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Internal vs External Nasal Valve Collapse

Author Iman Iqbal covers Internal vs External Nasal Valve Collapse on BackTable ENT

Iman Iqbal • Jun 14, 2024 • 36 hits

Nasal valve collapse is characterized by dynamic airflow obstruction within the nasal passages. This collapse can occur either at the internal or external nasal valves, leading to significant impairment in nasal airflow and quality of life. Dr. Moustafa Mourad, an esteemed facial plastic and reconstructive surgeon, emphasizes that understanding the intricate interplay between anatomical factors, such as cartilage strength and orientation, and functional dynamics is paramount in diagnosing and managing nasal valve collapse effectively. Moreover, with demographics, prior surgeries, and other risk factors contributing to the development of nasal valve dysfunction, clinicians must adopt a holistic approach to patient assessment and treatment planning.

This article delves into the multifaceted nature of nasal valve collapse, exploring both internal and external nasal valve anatomy, pathophysiology, etiology and clinical presentation, featuring excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.

The BackTable ENT Brief

• The nasal valve consists of the internal and external valves, each contributing to nasal airflow dynamics.

• Internal nasal valve collapse often manifests with the need for cheek pulling or Breathe Right strip use. External nasal valve collapse is seen with nostril pinching during physical exertion.

• Anatomical variations in cartilage strength and orientation influence the severity and presentation of nasal valve dysfunction.

• Cephalically oriented cartilage, pointing towards the inner eye corners, pose a higher risk of external valve collapse due to decreased nasal sidewall support.

• Nasal valve collapse becomes more prevalent with aging as cartilages lose structural integrity.

• Prior nasal surgeries or dorsal trauma can result in nasal valve collapse, especially in younger patients who undergo procedures like dorsal hump reduction without adequate management of nasal valves.

• Athletes are prone to nasal valve weakening due to repeated high-pressure breathing, which contributes to intrinsic and extrinsic cartilage weakening over time.

• External nasal valve collapse after septoplasty is also common, often stemming from inadequate pre-operative assessment, leading to persistent nasal obstruction despite initial airflow improvements.

Internal vs External Nasal Valve Collapse

Table of Contents

(1) Nasal Valve Collapse Anatomy

(2) Internal vs External Nasal Valve Collapse

(3) Risk Factors Leading to Nasal Valve Collapse

(4) External Valve Collapse After Septoplasty

Nasal Valve Collapse Anatomy

The nasal valve is made up of the internal and external nasal valves. The internal nasal valve is composed of the upper lateral cartilages and the dorsal septum, and the external nasal valve is formed by the lower lateral cartilages. In nasal valve collapse, the nasal passages' airflow is narrowed due to changes in either the internal or external valves. Dynamic nasal airway obstruction is also a key indicator of nasal valve collapse; it can be seen when breathing worsens with deeper breaths or improves with physical manipulation like cheek pulling.

In addition, individual anatomical differences play a significant role in how nasal valve dysfunction develops and manifests. Some patients may have inherently stronger cartilages, while others have weaker ones, affecting the severity and onset of nasal valve collapse symptoms. As such, individualized assessment to determine the primary contributing factors is necessary.

[Dr. Moustafa Mourad]
Let's just start off with what the nasal 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.

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.

Listen to the Full Podcast

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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Internal vs External Nasal Valve Collapse

Understanding the distinction between internal and external nasal valve collapse is crucial for accurate diagnosis and effective treatment of nasal obstruction. Internal nasal valve collapse often presents with symptoms such as the need to pull up on the cheeks or use Breathe Right strips to improve airflow. This is more common in patients with a history of nasal trauma or surgery. In contrast, those with external nasal valve collapse typically experience symptoms during physical exertion, such as exercise, where their nostrils pinch and obstruct airflow without accompanying nasal discharge or congestion.

A thorough patient history and physical examination, including maneuvers like lifting the nasal tip and cheek skin, can help distinguish between internal vs external valve collapse. Additionally, photographic mapping of the patient's internal nasal valve anatomy to their surface anatomy aids in diagnosing the specific type of nasal valve collapse.

In addition to this, it’s important to have patients rate their baseline breathing on a scale from 1 to 10, both before and after decongestion. Patients may show a positive response to Afrin, suggesting medical causes like turbinate hypertrophy or allergies for their obstructive symptoms, so patients may be able to avoid surgical intervention. However, for patients with no allergies and clear structural collapse, a procedural intervention may be necessary. This comprehensive approach, combining detailed patient history, physical examination, and targeted therapy, enables effective diagnosis and management of nasal valve collapse.

[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. 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 nasal valve 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]
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.

Risk Factors Leading to Nasal Valve Collapse

Nasal valve collapse is influenced by various risk factors including aging, trauma, and prior surgery. Over time, cartilages lose their structural integrity, so individuals in their 30s and 40s may begin to notice pinching of the nose during deep breaths or physical activity, a sign of deteriorating nasal valve structure. Trauma, both from dorsal impacts and nasal tip injuries, can also result in nasal valve collapse. This is prominently seen in younger patients in their 20s and 30s who have had prior nasal surgeries like dorsal hump reduction without proper management of the nasal valves.

Additionally, athletes, particularly those engaged in activities that involve significant nasal breathing pressure such as swimming, often encounter nasal valve weakening in their later years. The intrinsic and extrinsic weakening of nasal cartilages over time is exacerbated by repeated high airflow during athletic activities. Demographic factors, including ethnicity and cartilage orientation, further influence the likelihood of developing nasal valve collapse, with certain ethnic groups like Caucasians displaying thinner, more vulnerable cartilages.

[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.

[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.

External Valve Collapse After Septoplasty

External nasal valve collapse after septoplasty is a significant concern, often due to inadequate pre-operative evaluation. Patients typically present with persistent nasal obstruction despite initial improvements in airflow. This occurs because the septoplasty, while correcting the septal deviation, creates a new pressure gradient that can cause the external nasal valves to collapse or pinch, especially during increased airflow.

Proper evaluation before septoplasty, including the assessment of contralateral nasal structures and cartilage orientation, is crucial in anticipating and mitigating this risk. Cephalically oriented cartilages (pointing towards the inner corners of the eyes) are less supportive of the nasal sidewall, increasing the risk of collapse. Simple maneuvers, such as lifting the nasal tip or assessing the nose during deep breaths, can help predict the likelihood of external valve collapse post-operatively. A comprehensive anatomical evaluation and proactive planning in septoplasty is thus necessary to prevent and manage external nasal valve collapse, ultimately enhancing patient care and surgical success.

[Dr. Moustafa Mourad]
One of the biggest things that I see is external nasal 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?"

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.

Podcast Contributors

Dr. Moustafa Mourad discusses Evaluation and Management of Nasal Valve Collapse on the BackTable 63 Podcast

Dr. Moustafa Mourad

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

Dr. Ashley Agan discusses Evaluation and Management of Nasal Valve Collapse on the BackTable 63 Podcast

Dr. Ashley Agan

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

Dr. Gopi Shah discusses Evaluation and Management of Nasal Valve Collapse on the BackTable 63 Podcast

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

Disclaimer: The Materials available on 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.



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