Surgical Treatment of Nasal Obstruction - UCSF CME€¦ · Rhinoplasty MMO will change ... Timing...
Transcript of Surgical Treatment of Nasal Obstruction - UCSF CME€¦ · Rhinoplasty MMO will change ... Timing...
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Surgical Treatment of Nasal Obstruction
Edward W. Chang, MD FACSChief of Education
Assistant Chief, Department of Head and Neck SurgeryFacial Plastic Surgery at Cosmetic Services
Kaiser Permanente-Santa Rosa Medical CenterFebruary 13, 2010
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Nasal ObstructionObjectives
The role of nasal obstruction in SleepThe role of nasal obstruction in Sleep--Disordered BreathingDisordered Breathing
Pathophysiology of nasal obstructionPathophysiology of nasal obstruction Methods of clinical assessmentMethods of clinical assessment Discuss various nasal procedures and timing Discuss various nasal procedures and timing
of the surgeriesof the surgeries
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Cultural and Linguistic Competence
Nasal obstruction can present differently in Nasal obstruction can present differently in different ethnicitiesdifferent ethnicitiesPlatyrrhinePlatyrrhine short nasal nose, broad baseshort nasal nose, broad baseMesorrhineMesorrhine having a moderately broad having a moderately broad
and highand high--bridged nosebridged noseLeptorrhineLeptorrhine a long narrow nosea long narrow nose
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Patent Nasal Airway
Establishes physiologic breathingEstablishes physiologic breathingFitzpatrick 2003Fitzpatrick 2003
Minimizes mouth breathingMinimizes mouth breathingAs the jaw opens, the tongue falls back As the jaw opens, the tongue falls back
into the PASinto the PAS May improve nCPAP toleranceMay improve nCPAP tolerance
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Nasal Surgery and SDB
Verse 2002 LaryngoscopeVerse 2002 Laryngoscope Evaluation of nasal surgery on 26 patients Evaluation of nasal surgery on 26 patients
with OSAS and simple snoring (AHI<10)with OSAS and simple snoring (AHI<10) Limited efficacy in patients with OSASLimited efficacy in patients with OSAS Improved sleep quality and EDS Improved sleep quality and EDS
independent of the severity of SDBindependent of the severity of SDB
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Nasal Surgery and SDB
Nasal surgery rarely treats OSA Nasal surgery rarely treats OSA effectivelyeffectively, , EurEur RespirRespir J 2008J 2008
Blue Cross/Blue Shield 2009Blue Cross/Blue Shield 2009Nasal surgery for OSA investigational Nasal surgery for OSA investigational
and not medically needed and not medically needed Radiofrequency of Radiofrequency of turbinatesturbinates
investigational and not medically needed investigational and not medically needed
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Nasal Obstruction
May accentuate May accentuate SnoringSnoring May worsenMay worsen Obstructive Sleep ApneaObstructive Sleep Apnea Nasal Nasal steriodssteriods improve sleepiness and improve sleepiness and
reduce AHIreduce AHI, Thorax 2004, Thorax 2004
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Pathophysiology
Nasal occlusionNasal occlusion High nasal resistanceHigh nasal resistance More negative pharyngeal pressureMore negative pharyngeal pressure Upper airway collapseUpper airway collapse
Upper airway as a Starling ResistorUpper airway as a Starling ResistorPark, SSPark, SS Lung, 1993Lung, 1993
Nasal role unclear in SDBNasal role unclear in SDBKushidaKushida, CA , CA OCNA, 2003OCNA, 2003RappaiRappai, M, M CHEST, 2003CHEST, 2003
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Nasal Obstruction as a Risk Factor
Young, et. al. 1997Young, et. al. 1997 911 subjects failed to 911 subjects failed to
demonstrate a demonstrate a correlation between correlation between OSAS severity and OSAS severity and objective nasal objective nasal resistanceresistance
Young, et. al. 2001Young, et. al. 2001 Population based Population based
sample of 4,916sample of 4,916 Nasal obstruction is a Nasal obstruction is a
risk factor for snoringrisk factor for snoring Snoring on the Snoring on the
continuum of SDBcontinuum of SDB Linked to significant Linked to significant
morbiditymorbidity
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Nasal Obstruction as a Risk Factor
Lofaso et.al. 2002 looked at 541 patientsLofaso et.al. 2002 looked at 541 patients Cephalometrics, BMI, PSG and Cephalometrics, BMI, PSG and posterior posterior
rhinometryrhinometry was donewas done OSAS was defined as AHI>15OSAS was defined as AHI>15 Daytime nasal obstruction is an independent risk Daytime nasal obstruction is an independent risk
factor for OSASfactor for OSAS Increase in negative oropharyngeal pressure Increase in negative oropharyngeal pressure
during inspirationduring inspiration Predisposition to upper airway collapse Predisposition to upper airway collapse
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Nasal Surgery and n CPAP
Friedman et. al. 2000Friedman et. al. 2000 50 patients with nasal obstruction and 50 patients with nasal obstruction and
OSASOSAS Subjectively 98% improvement in nasal Subjectively 98% improvement in nasal
breathingbreathing No significant change in RDI or LSATNo significant change in RDI or LSAT nCPAP pressures decreased after surgerynCPAP pressures decreased after surgery
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Controversy
Will reducing the nasal resistance allow Will reducing the nasal resistance allow patients to go into a deeper level of sleep patients to go into a deeper level of sleep causing more hypopneas and apneas?causing more hypopneas and apneas?
Since sinusitis is associated with mucosal Since sinusitis is associated with mucosal inflammation and nasal obstruction, is there inflammation and nasal obstruction, is there justification for FESS, septoplasty and justification for FESS, septoplasty and turbinate reduction as turbinate reduction as first line therapies for first line therapies for OSASOSAS??
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Nasal AnatomyLocation of Obstruction
SeptumSeptum TurbinateTurbinate Internal ValveInternal Valve External ValveExternal Valve Posterior pharynxPosterior pharynx
TumorTumor
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Internal Nasal Valve•Limen Vestibuli
•Main Regulator ofNasal Flow
•Ideal Angle = 10-15o
•ComponentsSeptumAnt.Inf.TurbinateULC
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External Nasal Valve
Components:Components:
LLCLLCColumellaColumellaNasal FloorNasal Floor
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Nasal ObstructionClinical Assessment
History and PhysicalHistory and Physical
InternalInternalAnterior rhinoscopyAnterior rhinoscopyFiberoptic examinationFiberoptic examination
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The NoseClinical Assessment
ExternalExternal•• InspectionInspection•• PalpationPalpation•• Review of Review of standardized standardized photographsphotographs
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Location of Obstruction
DNSDNS Internal Valve Internal Valve
CollapseCollapse RR-- StaticStatic LL-- DynamicDynamic
External Valve External Valve CollapseCollapse LL-- AlarAlar
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Rhinophyma impeding nCPAP
Severe OSAS, s/p PI Severe OSAS, s/p PI and Trachand Trach
Controlled on nCPAPControlled on nCPAP Increasing difficulty in Increasing difficulty in
nCPAP usenCPAP use Dermabrasion under Dermabrasion under
general anesthesiageneral anesthesia Post operative nCPAP Post operative nCPAP
via nasal pillows via nasal pillows
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Nasal Obstruction
Turbinate HypertrophyTurbinate Hypertrophy Allergy workAllergy work--upup Refractory to medical therapyRefractory to medical therapy Examination shows boggy, enlarged Examination shows boggy, enlarged
turbinates +/turbinates +/-- DNSDNS
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RFVTR of the Turbinate
Pilot StudyPilot Study Oto/HNS Oto/HNS 19981998 22 pts22 pts 382 J382 J nCPAPnCPAP LaryngoscopeLaryngoscope 20012001 21 pts 35021 pts 350--500J500J Smith et alSmith et al LaryngoscopeLaryngoscope 19991999 11 pts11 pts 450 J450 J Utley et alUtley et al LaryngoscopeLaryngoscope 19991999 10 pts 450x2J10 pts 450x2J
Anterior and Middle lesionsAnterior and Middle lesions Coste et alCoste et al LaryngoscopeLaryngoscope 20012001 14 pts 340x3J14 pts 340x3J
Upper AnteriorUpper Anterior Lower AnteriorLower Anterior MiddleMiddle
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Temperature Controlled Radiofrequency Volumetric Tissue Reduction
Turbinate Reduction
May decrease nasal Congestion
May help decrease snoring
May decrease cpap pressures
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Turbinate Reduction
Sapci et. al., Laryngoscope 2003Sapci et. al., Laryngoscope 2003 Mucociliary function with RF reduction, Mucociliary function with RF reduction,
CO2 ablation, and partial turbinectomyCO2 ablation, and partial turbinectomy RFRF effective in improving nasal obstruction effective in improving nasal obstruction
while while preserving mucociliary functionpreserving mucociliary function Partial turbinectomy had similar resultsPartial turbinectomy had similar results CO2 significantly CO2 significantly reduced mucociliary reduced mucociliary
functionfunction
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Nasal Obstruction
Deviated SeptumDeviated Septum 2020--85% of population on examination have 85% of population on examination have
a deviated nasal septuma deviated nasal septum Whether or not there is functional Whether or not there is functional
obstruction determines if treatment is obstruction determines if treatment is neededneeded
Medical vs. SurgicalMedical vs. Surgical
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Nasal Alar Rim ReconstructionAlar Structural GraftsRJ Troell, et al Oto/HNS 2000;122:204-11
79 patients79 patients 40 NVG 40 NVG 39 NARR39 NARR ResponseResponse 75%75% 94.9%94.9%
NARR NARR Irradiated rib cartilageIrradiated rib cartilage Longer, structurally stifferLonger, structurally stiffer
PA PA HilgerHilger Arch FPS 2009Arch FPS 2009 AlarAlar Rim GraftingRim Grafting
Host cartilage in inferior pocket Host cartilage in inferior pocket Support to external nasal valveSupport to external nasal valve
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Internal Valve
Schlosser and Park Schlosser and Park 1999 1999 Arch FPSArch FPS Clark and Cook Clark and Cook 2002 2002 LaryngoscopeLaryngoscope StuckerStucker et alet al 20022002 Am J RhinolAm J Rhinol StuckerStucker et alet al 20022002 Arch Oto/HNSArch Oto/HNS LeeLee and Glasgoldand Glasgold 20012001 Arch FPSArch FPS PearlmanPearlman et al et al 20042004 Arch FPSArch FPS
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Nasal Airflow Dynamics
Bernoulli PrincipleBernoulli Principle As the speed of a moving fluid (liquid or gas) As the speed of a moving fluid (liquid or gas)
increases, the pressure within decreasesincreases, the pressure within decreases
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Nasal Airflow Dynamics
PoiseuillePoiseuille’’s Laws Law Air flow is a function of the fourth power of the radiusAir flow is a function of the fourth power of the radius
Resist = k(l) / rResist = k(l) / r44
CrossCross--sectional area of the internal valve is between 55 sectional area of the internal valve is between 55 and 83 mm sqand 83 mm sq
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Internal Valve External devices used by professional External devices used by professional
athletes to alter the valve area have been athletes to alter the valve area have been shown to have objective effect on shown to have objective effect on performance*performance*
Park showed that the combination of Park showed that the combination of spreader grafts and flaring suturespreader grafts and flaring suture to be to be superior to either modality alone in superior to either modality alone in staticstaticobstructionobstruction
For For dynamicdynamic sidewall collapse, a sidewall collapse, a batten batten graftgraft at the location of collapse is at the location of collapse is recommended recommended
* Griffin JW, Laryngoscope. 1997;107:1235-8
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Nasal ObstructionTiming of Procedures
The location of the nasal obstruction determines the The location of the nasal obstruction determines the timing of the procedurestiming of the procedures
Turbinate reductionTurbinate reduction -- Temperature Controlled Temperature Controlled Radiofrequency, Office procedureRadiofrequency, Office procedurePrior to nCPAPPrior to nCPAPMay decrease nCPAP pressures, and increase May decrease nCPAP pressures, and increase
compliancecompliance
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Nasal Obstruction
Nasal procedures post Phase INasal procedures post Phase ISeptoplastySeptoplastyStructural grafts Structural grafts -- external valve reconstructionexternal valve reconstruction
Phase I surgery may alleviate the nasal Phase I surgery may alleviate the nasal obstruction by decreasing negative pressuresobstruction by decreasing negative pressures
FESSFESSAttempt to delay until OSA improvedAttempt to delay until OSA improved
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Nasal Obstruction
Nasal surgeries post Phase IINasal surgeries post Phase IIInternal Valve ReconstructionInternal Valve ReconstructionRhinoplastyRhinoplastyMMO will change the nasal MMO will change the nasal
appearanceappearanceExternal approachExternal approach
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Conclusions
Nasal obstruction plays an Nasal obstruction plays an importantimportant but but minimumminimum role in OSASrole in OSAS
Surgical corrections can help in nCPAP use Surgical corrections can help in nCPAP use and complianceand compliance
Can help subjectively in quality of sleep and Can help subjectively in quality of sleep and EDSEDS
Crucial to determine the level of nasal Crucial to determine the level of nasal obstructionobstruction
Timing of procedure is based on the Timing of procedure is based on the location of obstructionlocation of obstruction
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Thank You!