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Vivaer to Address Nasal Obstruction Due to a Narrow Nasal Valve

by , last modified on 8/4/21.


Nasal obstruction is a very common complaint of patients who present to an ENT office. Nasal obstruction can be due to many different issues including but not limited to:

deviated septum
nasal polyps
large turbinates
large adenoids

Most patients have some passing familiarity with these structural problems.

However, another less recognized factor that may cause nasal obstruction is a narrow internal nasal valve. The internal nasal valve is located about 1cm into the nose where it pinches together beyond the nasal opening. See black arrow in picture. The internal nasal valve area represents the narrowest segment of the nasal airway. It is defined as the area bounded by the lower edge of the upper lateral cartilage (ULC) which influences the lateral wall, nasal septum, and head of the inferior turbinate.

If this area is TOO narrow, nasal obstruction will occur. The narrow nasal valve will have a shape similar to an upside down "V". Patients suffering from nasal obstruction due to a narrow internal nasal valve will often use breath-rite strips or nasal dilators to open up this area. Patients will also often pull on the cheek away from the nose to temporarily open up this narrow region as demonstrated below in order to improve nasal airflow (this is known as Cottle's maneuver).



Traditional Surgical Approaches

Traditional surgeries that have been performed to permanently address a narrow internal nasal valve to improve nasal airflow include:

• Spreader graft rhinoplasty (RED arrow pointing to thin strips of white cartilage)
• Alar batten graft rhinoplasty (BLUE arrow pointing to oval shaped white cartilage)

Watch a video to see how these "nosejob" surgical procedures can improve nasal breathing. Unfortunately, these procedures require incisions and WILL change the way your nose looks.

However, there is now a minimally invasive procedure to improve nasal airflow due to a narrow internal nasal valve without the need for incisions and without altering the appearance of the nose.

Vivaer Nasal Airway Remodeling

Called Vivaer, it utilizes low-temperature, non-ablative radiofrequency energy to effectively reshape the nasal airway to improve airflow without any incisions. The device accomplishes this by gently shrinking the submucosal nasal tissues and cartilage in the internal nasal valve region thereby alleviating obstruction of the nasal airway. This procedure is analogous to body sculpting plastic surgeons use to get rid of unwanted fat.

Clinically, the outcome is such that it turns a narrow nasal valve shaped like an upside-down "V" shape into a "U" shape with corresponding greater cross-sectional nasal valve airway diameter.

The Vivaer stylus is designed with a precisely curved treatment head such that when pressed against the tissues of the nasal valve, it contours the nasal valve treatment area. Radiofrequency energy delivered into the submucosal tissue layers during treatment then causes the tissue to contract and fix around the curved Vivaer tip. The shrinking and tightening of the collagen fibers in the induced curve of the treatment area can cause a lasting modification in the shape of the nasal valve area, specifically on the lower edge of the upper lateral cartilage which composes the lateral nasal wall.

• There are NO incisions – The procedure requires no incisions and is performed by simply treating at the surface of the desired area
• There is NO change to the nasal appearance – Vivaer gently heats and shrinks submucosal tissue including cartilage, to relieve nasal obstruction without affecting the exterior appearance of the nose
• This procedure is covered by insurance

Watch the video here to see how the whole thing works:

Aftercare is fairly straightforward. Pain control (if done alone) is mainly with tylenol and ibuprofen. The patient should also perform saline flushes or sprays into the nose at least 4 or more times a day for 2-4 weeks (until crusting that develops during the healing process has fully resolved). Antibiotic ointment of choice should also be applied to the surgical site using a finger or q-tip. If no other procedures (ie, septoplasty) are performed, patients can resume all non-strenuous activites without restrictions. Read postop instructions here.

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Patients who are candidate for Vivaer must first:

• Be over 18 years of age
• Be evaluated for allergies and other nasal anatomic factors that may contribute to nasal obstruction
• Have improved nasal airflow with the modified Cottle maneuver (small curette used to gently move the side of the internal nasal valve outward away from the midline; this maneuver is more sensitive and specific than the Cottle maneuver described above.)

PLEASE NOTE: At least in our practice, this procedure is currently performed only in the hospital. Other practices may be able to perform in the office, but this option is currently not available in our practice.


In‐office treatment of nasal valve obstruction using a novel, bipolar radiofrequency device. Laryngoscope Investigative Otolaryngology. 2/4/19

Temperature-controlled radiofrequency device treatment of the nasal valve for nasal airway obstruction: A randomized controlled trial. International Forum of Allergy and Rhinology. July 9, 2021.

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