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

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

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

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

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

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

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

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

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

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

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

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??

Nasal AnatomyLocation of Obstruction

SeptumSeptum TurbinateTurbinate Internal ValveInternal Valve External ValveExternal Valve Posterior pharynxPosterior pharynx

TumorTumor

Internal Nasal Valve•Limen Vestibuli

•Main Regulator ofNasal Flow

•Ideal Angle = 10-15o

•ComponentsSeptumAnt.Inf.TurbinateULC

External Nasal Valve

Components:Components:

LLCLLCColumellaColumellaNasal FloorNasal Floor

Nasal ObstructionClinical Assessment

History and PhysicalHistory and Physical

InternalInternalAnterior rhinoscopyAnterior rhinoscopyFiberoptic examinationFiberoptic examination

The NoseClinical Assessment

ExternalExternal•• InspectionInspection•• PalpationPalpation•• Review of Review of standardized standardized photographsphotographs

Location of Obstruction

DNSDNS Internal Valve Internal Valve

CollapseCollapse RR-- StaticStatic LL-- DynamicDynamic

External Valve External Valve CollapseCollapse LL-- AlarAlar

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

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

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

Temperature Controlled Radiofrequency Volumetric Tissue Reduction

Turbinate Reduction

May decrease nasal Congestion

May help decrease snoring

May decrease cpap pressures

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

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

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

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

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

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

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

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

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

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

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

Thank You!