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December 13, 2018

Is It Time to Rethink the Approach to Internal Nasal Valve Stenosis?

Author Affiliations
  • 1Division of Otolaryngology–Head & Neck Surgery, Department of Surgery, Commonwealth Health Center, Garapan, Saipan, Northern Mariana Islands
JAMA Otolaryngol Head Neck Surg. Published online December 13, 2018. doi:10.1001/jamaoto.2018.3356

Spreader grafts have long been a preferred surgical treatment for middle vault reconstruction. First described by Sheen in 1984 for aesthetic purposes,1 indications for spreader grafting have been subsequently expanded to include patients with functional obstruction. The technique represents the current gold standard for symptomatic internal valve stenosis.

Scores of case series have been published over the past 30 years that promote numerous variations in both open and closed spreader grafting techniques. Nonetheless, multiple recent systematic reviews have shown these studies to be nearly exclusively observational and with very low-level evidence. In 2017, Goudakos and colleagues2 published a review that identified 53 studies evaluating treatments for internal valve stenosis. Fifty of the included studies presented exclusively retrospective, observational data. A lone prospective randomized trial was encountered that failed to show a functional advantage with spreader grafting relative to a control group. Although others have found more promising results, very few studies have evaluated the technique in a truly objective fashion, and the collective evidence to support the procedure is mediocre at best. The results have been particularly lukewarm when patients undergoing a standard septoplasty and turbinate reduction have been used as a control.3 Such findings prompt close reflection of internal nasal valve anatomy: a standard closed septoplasty and turbinate reduction directly addresses 2 of the key components of the internal valve, which may mitigate the beneficial effects of grafting.4 Such a consideration is important because the standard open approach to middle vault reconstruction unquestionably imparts substantial additional time, risk, and cost. Despite the benefits of closed approaches, the disadvantages of tissue harvesting or the drawbacks of using alloplastic or cadaveric materials remain.

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