Nasal obstruction is one of the most common complaints of patients visiting the otolaryngology department [1]. This condition can lead to symptoms, including nasal congestion, runny nose, sneezing, postnasal drip, headaches, decreased concentration, and sleep disturbances. In severe cases, nasal obstruction can significantly reduce quality of life. The prevalence of nasal obstruction varies depending on the population and studies; however, it is estimated that approximately 10%–20% of the adult population experiences nasal obstruction [2]. The primary causes can be broadly categorized into inflammation or anatomical abnormalities. The anatomical abnormalities included nasal septum deviation, turbinate hypertrophy, and nasal valve insufficiency (external and/or internal).

External nasal valve deformity is related to congenital or acquired abnormalities after a previous nasal surgery. Appropriate measures can be taken if the anatomical abnormalities are clearly diagnosed. Anatomical abnormalities are typically observed in the caudal septum, columella, and alar rims. Septoplasty or columelloplasty can be performed in cases of caudal septal deviation or a large (obstructive) columella. If the alar rim is affected, it can be corrected using techniques such as alar batten grafts, lateral crural strut grafts, and lateral crural turn-in flaps [3].

Here, we report the case of a patient with no evident anatomical variations or other abnormalities, making diagnosis difficult. The patient reported feeling much more comfortable breathing when the volume of the external nasal valve was gently reduced, similar to wearing glasses on the nose. The patient also complained of a blocked nose, even with a slight obstruction. Therefore, we devised a related surgical method, treated the patient, and reported the present case.

A 48-year-old woman visited the outpatient clinic with long-standing symptoms of excessive air entering her nose, which caused a sharp and dry sensation in her nose and throat. The patient presented with a stuffy nose. The symptoms worsened in dry environments and improved when she pressed both sides of her nasal valve with glasses or fingers. She used a tissue to block her nose while sleeping. Only then did she feel comfortable.

Although the patient had no underlying diseases, she had undergone augmentation rhinoplasty using an L-shaped silicone implant 10 years ago, which appeared to narrow the columella (Fig. 1). Additional evaluation using paranasal sinus computed tomography showed no evidence of nasal septal deviation or anatomical abnormalities that could lead to empty nose syndrome (Fig. 2), except that the columella was slightly narrowed.

Figure 1. This photo shows a relatively narrow columella thought to be caused by a previous rhinoplasty (capsular contracture).

Figure 2. The paranasal sinus computed tomography showed no anatomical abnormalities that could lead to empty nose syndrome.

Furthermore, there were no significant findings on acoustic rhinometry (Fig. 3).

Figure 3. No significant findings on acoustic rhinometry (pre-operation).

Surgery was performed under general anesthesia, and an external rhinoplasty approach was also used. An inverted V-shaped incision was made in the columella. We exposed the L-shaped silicone and removed the silicone that descended to the nasal tip and columella. The silicone was retained in the nasal dorsal area. The septal cartilage was then harvested.

We devised a columella-widening operation using a 3-layered strut graft with septal cartilage, which was inserted within the columella to the anterior caudal part (Fig. 4). Surgery was completed by fixing the graft and suturing the skin.

Figure 4. Illustration of schematic design of 3-layered strut graft (bird-eye view).

Upon comparison pre- and post-operatively, the columella widened, and the patient reported that breathing was much easier (Fig. 5). The postoperative acoustic rhinometry showed no significant differences (Fig. 6).

Figure 5. This is a post-surgery photo (6 months). The columella is much wider than before.

Figure 6. Acoustic rhinometry conducted post-operation.

This case report presents a unique and challenging scenario in a patient with an external nasal valve deformity characterized by subjective symptoms of excessive air entering the nose and discomfort in the nose and throat despite the absence of clear anatomical abnormalities or underlying diseases. The patient has a slightly narrowed columella. We hypothesized that this was caused by previous rhinoplasty involving the insertion of an L-shaped silicone implant [4]. The thinning of the nasal columella area is thought to be due to capsular contracture caused by the L-shaped silicone [5].

Research indicates that approximately 3% of patients who undergo silicone implantation experience complications, such as those observed in this case [5]. The patient’s symptoms were significantly alleviated by a novel surgical approach involving columella widening with a 3-layered strut graft, using the septal cartilage to thicken the columella as much as possible.

External nasal valve deformities often pose diagnostic difficulties, particularly when conventional imaging techniques can identify no obvious anatomical abnormalities. This case highlights the importance of considering the functional aspects of nasal airflow in addition to structural deviations. The subjective improvement in breathing comfort following surgical intervention suggests a potential interplay between the external nasal valve and sensory perception.

The use of a 3-layered strut graft to address patient symptoms demonstrates the versatility of surgical techniques in addressing functional concerns. Insertion of the graft within the columella led to a noticeable improvement in the patient’s breathing, indicating the potential efficacy of this method for managing cases of external nasal valve insufficiency with subjective discomfort.

The lack of significant changes in the postoperative acoustic rhinometry measurements within the nasal cavity is intriguing [6]. Although this outcome could be expected, owing to the impact of surgery on the outer aspect of the nasal cavity, it prompts us to consider the need for more refined diagnostic tools that capture changes in airflow dynamics in the external valve region. Further research and development in this area could enhance the ability to accurately assess and quantify the functional outcomes of surgical interventions targeting external nasal valve deformities.

It is essential to acknowledge the limitations of this case report, including its single-patient nature and the absence of a control group for comparison. Although the patient’s subjective improvement was compelling, future studies involving a larger cohort and objective measurements are warranted to validate the effectiveness and generalizability of the columellar widening technique.

The authors have nothing to disclose.