Surgical Treatment of Nasal Obstruction

Transcription

1 Surgical Treatment of Nasal Obstruction P. Daniel Knott, MD FACS Director, Division of Facial Plastic and Reconstructive Surgery Department of Otolaryngology/Head and Neck Surgery UCSF Medical Center Nothing to disclose Disclosure

2 Identify the problem Accurate diagnosis Treatment options Outcomes studies Plan Identifying the Problem What is nasal obstruction? Visible deformities? Patient s subjective complaint? Identified with questionnaires? Identified with in office examination? Identified with imaging tests? Identified with air flow testing?

3 Hard Core Nasal Obstruction I shall not today attempt to define the kinds of material I understand to be embraced within that shorthand description; and perhaps I could never succeed in intelligibly doing so. But I know it when I see it... Potter Stewart, Jacobellis v. Ohio, 1964 External Nasal Valve Anatomy External nasal valve Nasal vestibule Compartment caudal to INV Fibrofatty tissues of alar lobule & LLC Fascia continuous w/perichondrium and periosteum Caudal septum Piriform aperture

4 Components Internal Nasal Valve Septum Valve angle Inferior turbinate Lateral wall compliance Internal Nasal Valve Murat Cem Mı man et al. Internal Nasal Valve: Revisited With Objective Facts. Otolaryngology Head and Neck Surgery (2006) 134, 41-47

5 Patient Evaluation Office Examination External examination Photo review Anterior rhinoscopy Cottle Exam

6 Imaging Testing Objective Airflow Evaluation Acoustic Rhinometry Validated technique, but controversial Used clinically in Europe Tests minimum cross sectional area (MCA) Drawbacks Sensitivity to malpositioning Need to occlude nasal cavity during measurements

7 Objective Airflow Evaluation Rhinomanometry Validated but controversial Use of differing units of measure Nose must be decongested for study Measures nasal airflow and pressure gradients Objective Airflow Evaluation Nasal Spirometry Useful for septal deflections to one side only Establishes a ratio of airflow (nasal partitioning ratio) NPR Easy to perform Post op values may be compared to pre op. Fyrmaps et al, Value of bilateral simultaneous nasal spirometry in the assessment of patients undergoing septoplasty, Rhinology 2011.

8 Nasal Obstructive Symptoms Evaluation (NOSE) Scale Validated disease specific quality of life (QOL) assessment. Scaled from 0 to 100 Higher scores = more severe nasal obstruction Questionnaires NOSE

9 Questionnaires ROEI: Rhinoplasty Outcomes Evaluation Index Outcomes Paucity of level 1 and 2 data No consistent outcomes measures No consensus on role for surgery or which surgical techniques are best Most research driven by new technology

10 Surgical Technique External Nasal Valve Hurbis, Archives of Facial Plastic Surgery, 2008

11 Septum One of the most common operations Performed open or endoscopically Killian or hemitransfixion incision Complications Nasal tip ptosis Septal perforation Saddle nose deformity Columellar retraction Septum Need to preserve L strut Swinging door flap Extracorporeal septal reconstruction

12 Nasal Obstruction Septoplasty Effectiveness Study 59 pts 3 and 6 months after septoplasty, +/ partial turbinectomy Mean NOSE score at 3 months after septoplasty 67.5 versus 23.1, P < Pt satisfaction very high Pts used fewer nasal medications Oral decongestants (P 0.02) Nasal steroids (P 0.01) Pretreatment NOSE score Only independent predictive variable for larger improvement P Stewart MG, Smith TL, Weaver EM, et al. Outcomes after nasal septoplasty: results from the Nasal Obstruction Septoplasty Effectiveness (NOSE) study. Otolaryngol Head Neck Surg. 2004;130: Valve Angle Usually 10 15% in normals Increase the AUC Spreader grafts described by Sheen

13 Valve Angle Easiest via open approach Typically 1 to 2 mm thick Extend subperichondrially along ULC H Graft Valve Angle Widens the midvault and supports ULC Needs bed in the dorsal septum for stability Fixated to septum and ULC

14 Valve Angle H Graft surgery Valve Angle

15 Valve Angle Auto spreader graft technique Inadequate septal cartilage

16 Nasal Valve Outcomes Rhee, J et al. Nasal Valve Surgery Improves Disease Specific Quality of Life. Laryngoscope, 115: , 2005 Inferior Turbinate Assess with decongestion Surgery reserved for recalcitrant pts Multiple treatment options Office based RFA OR Cautery Submucosal bony resection Submucosal microdebrider Inferior turbinectomy Outfracture

17 Inferior Turbinate Goal is mucosal preservation Avoidance of synechial banding Most techniques also involve outfracture Inferior Turbinate Somnoturbinoplasty Needle inserted into turbinate RFA energy delivered

18 Inferior Turbinate SMR with microdebrider Rapid and effective Performed with endoscopes or headlight Needs specialized equipment Pediatric and adult blades Nerve damage, fibrosis, volumetric reduction Inferior Turbinate SMR with bony resection Removes only the head Treats the functionally significant component Avoids atrophic rhinitis

19 Inferior Turbinate Systematic review with 6 month FU 96 studies 1 level 1 and 2 level 2 evidence 93 of 96 reported symptom improvement of 50% or greater Total turbinectomy improved only 27% of patients, and 89% reported chronic dryness and crusting Batra PS, Seiden AM, Smith TL, Surgical management of adult inferior turbinate hypertrophy: A systematic review of the evidence, Laryngoscope, Lateral Nasal Wall

20 Lateral Nasal Wall Clark, JM, Cook, TA. The Butterfly Graft in Functional Secondary Rhinoplasty. Laryngoscope, 112: , 2002

21 Lateral Nasal Wall Clark, JM, Cook, TA. The Butterfly Graft in Functional Secondary Rhinoplasty. Laryngoscope, 112: , 2002 Lateral Nasal Wall Sen, C, Iscen, D. Use of the Spring Graft for Prevention of Midvault Complications in Rhinoplasty Plast. Reconstr. Surg. 119: 332, 2007.

22 Lateral Nasal Wall Implantable butterfly implant PTFE or Titanium Straight or pre bent Lateral Nasal Wall

23 Lateral Nasal Wall Lateral nasal wall suspension Bone anchored screw Not suture elevation but suspension Lateral Nasal Wall 8 patient study Underwent adjunctive procedures

24 Functional Rhinoplasty Outcomes 41 pts Post operative mean NOSE scores 58.4 vs 15.7; P.01 Linear symptom scale 7.6 vs 2.2; P.01 Most, SP. Analysis of Outcomes After Functional Rhinoplasty Using a Disease Specific Quality of Life Instrument. Arch Facial Plast Surg. 2006;8: