Alar Collapse in Rhinoplasty

Definition and Anatomy

• Cummings Otolaryngology, p. 568-569

Causes / Aetiology

Primary (Pre-existing)

• Inherent lateral crural weakness
• Recurvature of the lateral crura
• Cephalic malposition of the LLC (acute orientation >35-45 degrees off midline reduces lateral wall support)
• Lax connective tissue (aging)

Iatrogenic (Post-rhinoplasty)

• Excessive cephalic strip resection of the lateral crura (minimum 6 mm of residual cartilage must be preserved)
• Inadequate support of the lateral wall after tip modification
• Post-operative scar contracture tightening the sidewall
• Cephalic malposition introduced or worsened surgically
• Caudal septal dislocation
• Previous filler injection to the nasal sidewall (mass effect on the internal nasal valve via inferomedial lateralization of the ULC)

"Alar collapse and retraction is frequently caused by over-resection of the LLCs in an attempt to sculpt the nasal tip." - Cummings Otolaryngology, p. 688

Clinical Features

• Nasal obstruction worsening on inspiration (especially rapid/forceful breathing)
• Exaggerated supra-alar crease visible on frontal view
• Alar-columellar disharmony: excessive columellar show (normal = 2-4 mm on lateral view), notching at the apex of the alar margin
• Aesthetic: pinched tip, parenthesis deformity on frontal view (when LLC is both bulbous and cephalically oriented)
• On examination: dynamic inward collapse of the alar sidewall during sniffing

Diagnosis

• Cummings Otolaryngology, p. 685

Surgical Correction

1. Alar Batten Grafts

• Taken from septal or conchal cartilage
• Placed in a subcutaneous pocket at the point of maximal lateral wall collapse, slightly overlapping the lateral crura
• Can be positioned cephalad, caudal, or directly over the lateral crus; may extend over the bony piriform aperture for added stability
• Correct both internal and external nasal valve collapse
• Shown to correct both types of valve collapse even in non-scarred noses

Intraoperative base view: lateral crural strut grafts (LCSGs) sutured to the undersurface of the lateral crura - Cummings Fig. 34.16

2. Lateral Crural Strut Grafts (LCSGs)

• Typically fashioned from septal cartilage
• Sutured directly to the dissected undersurface of the lateral crura
• Can flatten recurvature of the lateral crus
• Re-orients the caudal margin above the cephalic margin
• Extends to the piriform aperture for structural stability
• Particularly useful when the lateral crus is displaced or malpositioned

Repositioned lateral crura using LCSGs - Cummings Fig. 34.18

3. LLC Repositioning (for Cephalic Malposition)

• Defined as LLC orientation >35-45 degrees off midline
• The lateral crus is elevated from its bed and reinserted into a more caudal and posterior pocket
• Often combined with a strut graft for added support
• Achieves functional correction of valve collapse AND cosmetic improvement (nasal length, projection, rotation)
• Can be performed via endonasal or external approach (external is technically less demanding)

4. Alar Retraction with Composite Grafts

• Mild: Cartilage grafts placed through a marginal incision into a snug subalar pocket
• Severe: Composite graft from the cymba conchae of the opposite ear placed into a pocket dissected between the alar rim and the residual LLC, displacing the alar rim caudally
• An alternative: septal or rib cartilage spacer graft placed in the scroll area (between ULC and LLC) to push the LLC caudally

5. Spanning / Lateral Crural Flip-Over Techniques

• Spanning grafts straddle the dorsal septum attached to the lateral crura, keeping them in the desired orientation
• Flip-over technique: severely convex/concave lateral crus is completely mobilized and re-inserted with the concavity converted to convexity, sutured to the medial segment

6. Turn-In Flap (for alar retraction with soft tissue deficit)

• The strip of cephalic trim can be used as a turn-in flap to splint the remaining lateral crus strip and reduce excessive curvature

Summary of Graft Options

Prevention

• Preserve a minimum 6 mm strip of lateral crural cartilage after cephalic trim
• Preserve vestibular mucosa to reduce contracture risk
• Avoid over-aggressive tip suturing, which can create tension on the lateral crus
• Pre-operatively identify cephalic malposition and plan repositioning rather than simple trimming
• Identify pre-existing alar collapse with the modified Cottle maneuver and address it at the time of primary rhinoplasty

• Cummings Otolaryngology Head and Neck Surgery, pp. 568-569, 685, 688-689
• Scott-Brown's Otorhinolaryngology Head & Neck Surgery Vol 1, pp. 1195-1196
• Scott-Brown's Otorhinolaryngology Head & Neck Surgery, p. 1195
• K.J. Lee's Essential Otolaryngology

ENT Manifestations of GERD / Laryngopharyngeal Reflux (LPR)

Terminology and Concept

"Laryngopharyngeal reflux (LPR) may not manifest symptoms of gastroesophageal reflux disease (GERD), such as classic heartburn or indigestion." - K.J. Lee's Essential Otolaryngology, p. 919

Pathophysiology

• Hydrochloric acid - directly corrosive; partially suppressed by PPIs
• Pepsin - activated at pH <4 but remains active almost up to neutrality (pH 7) using human pepsin. Pepsin binds to and is taken up into laryngeal epithelial cells by endocytosis; can be reactivated by subsequent acid exposure. Even acidic drinks (cola, pH <2) can re-activate deposited pepsin. Pancreatic proteases, bile acids, and partially digested food may also contribute.

• Scott-Brown's Otorhinolaryngology, p. 1137

ENT Manifestations

1. Laryngeal Manifestations (Most Important)

A. Reflux Laryngitis / Posterior Laryngitis

Laryngoscopic view: generalized laryngeal erythema and ventricular effacement ("active larynx") - Scott-Brown's Vol 2, Fig 44.1

Severe posterior laryngeal inflammation - Scott-Brown's Vol 2, Fig 44.2

Important caveat: No single finding is pathognomonic. Laryngeal abnormalities are reported in 64-86% of normal controls. Pseudosulcus vocalis has the best PPV (67-90%) but must be interpreted with clinical context.

B. Contact Ulcer / Vocal Process Granuloma

• Ulceration and granuloma formation at the vocal processes of the arytenoids from repeated acid/pepsin exposure
• Presents with throat pain, foreign body sensation, dysphonia

C. Subglottic Stenosis

• LPR is an established contributing factor to idiopathic subglottic stenosis and to acquired subglottic stenosis post-intubation
• Gastric acid impairs mucosal healing after laryngotracheal injury - Scott-Brown's Vol 2, p. 548

D. Laryngomalacia (Paediatric)

• Up to 90% of infants with laryngomalacia have associated GER
• Increased intrathoracic pressure from airway obstruction promotes reflux; the same vagal dysfunction that affects laryngeal tone also affects the lower esophageal sphincter
• Pepsin has been identified in tracheal aspirates and arytenoid mucosa of infants with severe laryngomalacia

E. Laryngospasm

• Refluxate triggering the larynx can provoke reflex laryngospasm
• May present as episodic choking, throat tightening, or cough syncope

F. Vocal Cord Dysfunction (VCD) / Paradoxical Vocal Fold Movement

• LPR is a recognized trigger for VCD - reflux-induced irritation causes aberrant vocal fold adduction during inspiration
• Presents as inspiratory stridor, often misdiagnosed as asthma

2. Pharyngeal Manifestations

3. Nasal and Sinus Manifestations

• Chronic rhinosinusitis: LPR is implicated as a co-factor in refractory chronic rhinosinusitis; refluxate reaching the nasopharynx may trigger mucosal inflammation
• Adenoid hypertrophy: Extra-oesophageal reflux is possibly associated with adenotonsillar hypertrophy; pepsin has been identified in adenoid tissue

4. Ear Manifestations

• Eustachian tube dysfunction / Otitis media with effusion (OME): LPR is listed among concomitant disorders causing chronic obstructive Eustachian tube dysfunction. Refluxate reaching the nasopharynx can inflame the tubal orifice and Gerlach's tonsil, impairing ET function. Pepsin has been detected in middle ear fluid and adenoid tissue, suggesting a possible direct pathogenic role.
• Evidence linking gastric reflux to OME exists (Tasker et al.) but the causal relationship remains debated.
• Cummings Otolaryngology, p. (Eustachian tube chapter)

5. Respiratory / Aerodigestive Manifestations

• Chronic cough: GERD is the 3rd most common cause of chronic cough (after postnasal drip and asthma), accounting for ~21% of cases. Mechanism: irritation of upper respiratory tract (with/without microaspiration) + esophageal-bronchial vagal cough reflex. 43-75% of patients with GERD-related cough have no typical reflux symptoms.
• Asthma / reactive airways: Reflux can trigger or worsen asthma via aspiration and vagal reflex bronchospasm
• Recurrent croup / stridor in infants: LPR can present as stridor, croup, apnea, and hoarseness in infants
• Recurrent laryngeal papillomatosis: Laryngopharyngeal acid exposure is increasingly recognized as a contributor to papilloma recurrence

6. Dental Manifestations

• Dental erosion: Prevalence 17-68% in GERD patients. Chronic acid exposure causes loss of enamel - painless at first, then sensitivity. Palatal surfaces of upper teeth affected earliest (from regurgitation).

Diagnostic Tools

Summary of ENT Manifestations

GERD / LPR Extra-esophageal ENT Manifestations
│
├── Larynx
│   ├── Reflux laryngitis (posterior laryngitis)
│   ├── Contact ulcer / vocal process granuloma
│   ├── Subglottic stenosis
│   ├── Laryngomalacia (paediatric)
│   ├── Laryngospasm
│   └── Vocal cord dysfunction
│
├── Pharynx
│   ├── Globus pharyngeus
│   ├── Chronic throat clearing
│   ├── Postnasal drip sensation
│   ├── Dysphagia
│   └── Halitosis / recurrent sore throat
│
├── Nose/Sinuses
│   ├── Chronic rhinosinusitis (refractory)
│   └── Adenoid hypertrophy
│
├── Ear
│   ├── Eustachian tube dysfunction
│   └── Otitis media with effusion
│
├── Airway/Respiratory
│   ├── Chronic cough (3rd most common cause overall)
│   ├── Asthma/reactive airways
│   └── Recurrent croup/stridor (paediatric)
│
└── Oral/Dental
    └── Dental erosion (enamel loss)

• Cummings Otolaryngology Head and Neck Surgery, Chapters 29, 47, 68, 131
• Scott-Brown's Otorhinolaryngology Head & Neck Surgery Vol 2, Chapter 44 (Extra-oesophageal Reflux)
• Scott-Brown's Otorhinolaryngology, Chapter 77 (LPR)
• K.J. Lee's Essential Otolaryngology, pp. 919, 1260
• Textbook of Family Medicine 9e, Reflux Laryngitis section
• Recent guideline: Spanish multidisciplinary ReFaL Consensus on LPR diagnosis and management (2026, PMID 41391506)