and opening the internal nasal valve angle. So, in our opinion CSG is the preferred surgical technique when the there weakness in the lateral nasal wall and septum is straight and sufficiently strong as in the cases of congenital narrow middle third in tall narrow nose.
In the conchal splay graft technique the recoil power may cause marked widening the valve but also make excessive broadening of the middle third of the nose so, we advise to add our modifications in the technique as the regarding the cross-hatching and dividing the caudal end of the graft into 2 flanges.
The subjective satisfaction of the patient after surgery is important but when dealing with a case for rhinoplasty either functionally or aesthetically it is mandatory to discuss the patient requests and what can be done and what can not. This will be of great value postoperatively that the patient found what he needed preoperatively has occurred. Any steps we see that it is important in any maneuver we also should discuss it with the patient and obtain his or her agreement. We find that the psychological assessment and support is very important in working in this field.
Even there is a relatively low correlation between objective and subjective evaluation we found that there is no reason for omitting the objective testing in the diagnosis and evaluation of the treatment especially when this method is available, non invasive, easily to operate and valid results so, we recommend use of acoustic rhinometry as an objective test for evaluating the INV.
Nasal obstruction is a very common problem as it is the presenting symptom of a large number of patients in otolaryngology practice. Nasal obstruction can be due to variety of mucosal and anatomical factors and many patients both play a role. The main anatomic causes of diminished nasal patency are deviations of the septum and insufficiency of the internal or the external nasal valves.
Nasal valve collapse is the result of various causes. One of the most important is the failure of the lateral structures of the nose during rhinoplasty. Other causes include trauma and congenital flaccidity of the upper lateral cartilage. The malfunctioning of the valve is responsible for nasal obstruction and respiratory difficulties, generating problems of both static and dynamic nature.
Our study included 30 patients selected from Benha university hospital out patient clinic in the period from March, 2008 to March 2010. Our patients complained from nasal obstruction due to nasal valve incompetence, all of them were positive Cottle sign.
Our patients were divided into two groups:
Group (A): included 15 patients with nasal valve incompetence and the internal nasal valve had been reconstructed by the spreader graft.
Group (B): included 15 patients with nasal valve incompetence and the internal nasal valve had been reconstructed by the splay conchal graft.
In each group we proceeded as the following:
A- Preoperative assessment
1- History and clinical examination (general and ENT) including Cottle and modified Cottle test.
2- Photographic assessment
3- Acoustic rhinometry
B- Operative procedures
The INV reconstructed through an open rhinoplasty (external) approach either by spreader graft as in group (A) or by conchal splay graft as in group (B)
B- Postoperative assessment
Follow up of the patient in regular visits in 2, 4, 6 weeks and 2, 4, 6 months after surgery and proceeded as the following
1- clinical examination and detecting the grade of improvement in nasal breathing , repeating the Cottle test and recording the data which obtained at 6 months postoperatively.
2- Reassessment aesthetically through photographs 6 months postoperatively
3- Repeating the A.R. measurements 6 months after surgery.
Our results showed improvement in both groups either in subjective sensation of breathing and in acoustic rhinometry measurement
and only 2 patients in each group were not satisfied as regarding the results of improvement.
Our results showed minimal complication such as skin allergy or mild haematoma. No major complication such as hemorrhage, infection or extraction of the graft was detected.
We concluded that either technique (SG or CSG) is valid for correcting the INV incompetence but with application of the technique in its indicated and suitable cases to obtain the best results and the acoustic rhinometry is good objective test to evaluate the results of each method.