BackTable / ENT / Podcast / Transcript #63

Podcast Transcript: Evaluation and Management of Nasal Valve Collapse

with Dr. Moustafa Mourad

In this episode of BackTable ENT, Dr. Agan and Dr. Shah discuss nasal valve collapse and repair with Dr. Moustafa Mourad, a New York City-based facial plastic and reconstructive surgeon. You can read the full transcript below and listen to this episode here on BackTable.com.

(1) Nasal Valve Structure & Function

(2) Causes & Risk Factors for Nasal Valve Collapse

(3) Nasal Valve Collapse Patient Evaluation & Physical Examination

(4) External Valve Collapse Following Septoplasty

(5) Surgical Techniques for Nasal Valve Repair

(6) Cartilage Grafts in Nasal Valve Repair Surgery

(7) Evaluating New Nasal Valve Technologies

(8) Tranexamic Acid (TXA) in Nasal Surgery

(9) Post-Operative Care & Prevention of Complications After Nasal Valve Repair

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Evaluation and Management of Nasal Valve Collapse with Dr. Moustafa Mourad on the BackTable ENT Podcast)

Ep 63 Evaluation and Management of Nasal Valve Collapse with Dr. Moustafa Mourad

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[Dr. Ashley Agan]
Hi, everybody, welcome to The Backtable ENT Podcast. We're a podcast that focuses on all things otolaryngology and we've got a really great show for you today. Thanks for stopping by.

[Dr. Gopi Shah]
We have an awesome show today. We have Dr. Moustafa Mourad. He's an otolaryngologist and facial plastic surgeon practicing at Mourad NYC Facial Plastic and Reconstructive Surgery in New York City. He specializes in head and neck oncology and reconstruction, facial reanimation, and nasal surgery. Dr. Mourad is here to talk to us today about nasal valve collapse. Welcome to the show, Moustafa.

[Dr. Moustafa Mourad]
Thanks for having me. It's a pleasure to be here.

[Dr. Gopi Shah]
Moustafa, do you want to first just tell us a little bit about yourself and your practice?

[Dr. Moustafa Mourad]
Yes. I'm here in New York City in the Upper East Side of Manhattan. I have a broad practice scope. I do everything from head and neck cancer, free flap reconstruction to cosmetic surgery, rhinoplasty, facelifts, blepharoplasty. It's what I enjoy about facial plastics. There's a broad range of things that you could do. Yes, I do it all, the whole spectrum from a free flap to a rhinoplasty. I also take care of cancer patients. It's always been a pleasure and honor to take care of them.

(1) Nasal Valve Structure & Function

[Dr. Ashley Agan]
Awesome. Today, we're going to focus on talking about nasal obstruction and specifically the nasal valve. Why don't we just start by talking about how you evaluate those patients and remind myself and Gopi--

[Dr. Gopi Shah]
I'm like, "The nasal valve? Batten?" This is over 10 years for me.

[Dr. Moustafa Mourad]
Let's just start off with what the valves are. There's two sets of valves in the nose. There's your internal nasal valves, which are made up of the upper lateral cartilages and the dorsal septum and also the septum and inferior turbinate. That's the internal nasal valve. The external nasal valve is essentially the tip cartilages, which is the lower lateral cartilages. They both function in a valve-like way.

It's funny because, in pre-med we take all these physics classes and we don't understand like, "Why do we have to learn physics?" I'm sure you guys are like, "I don't remember anything about physics." If you remember physics and some of the aerodynamic stuff, you're pretty well equipped to handle and understand nasal valve pathology. When it comes to evaluation of nasal valves, basically the most telltale sign of a nasal valve collapse is dynamic nasal airway obstruction.

What I mean by dynamic is essentially the breathing is affected by a couple of things. One is the breathing can get worse the deeper you breathe in so that the nostrils or the external nasal valves begin to pinch. The structural improvements in the nose will improve the airflow. If you pull on your cheeks, that'll also help the internal nasal valves get a little bit stronger and allow a lot more air to pass in. These are structural problems and you have to parse things out and try to determine, is this a deviated septum? Is this allergy? Is this polyps? Is this internal valve? Is this external valve? The evaluation can be pretty in-depth.

[Dr. Ashley Agan]
Is it common that people have more than one thing, where it's like they have the valve problem, but they also have allergies and they also have this? I feel like that's a lot of what I see. Maybe it's not just one thing.

[Dr. Moustafa Mourad]
Right. Breathing is multifactorial. I always sit down with my patients and you have to do a really thorough evaluation, figure out what it is that's bothering them. It's not uncommon to have a deviated septum and some allergies. It's not uncommon to have maybe some internal nasal valve collapse and a deviated septum. You have to sit down and ascertain what's the most impactful part of your nasal airway obstruction and what's the best correction. Sometimes it could be sprayed. Sometimes it could be a procedure. Everything has its own weighted impact on how you're breathing.

[Dr. Ashley Agan]
As far as for nasal valve collapse, is that something that would potentially get worse with time? Because when I think about some structural things, like a deviated septum, most people have had that same septum for years maybe, right? Maybe now it's causing more issues because they have more swelling in their nose related to allergies or something else, right? Or maybe they say, "I've never been able to breathe out of the left side of my nose." Whatever, I don't know.

With nasal valve collapse, that's something where I've noticed in the last few years, I can't really breathe at night, and if I wear some Breathe Right strips or pull up on my face, it's better. Or maybe it was always like that and now, the way the septum is, where it's a little bit worse.

[Dr. Moustafa Mourad]
I would say it's definitely something that probably could get worse with time. It's maybe something you didn't have a while ago and then things happen. You might have had nasal trauma that impacted the nasal valve area or just general aging. The nasal valves are constructed from cartilages. As we get older, those cartilages get weaker.

They're not the same strength as it was in your early 20s or early teens. In your 30s and 40s, you might begin to realize that my nose pinches when I breathe in or I try and run on a treadmill. Just aging in general will lead to worsening the nasal valve structure, and it impacts everybody differently. Some people have stronger intrinsic cartilages. Some people have weaker intrinsic cartilages.

Everybody evolves according to their anatomy. It's definitely something that can develop over time. Just by sheer aging in general will make your valves get worse. Everything droops. Gravity pulls everything down, even the internal and external nasal pouts.

[Dr. Ashley Agan]
Blame it on aging.

(2) Causes & Risk Factors for Nasal Valve Collapse

[Dr. Gopi Shah]
Do you see this though, and you had mentioned nasal trauma, or perhaps do you see this in younger patients, like young adults or late teens ever for the kids that may have had nasal trauma early on, or maybe some sort of septorhinoplasty when they were 16, 18, and now they're 28? Do you have that history as well, or those risk factors?

[Dr. Moustafa Mourad]
Demographics, the risk factors will change based on demographics, but one of the most common causes of nasal valve collapse that I see in my practice is for patients that have had surgery before, and the nasal valves weren't appropriately managed. They had a dorsal hump reduction or some kind of internal procedure, and they didn't address the nasal valves. That's a very common one to see in people in their 20s and 30s.

Older patients in their 40s and 50s, I typically see, that haven't had surgery, they just have general aging and weakening of those cartilages. Also trauma. People that have dorsal trauma impact the internal nasal valves. I've seen people that have gotten nasal tip trauma where they get dislocation in the nasal tip cartilages, and that will cause nasal collapse.

One of the most important things that I've seen for patients having valve collapse is athletic people. People that were athletes in their teens and early 20s, they use their noses a lot, especially swimmers. They're blowing air against pressure a lot through their mouth and their nose. What I've come to realize is when they get into their 30s, 40s, and 50s, their nose has been weakened. The cartilages are super weak.

I get a lot of very athletic people who are like, "Oh, I could run all the time. Now every time I get on a treadmill, my nose pinches closed and I can't breathe." That's a lot of just inherent intrinsic weakening of those cartilages. That's one of the biggest causes that I see too.

[Dr. Ashley Agan]
I think it makes sense, just thinking about those cartilages bending over time. The more you apply that stress, it just weakens. If you're someone who's done more of that, then it would maybe present earlier. I think that makes sense in my mind.

[Dr. Moustafa Mourad]
That's the whole point I was making about physics. When you breathe in, you're increasing the airflow through the nose and it creates a pressure gradient. The fast-moving air that goes through the nose is the lower pressure and the more stagnant, slow air on the outside of the nose is higher pressure. The nose will intrinsically-- the air will want to push from the outside of the nose to the inside of the nose. It creates this pressure gradient that weakens over time. Air is constantly pushing down on the outside of the nose and the more you breathe in, the faster the air you move in, the more it pinches over time and that just weakens it.

[Dr. Ashley Agan]
Are certain people with thinner cartilages more at risk? Are women more at risk than men, or is there a certain type of nose that's more at risk for developing collapse over time because it's just thinner cartilages?

[Dr. Moustafa Mourad]
Yes. A lot of Caucasian patients have thinner cartilages. It depends on which demographic of Caucasians, but ethnicity definitely will impact the strength of those cartilages just in the same way that it impacts the length of the nasal bones. Ethnicity plays a factor. Also, the intrinsic structure of the actual nose. The orientation of those cartilages will definitely impact how those nasal cartilages function and evolve over time.

Patients that have cephalically oriented cartilages, so, pointing more upwards, the nasal cartilages will certainly develop external nasal valve collapse over time. What you'll notice is their noses will start to droop and they'll develop this beak-like appearance to their nose as those cartilages weaken over time. The orientation, the structure, ethnicity, I don't necessarily see a difference in gender, male versus female, but anything that impacts the strength of a cartilage or the way the shape length will always impact how that nasal cartilage evolves with time.

[Dr. Ashley Agan]
That makes sense.

(3) Nasal Valve Collapse Patient Evaluation & Physical Examination

[Dr. Gopi Shah]
I would imagine, are the presentations pretty similar between-- if somebody has a really bad internal nasal valve collapse versus external nasal valve collapse, is the main issue nasal obstruction, and it's pretty similar, or are there certain nuances in the history?

[Dr. Moustafa Mourad]
I would say there's different nuances. Just strictly talk about internal nasal valves when somebody comes in and they have internal nasal valve collapse, you, Ashley, alluded to this, they'll say things like, "I have to pull up on my cheeks to get some air in." I have to sleep with Breathe Right strips, my nose feels like it's-- I just can't get air through my nose and I have to do these things structurally to improve it."

The skin of the cheeks are connected to those upper lateral cartilages. Anybody that says, "I have to pull up here on their cheek skin," it's a telltale sign that it's an internal nasal valve issue. External nasal valve, people usually come in with a different set of complaints. They'll say something like, "I can breathe okay usually, but when I exercise, I can't breathe. It's when I breathe harder through my nose, I can't breathe really well." Then you're like, "Okay, well, is it exercise-induced like rhinitis?" "No, I don't get any discharge or discomfort or congestion. It's like I can't breathe."

"Your nostrils pinch." They go, "Yes, that's what happened. I can't get the air through, and the quicker I breathe through my nose, my nostrils pinch down." That's usually a very strong telltale sign that the external valves are very weak, and when they're using their nose a lot, their nostrils are pinching. That's usually the two different types of presentation.

[Dr. Ashley Agan]
Are there any other specific questions that you like to ask to help tease things out? Or is it just the main things that we would ask any nasal obstruction patient?

[Dr. Moustafa Mourad]
It's usually the-- a lot of times it's the same stuff. You want to make sure like, "Okay, is it one side or both sides? Does it alternate like alternating congestion?" It's usually allergies or some kind of medical-related issues. Everything plays together. Everything has a stronger impact on that breathing. Your job is like as a detective, is to try and figure out, "All right, well, what's the most efficient, best way that I could help you in the immediate term in the long term?" Ultimately, yes, you just have to take a really thorough history and just think of it from an anatomical medical standpoint.

[Dr. Gopi Shah]
Then what's your physical exam like? Are you scoping all the patients?

[Dr. Moustafa Mourad]
Yes. I always start off by asking-- I scope all my patients, but when it comes specific to the internal, external nasal valves, I'll have them just breathe at baseline. Tell me about your breathing, scale it on 1 to 10, 10 being the best breathing ever, 1 being you can't pass any air. I get a baseline for either nostril. I do this decongested and regular. I also decongest them after and do the same exam. Then I'll do a couple of maneuvers. One is I'll lift up the tip and see if that helps.

Where does that bring you on a scale from 1 to 10? Does it take you from a 3 to a 5? Because that also can be very indicative of external valve collapse. Then I also do a modified or a caudal maneuver where I pull up on the cheek skin and say, "Where does that bring you on the scale?" Doing it congested and decongested also helps in figuring out some of the medical-related issues. Then I have them take a deep breath in and I look at the nose. Is it pinching? That's also a very telltale sign of external nasal valve collapse.

Then what I do is I take their photos and then I map their surface anatomy to their internal anatomy. I'll do that with them. I'll take their photo, put it on a screen, and I'll start to draw out those cartilages. If those cartilages are cephalically oriented, I'll show them and I'll map that out and I can have a pretty strong suspicion that they have might have some external valve issues, or if they have an inverted V and there's a mid-bolt pinching, then I'll correlate that with internal nasal valve. It's a pretty in-depth process, but I think it really helps you get to understand the patient's-- really their nasal anatomy and the nasal pathology that they might be suffering with.

[Dr. Ashley Agan]
That's really thorough. That's great.

[Dr. Gopi Shah]
I'm like, I would love to have that drawn out and mapped out. That's amazing.

[Dr. Ashley Agan]
I assume, with their response to Afrin, if they're like, "Oh, wow, that stuff's great. Can I get some of that?" It's much better. Would you correlate that with turbinate hypertrophy, allergies, or something less related to the nasal valves?

[Dr. Moustafa Mourad]
Yes. One is that the internal scope exam changes with the Afrin. They might go from these pale, boggy turbinates to pristine-- there's definitely some medical vasodilation and irritation. If their response to the Afrin is disproportionate to the response to just the physical maneuvers of lifting the tip up, lifting the cheek skin up, then I would certainly probably try them on medical therapy.

Usually, I try them on medical therapy if they have some kind of medical thing in their history, they do have bad allergies or, and they've never been on a Flonase or a steroid because even if you have all of this stuff, it might be just that the allergies are pushing you over the head. You might have internal valve collapse, external valve collapse, but then you give them some steroids and just reducing those turbinate sizes will make them feel good enough that they could avoid a procedure. That's usually my protocol, unless they have zero allergies and their mid-valve is totally pinched. Then we might go straight to a procedure.

[Dr. Ashley Agan]
Sometimes you have those patients that are like, "I've tried it. I've tried it. I've tried all the things. I'm here for you to fix this."

(4) External Valve Collapse Following Septoplasty

[Dr. Moustafa Mourad]
Exactly, which is actually probably the majority of my patients as they come in, they've been on steroids and sprays and irrigations, or they've had a procedure in the past that's failed. One of the biggest things that I see is external valve collapse after septoplasty, which I think is actually a really important thing.

I don't know. I haven't found-- there's a small series, I think that was in the ENT clinic journal. A lot of patients will go in and they'll have a deviated septum surgery. After the surgery, they say, "I could breathe better, but I'm still obstructed." I think it's a failure at the pre-op evaluation point. If you think about it, if their septum is really deviated to their left, and they breathe in, they're 100% obstructed. They can't move any air. Then they have the septoplasty and now they can move. It's 100% open. They can move air in.

Now that pressure gradient of air is passing through the nose and now their nose is pinching. I see a lot of patients that have had septoplasty and they go in and they think they need a revision septoplasty, but instead, they need their external valves addressed. You have to look at everything. It's like playing a game of chess. You're like, "All right, well, if I do this and get this medicine or do this maneuver in the procedure, then what's the nose going to look like and how is it going to behave after?"

You have to anticipate all the things that come at you. When you do a septoplasty, you have to definitely make sure that you're looking at the valves, the external valves. Not so much the internal valves because, usually the deviation’s that bad, the internal valves are okay after and they're pretty open. It's a lot of fun, actually.

[Dr. Ashley Agan]
When you're anticipating, "Okay, this patient might have external valve collapse after septoplasty," are you looking-- because when you're looking at them breathe pre-op, they're not moving air through that side, so they're probably not going to pinch. Are you looking at the contralateral side and say, "Oh, that side does come in and pinch a little bit?" What are some signs that tell you, "Okay, this person is at risk."?

[Dr. Moustafa Mourad]
I'm going to have to quit my job. You already know what I'm doing. [laughter]

[Dr. Ashley Agan]
I want to tell your secrets. [chuckles]

[Dr. Moustafa Mourad]
You're telling my secret. I'm telling you guys all my secrets. I look at the other side.

[Dr. Ashley Agan]
Yes, but we don't draw the way you draw. That's you.

[Dr. Moustafa Mourad]
Yes. Maybe I have too much time with my patients. I'll look at the other side. One is that one side can just be hyperactive and weakened in general, and it doesn't necessarily mean that the other side, the obstructed side, is going to collapse, too. Then I just look at the structure, the orientation. If somebody's got cephalically oriented cartilages, that's a sure-tell sign.

If you think about it, if your cartilages are pointing up towards the inside of your eyes, the medial canthal area, they're just not providing the side wall structure and support that they need. Again, mapping out their anatomy is just as important to understand if they're going to have external bowel collapse after a septoplasty. Then all the other stuff like the intrinsic cartilage strength and stuff.

[Dr. Gopi Shah]
Of course.

[Dr. Ashley Agan]
Yes. I'm sure since you do and have done so much rhinoplasty that you're just thinking when you look at the nose, you're already thinking about what does that structural framework look like underneath the skin? Because that's what you do.

[Dr. Moustafa Mourad]
Yes, rhinoplasty, I enjoy doing rhinoplasty a lot. In a lot of ways, it's much tougher than a pre-flap or some of these bigger, more tertiary cases because one is the aesthetic stuff of it, even from the functional standpoint. Like I said, it's like playing chess, you just have to anticipate what's going on in that nose. It's fun because it's an anatomical question. We're surgeons, we like anatomy. It's like, "Okay, well, you're playing this game with this nose and you're trying to figure out how it's going to behave." That's why I really like rhinoplasty. It's a different type of procedure or surgery than some of the other surgeries that I do.

[Dr. Gopi Shah]
When we're talking about septoplasty being sort of a risk factor, not necessarily a risk factor, but that if you don't address the valve, I would understand that we're probably talking about more of the caudal, right? The caudal septal deviation, not necessarily the bony septal septum deviation in the back.

[Dr. Moustafa Mourad]
I'll see in both times. Revision septoplasty in general, I see a lot of people with caudal septal deflections that just don't get addressed at the time of surgery. When they come in, they're like, "I had a septoplasty and I couldn't breathe." I always ask them, "All right, well, one, was it the same side before surgery that you couldn't breathe in? Or is it the other side? Did you have any relief when the splints came out?" Then I look at them.

Usually, a lot of times for revision septoplasty, I'll see these patients with a caudal septal deflection that just wasn't touched. It's a difficult place to address-- if you're not comfortable with the caudal septum, it impacts the tip. There's a lot going on. Your maxillary spine. there could be a fracture at the anterior septal angle. A lot of surgeons just aren't comfortable with the caudal septum in general. When it comes to septoplasty and external valve collapse after, I would say it's definitely in the cartilaginous septum, either mid-septum, caudal septum.

I don't necessarily see it with people that have had bony septal deflections. That's a tough thing to correlate because, like I said, a lot of people are coming in and I don't necessarily know what their deviated septum looked like when they went to their other surgeon and had their first surgery. The caudal septal deflection, I'll tell you, definitely will correlate. That just, in general, doesn't even have to do with external valves. It didn't resolve with the first septoplasty because the first septoplasty didn't address that area.

[Dr. Ashley Agan]
Another thing that I feel like is common, patients are trying to find things to help them breathe better, like the Breathe Right strips. Another thing I see is the nasal cones. They stick in the nose and prop it open. If a nasal cone works, is that more indicative of an external valve collapse or not?

[Dr. Moustafa Mourad]
It depends. I think it could be both internal and external. You're just basically stenting open the entire airway. It's going to push up on the internal valves, it's going to push up on the external valves. I don't know what you guys do in your practices. Do you guys use the cones or do you guys recommend them?

[Dr. Ashley Agan]
It's an option for people who don't want surgery at all, but feel like they need some help when they sleep, but no, I wouldn't say that I use them a ton. I just know of them, I guess. I see kids. I'm just looking at the adenoids all day.

[Dr. Moustafa Mourad]
Maybe the cones will help those adenoids open up. I see a lot of patients that come in that say they've found them online. I have yet to meet-- maybe some doctors prescribe it. I would say, yes, I've never prescribed it. Patients have definitely self-treated themselves with them in the past. There's something going on structurally, is what it tells me. I just don't know what it is.

(5) Surgical Techniques for Nasal Valve Repair

[Dr. Gopi Shah]
When do you start considering a surgical repair?

[Dr. Moustafa Mourad]
If there's a clear line, and I tell patients this all the time, how do I decide if you need surgery? If I could draw a line from your complaint to your anatomy, then you're a good surgical candidate, right? If you told me, "I can't breathe out of my left side," and that left side is collapsed, you got an inverted V on that side and a deviated septum on that side and the nose is pinching on that side, then you're pretty much a home run candidate.

All right, well, let's proceed with surgery because I can draw that line between your anatomy and your complaint. Somebody has a lot of compounding issues, the anatomy doesn't line up entirely, or I feel like they're undertreated for other medical issues, then I'll consider doing sprays and steroids and irrigations and things like that. Usually, by the time they've gotten to me, they usuall, have been through to a lot of ENTs or a lot of surgeons. They decided that they need surgery.

[Dr. Ashley Agan]
When you're doing these surgeries, I'd love to get into some of the details of, the technique. I know it's not one-size-fits-all. every nose is different. Just in general, are most of these patients going to require an open rhinoplasty or do you do endonasal, or where do you get your cartilage? These types of questions.

[Dr. Gopi Shah]
What kind of vocal? Awake, asleep, in your clinic, in the hospital?

[Dr. Moustafa Mourad]
Wait, am I awake or am I asleep? [laughter] It's going to depend on the anatomy. Internal nasal valve can be addressed pretty simply through a closed approach. You put some spreaders in there. I do a full transfixion incision, approach the dorsal septum, create a pocket, do the septoplasty, and put some septal cartilage in. That's pretty simple.

When it comes to the external nasal valve, from a functional standpoint, it's really going to depend on what those cartilages look like. If they're really weak and they're cephalically oriented, then usually I'll reorient them and do an open rhinoplasty approach. I have to caution the patient that usually this will change the way that your tip looks and will have some aesthetic impacts, usually for the better, but you have to be very cautious with those patients.

If you don't need reorientation, then I usually do it through a closed approach. You could do a lower lateral strut graft where you're just dissecting off the vestibular mucosa and you're placing it in a pocket along the piriform. That usually will secure it and create that sidewall strength for the external nasal valves.

(6) Cartilage Grafts in Nasal Valve Repair Surgery

[Dr. Ashley Agan]
If you see a patient had a septoplasty, where do you like to get your cartilage from if you can't get it from the septum?

[Dr. Moustafa Mourad]
I'm a big proponent of a patient's own rib graft or doing their own rib. One is the rib harvest technique I have is pretty efficient. A lot of people go in and harvest the rib on block, so they'll take the entire rib. I was trained to do an in-situ carving, where I just remove-- I carve the rib while it's in the patient. Is it in-situ? Is that the word?

Basically, I just take the rib and I carve out what I need in terms of my grafts. It's like a 20-minute harvest. It's like little to no morbidity. Usually, I offer a patient their own rib or a cadaver rib. The reason I don't really like cadaver rib is I've seen it warp right on the table. I'll put it in some saline and the thing just warps. There's no real living tissue in it, it's radiated, chemically treated. Usually, I would like to go to a rib.

People sometimes will do ear cartilage, but I don't think gives you the strength that you need in the long-term outcomes. Again, we all have to assess our long-term outcomes to see how we're doing. I don't think you can go wrong with a strong piece of rib, spanning the structure of the sidewall or the valves.

[Dr. Ashley Agan]
For the rib, is it kind of like, I don't know, skiving into and shaving to a certain depth that you need?

[Dr. Moustafa Mourad]
Yes.

[Dr. Ashley Agan]
That's very cool.

[Dr. Moustafa Mourad]
You're just basically carving a piece of a canoe. You make a little canoe shape, like a little V, and then you just carve out. It's really efficient. It's been great. Patients don't complain of pain and-

[Dr. Ashley Agan]
Pneumothorax.

[Dr. Moustafa Mourad]
There's no risk of pneumothorax. I still tell my patients that there's a theoretical risk, but I just don't think that you could because you're leaving a layer along the pleura, so there's no way you can really get into it.

[Dr. Ashley Agan]
Do you leave a Penrose if you're just carving a drain or anything for the rib-

[Dr. Moustafa Mourad]
No Penrose.

[Dr. Ashley Agan]
-because it's just a canoe, in-situ, it's minimal, and you just close it up?

[Dr. Moustafa Mourad]
Just close it up. It's been really good. It's treated me really well. You can do it at a surgery center. Like I said, I offer both. I always tell my patients, you can have a cadaver rib or you can have your own rib, and these are the benefits. The incision is really the big downside of your own rib, but it's about a centimeter and a half to two centimeters, and most people don't mind it.

[Dr. Gopi Shah]
Do you get chest X-rays afterwards?

[Dr. Moustafa Mourad]
No. Patients have done well.

[Dr. Ashley Agan]
Cool. Very cool. What kind of suture do you like? Don't you have to suture the spreader grafts?

[Dr. Moustafa Mourad]
If I do it endonasal--

[Dr. Ashley Agan]
I don't know. I'm thinking of the pocket. I thought we used to. When I was a resident, we did.

[Dr. Moustafa Mourad]
That's actually a really good question. Endonasal, I'll just do a pocket. I don't need to suture it, but when I do it open, I'll do a 5-0 PDS. Here's the kicker, which took me a while to figure out when I was first coming out, is you got to use a taper needle. This is stuff that people don't talk about. They come out after doing a fellowship and they've seen their fellowship director, suture in a thousand spreader grafts. Then they cut out and they're just like, "Why is this not working the way it worked with Dr. So-and-so?" You begin to question. It's the unspoken things.

For all the young listeners out there, definitely use a taper needle, especially in the beginning because a taper needle won't shred and crush your cartilage and slice it into 100 different pieces.

[Dr. Ashley Agan]
Speaking from experience.

[Dr. Moustafa Mourad]
Yes, there was some-- no one told me, it's like, "Oh, just give me the purple PDS, please. Oh, it's the same color, but it's not working the same. I must be the problem." Yes, the type of suture is a taper 5-0 PDS.

[Dr. Ashley Agan]
That's such a good point though. I've had a similar experience where when you're new and you're coming out of training, and you feel like you've set everything up just like you've always known to. Then I think we don't realize how much with our attendings, they work with the same nurses and scrubs and there are certain things that just happen and are there for them without them verbalizing it, that if you don't really pay attention, then you have to learn that the hard way sometimes. I've definitely been in that same situation.

[Dr. Moustafa Mourad]
One of the other things, the 5-0 PDS, they come on super long sutures and when you're putting a spreader graft, you're pulling out this really long suture.

[Dr. Gopi Shah]
Yes, it's going to yank on your cartilage.

[Dr. Moustafa Mourad]
It yanks. What I didn't realize is what my fellowship director is having done-- again, one of those unspoken things, is he would cut off two-thirds of the suture. It looked so easy, he just pulled through and it was just like, "Okay." It took me-- that's a year of pain in my life to figure that out. Do you guys have stories like that? Hard lessons learned when you first came out?

(7) Evaluating New Nasal Valve Technologies

[Dr. Ashley Agan]
Yes, absolutely. It's a really good point, actually. I want to ask you what your thoughts are some of the newer technologies and devices that are coming along that address the nasal valve. The LATERA implant or the VivAer Aerin Med device, and there's probably more, but basically, they're aimed at treating the nasal valve, but not in the way that we trained when we were speaking of rhinoplasty techniques.

[Dr. Gopi Shah]
Or those butterfly when they're something else at some point?

[Dr. Moustafa Mourad]
I'm going to caveat this with I have a selection bias. Most of the people that come to me have failed those interventions, but I haven't anecdotally and I guess, we're surgeons and we look at literature and all that, but I don't feel like patients have derived a lot of relief from those interventions. On top of that, I feel like especially with the LATERA, I've had to take them out. They get infected. Conceptually, they're fine. Conceptually, you're like, okay, you're addressing the valve in a structural way, but I've had to take them out because they've gotten infected and they cause problems.

In general, I don't really recommend using synthetics in the nose because, even if you place it, 20, 30 years from now, they can become infected. I don't offer that. I thoroughly tell my patients, "This is an option, synthetics or LATERAs or implants. I don't do it. This is the reason why. There's plenty of surgeons that will do it. It's important for you to understand all the options available to you," so that they don't feel like I cornered them into a specific surgical procedure.

[Dr. Gopi Shah]
I think what you said is key, right? It's who you see. If you do a lot of sinus, whether you balloon, don't balloon, whether you do tympanoplasty, do you do bio-design versus no, I always take fascia from the patient.

[Dr. Moustafa Mourad]
Right. In the world of ENT, it's funny because anecdotally from a personal standpoint, just the complexity of the valves from a structural standpoint, I feel like a lot of this stuff doesn't necessarily address it the way it should, but they are more simplistic so that they could be used by a broader range of otolaryngologists. Do I necessarily believe that they're a cure-all? No, and they probably have an inherent value that a certain amount of people will derive benefit from, but I don't think it's like, "Okay, well, Here's a LATERA, it's going to work in the internal nasal valve gland."

I hope you guys could appreciate, I spend a lot of time trying to figure out what's wrong with the nose and it's not just a matter of like, "It's the internal nasal valve. Here's a LATERA," because it could be the other things involved. I feel like that attempt, especially in otolaryngology, to try and make procedures more accessible to a broader range of surgeons, just making it simpler, I don't necessarily agree that patients will derive the benefit that they should, but it works in probably a subset of them.

[Dr. Ashley Agan]
Yes. I would imagine trying to take it out is a pain if you're having to take it out for infection. Is that--

[Dr. Moustafa Mourad]
Yes. Infection, but it's not even just infections. A lot of patients are uncomfortable. They're just like, "I had this placed."

[Dr. Ashley Agan]
They can feel it underneath their skin.

[Dr. Moustafa Mourad]
"I can feel it."

[Dr. Gopi Shah]
Can you take that out in clinic?

[Dr. Moustafa Mourad]
Usually, by the time they get to me, I don't because then I'll usually do-- I'll do a procedure, I'll take it out and then I'll reconstruct the valve area as well. Then there's other things where people were putting sutures, like Mitek sutures in the infraorbital regions and then suturing them over to the valve, which, conceptually makes perfect sense. They're like, "All right, well, pulling up on your skin makes you feel better. I'm going to put this permanent suture and tack it down to your periosteum." All that stuff just falls out of favor. I think surgeons that did it before, they're not doing it anymore because they probably had an unhappy patient because it probably didn't work.

(8) Tranexamic Acid (TXA) in Nasal Surgery

[Dr. Ashley Agan]
What do you like to use for local? How do you numb up the nose?

[Dr. Moustafa Mourad]
Usually just Lido with Epi, but it's an internal endonasal. I started using TXA, I don't know if you guys are on the TXA train.

[Dr. Ashley Agan]
Tell me more.

[Dr. Moustafa Mourad]
Have you guys even heard of it down in Texas?

[Dr. Gopi Shah]
No, tell us. I'm telling you, all I do is tonsils, tubes, and adenoids.

[Dr. Moustafa Mourad]
There's this thing called TXA. It stands for-- I'm going to have to-- I'm going to butcher the-- tranexamic acid.

[Dr. Gopi Shah]
Is that for nosebleeds? I think I've had the ER use that for nosebleeds maybe.

[Dr. Moustafa Mourad]
Yes, it's basically a pro-thrombotic medication that impacts-- and I'm not smart enough to tell you where. Let's get a real doctor here. Basically, it impacts the coagulation cascade and promotes some of the clotting. I'll mix that in two or three mLs of plain TXA with Lido with Epi and I'll use that to inject the soft tissue envelope of the nose. It really cuts back on a lot of the swelling, a lot.

[Dr. Gopi Shah]
Interesting.

[Dr. Moustafa Mourad]
If you go back to my Instagram and look at my on-table results when I was first-- a couple of years ago when I wasn't using it to my on-the-table results with it, you'll see it's just barely any swelling. After I do my osteotomies, lateral osteotomies, I'll inject pure TXA just to help those-- the orthopods use it. That's where we got it from is they'll use it for joints and stuff, but it helps reduce the amount of bleeding and it helps reduce the amount of swelling.

You got to be careful not to-- there's some strict contraindications, people with cancer, people with clotting disorders, things like that. Definitely, take your time and figure out which is the right patient to use it for. Now people are using it for facelifts, neck lifts, rhinoplasty, and now, do it for, nasal fractures and stuff like that.

[Dr. Ashley Agan]
Interesting. Yes, I had only heard of it for an epistaxis situation, so I didn't realize that that's the same TXA you were talking about for injections and local, but it makes sense now that you're talking about it.

[Dr. Moustafa Mourad]
Sinuses and stuff. I'll do it for sinus. You can give it IV. Not even just local, you can give it IV. It's one mg per kg IV, and sometimes if I don't give it and the anesthesiologist hasn't given it, I'll be like, "Hey--" I'll notice a lot more bleeding. Then I'll say, "Can you give some TXA," and then the bleeding, the oozing will stop.

[Dr. Gopi Shah]
Ah, interesting. For your sinus surgeries, you're doing the TXA IV, not topical on a pledget or not injected directly. It's IV. Okay.

[Dr. Moustafa Mourad]
IV. Lately, I've been experimenting with it on the pledget. I'm going crazy with the TXA at the surgery center. You put this thing in everything, vitamin TXA. I've been doing it with the pledgets too.

[Dr. Gopi Shah]
Like Bacitracin back in the day.

[Dr. Moustafa Mourad]
Yes, exactly. It's worked really good, and yes, it's like vitamin-- get some of that vitamin T.

[Dr. Ashley Agan]
Say again, when you mix it with your local, what's your-- how much do you--

[Dr. Moustafa Mourad]
Basically, two mLs of plain TXA or three mLs to seven to eight mLs of lidocaine with epinephrine, 1:100,000.

[Dr. Gopi Shah]
1% lido?

[Dr. Moustafa Mourad]
Yes, 1%.

[Dr. Ashley Agan]
Cool.

[Dr. Moustafa Mourad]
You just want to dilute it out, so you're not over-injecting with a prothrombotic agent into the nose.

[Dr. Ashley Agan]
Right. You feel like your post-op, there's less swelling, less edema.

[Dr. Moustafa Mourad]
Oh, yes. Even when I do the osteotomies, people would come out even three or four days later, it just ballooned and just blew, and they hated me. Now I'll do the TXA and they come to me a couple of days later and they just have these little blue marks under their eyes.

[Dr. Ashley Agan]
Awesome.

[Dr. Moustafa Mourad]
It's been great.

[Dr. Gopi Shah]
Yes, that's great.

(9) Post-Operative Care & Prevention of Complications After Nasal Valve Repair

[Dr. Ashley Agan]
It's probably a good transition point to talk about post-op care and what that's like. What are you telling these patients? What are expectations? Time to recover, different things like that. Can you talk about that?

[Dr. Moustafa Mourad]
Just talking about nasal valve surgery, not the whole rhinoplasty, rib, and all that stuff, but nasal reconstruction. Usually, I'll use splints, internal splints, and silastics. If I reorient the lower lateral cartilages, I'll also put these external splints on the outside on the nasal sidewalls. It helps prevent re-migration or cephalic migration of those grafts. Usually, I have them there for about 7 to 10 days. It's miserable, but you just don't want anything, any scarring to contract and push down or migrate any of those grafts because that would be pretty detrimental.

Usually, I tell them they have the mustache dressing under their nose and they'll typically bleed. It's like clockwork. By 24 hours after the surgery, the oozing will stop and they don't need that mustache dressing. At that point, I have them start irrigating out their nose. They'll irrigate out their nose about four or five times a day, even with the splints in. I tell them it's not going to get in. It's just really to keep the crust and the clot, they're growing bacteria, or pulling on a stitch, or pulling on a graft.

[Dr. Ashley Agan]
Yes. For your silastic splints and the external splints that you're placing as well, are you cutting or carving those out of silastic sheeting and how are you securing them? Tape or sutures or what does that look like?

[Dr. Moustafa Mourad]
Yes, I use the thin silastic sheets. I don't use the ones with little tubes in them. Those are really thick and comfortable as conceptually patients are like, "Oh, I want that, so I can breathe." They never breathe and they're really thick and they hurt the patient. I put the silastic sheets on the inside and I secure that one with a 3-0 prolene and then I'll cut the sheets into little rectangles and put them on the nasal sidewalls as well as a bolster and bolster down the sidewalls. I'll use a 3-0 nylon for that.

I don't know why I do nylon for one and proline for the other, but the color is different-- I don't know. It makes me identify different parts of the nose and it's easier to take out. I don't know. It's maybe voodoo. Who knows?

[Dr. Gopi Shah]
When you do the sheeting inside the nose, do you roll it or just put it in flat along the septum? Are you rolling it as a lumen and a tube or just putting it in flat?

[Dr. Moustafa Mourad]
Usually, I put them on either side of the septum and then I have the top edge of it roll up to sit in the internal valve area. I know a lot of people will trim the silastic, so it's just sitting flush against the septum and doesn't roll up in the internal valve.

[Dr. Gopi Shah]
It gives it that support where you put the spray.

[Dr. Moustafa Mourad]
Yes. Then you just sit there and you have to sit there for a week and pray that the grafts don't move. It's worked great. Patients, they have a lot of great-- the best part is when you take that stuff out and they can breathe great and they're like, "I haven't been able to breathe like this in years." There's tears and hugs and they're naming babies after you. [laughter] No, I like to have it roll up just a little bit to provide that support.

[Dr. Ashley Agan]
That comes out after, you said 7 to 10 days?

[Dr. Moustafa Mourad]
Yes.

[Dr. Ashley Agan]
After that, just saline forever?

[Dr. Moustafa Mourad]
Exactly. No, you could probably tell them a little on the aggressive side, but I'll tell them-- if I tell a patient to irrigate five times a day, they'll irrigate three. If I tell a patient to irrigate three times a day, they'll never irrigate. I tell them, "Four to five times a day for the next six weeks until I see you back at your second post-op, just so that, again, you don't want a crust pulling on the septum, causing perforation or migrating the septum or causing exposure of a graft," yes, I tell them about five times a day, just use the salt water and we provide it.

I give it to them for free, so they don't come back and say, "I ran out of salt." We're all surgeons, we want our patients to have the best possible outcomes. Usually, I'm pretty aggressive with the irrigations and--

[Dr. Ashley Agan]
Is it a Mist or a Neomed?

[Dr. Moustafa Mourad]
No, just like a Neomed.

[Dr. Ashley Agan]
Neomed. Total sinus irrigation. Okay.

[Dr. Moustafa Mourad]
The sinus irrigation. Yes.

[Dr. Gopi Shah]
The splint on the outside, it's cut like a little rectangle and then put on the outside of the nose and then just secured as a mattress or does it go over the top?

[Dr. Moustafa Mourad]
It's actually four rectangles. Two go on the outside and two go on the inside of the nostril. Then you're mattressing a little sandwich between the two and it goes over the sidewall. It reduces the swelling and it prevents everything from migrating.

[Dr. Gopi Shah]
I see. Cool. Do you do things in your practice like Arnica or are those things indicated or what are your personal little things that you like for your patients that are nuances?

[Dr. Moustafa Mourad]
On my pre-op counseling, I have a whole page on herbal supplements and medications to avoid because of bleeding. At the bottom, also, there's the voodoo section, I tell them it's the voodoo section. The vitamin C, the Arnica. I tell them if they're feeling motivated, then they can certainly do the protocol I have prescribed there, but there's no real literature to support it.

Some patients do it, some patients don't. I couldn't tell you the differences or not. Some patients go crazy. I had a patient the other day come in and they're like, "I've been on Arnica for a year," and I was like, "I didn't tell you to be on Arnica for a year. You can come off of it." From that standpoint, there's no herbals or over-the-counter that I will prescribe or tell them. It's just there, they want to do it. Really, it's the post-op care that I'm pretty vigilant about.

Some of the worst things that'll happen is a patient doesn't irrigate, they get a big crust that pulls on their stitch, and then all of a sudden, they have graft exposure and then you have to do a composite graft, or it migrates. If you're going to do these more aggressive type things in the nose, you just have to make sure that it's a clean, healthy healing environment to maximize their benefit.

[Dr. Ashley Agan]
Yes, absolutely.

[Dr. Gopi Shah]
That's great. What else are we missing? Ash, am I missing anything?

[Dr. Ashley Agan]
No, that's what I was about to say. Yes. Moustafa, is there anything you want to leave our listeners with? Anything that we've failed to ask you that are big pearls, big do's or don'ts?

[Dr. Moustafa Mourad]
No, I just hope that-- well, honestly, I hope I just didn't bore you guys.

[Dr. Gopi Shah]
No, this is great. I feel like I have a whole new appreciation for the lower lateral cartilages.

[Dr. Moustafa Mourad]
Oh, yes. That's the whole--

[Dr. Gopi Shah]
You reminded me, cephalically oriented is towards the head. That was good.

[Dr. Moustafa Mourad]
Yes. I could do my triological pieces on the lower lateral cartilages. Honestly, I know we live in a world where we're all-- crazy systems have taken over our clinics and we're forced to see patients. Fortunately, I'm in a position where private practice is a little more merciful. I think the most important thing, especially if you're younger or you're starting off, or you really want to do nasal surgeries, is that evaluation is everything.

You want your patients to be happy after surgery. You want to make sure you know what the problem is because you want to make sure the solution you have is going to help them. Nobody wants an unhappy patient. You don't want a septoplasty on somebody that has allergies because they're still going to have allergies after surgery and they're going to have an unhappy patient and nobody wants that. When it comes to the nose, there's enough stuff going on in there that you just got to have to look at it from an anatomical medical standpoint, and really just figure out what's the best way to help this person.

[Dr. Ashley Agan]
Great advice. That's a great way to end it, a great way to put a pin in. [laughter]

[Dr. Moustafa Mourad]
Yes.

[Dr. Gopi Shah]
Thank you so much.

[Dr. Ashley Agan]
Thank you, this was fun. It's a good refresher. Very comprehensive too.

[Dr. Gopi Shah]
Patients, our listeners, if our listeners want to find you, are you on-- You mentioned your Instagram.

[Dr. Moustafa Mourad]
Yes. NYCFaceDoc on Instagram, also nycfacedoc.com is my website. I recently got a TikTok, I'm not a TikTok doc, but one of my patients was a TikTok influencer, and I honestly made a TikTok, so I could follow her to follow my swelling to see my nose-

[Dr. Ashley Agan]
So you could keep up with your post-op. [laughter]

[Dr. Moustafa Mourad]
-so I could check in on my nose. I do have a TikTok, but there's not much on there. If patients want to get a hold of me, my website, nycfacedoc.com, or my Instagram's a great way too, nycfacedoc.com.

[Dr. Ashley Agan]
Awesome.

[Dr. Gopi Shah]
Awesome.

[Dr. Ashley Agan]
Thanks for taking the time. That was fun.

[Dr. Moustafa Mourad]
Thanks for having me.

[Dr. Ashley Agan]
Thank you. It was a good time.

Podcast Contributors

Dr. Moustafa Mourad

Dr. Moustafa Mourad is a private practice facial plastic and reconstructive surgeon in New York City.

Dr. Ashley Agan

Dr. Ashley Agan is an otolaryngologist in Dallas, TX.

Dr. Gopi Shah

Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.

Cite This Podcast

BackTable, LLC (Producer). (2022, July 5). Ep. 63 – Evaluation and Management of Nasal Valve Collapse [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.