Nasal Valve Obstruction

Transcription

1 Nasal Valve Obstruction J RANDALL JORDAN, MD, FACS Facial Plastic Surgery Department of Otolaryngology and Communicative Disorders University of Mississippi Medical School

2 Disclosures Financial- none Off-label-none

3 Nasal Physiology Nasal airway is a resistor, responsible for 2/3 of airway resistance during wakefulness Internal nasal valve primary area of resistance, about 30% of cross sectional area at nares Bernoulli effect leads to greater negative pressure at nasal valve and greater collapse

4 Nasal Physiology Nasal mm provide some dilation and synchronize w respiration but role during sleep is likely limited Nasal resistance is position dependent and increases when supine Nasal cycle more pronounced supine Pressure on shoulder/hip causes ipsilateral congestion and contralateral decongestion

5 Nasal Valve Areas Gunter,et al- Dallas Rhinoplasty, Vol I

6 Support Mechanisms Major -Lower lateral cartilage strength -Upper lateral cartilage attachment [scroll] -Medial crural footplateseptal Minor -Dorsal Septum -Tip ligaments -Sesamoid-pyriform attachments -Nasal spine -Skin/soft tissue -Membranous septum Tardy E. Rhinoplasty- the art and the science;vol I p118

7 Nasal Obstruction Diagnosis History- onset? fixed? supine? Exam- external deviation? external collapse? Cottle maneuver? Exam- internal: septum, turbinates, valve Response to Oxymetazoline?

8 NVC Diagnosis

9 NVC Diagnosis Cummings: Otolaryngology Head and Neck Surgery, 4th edition. Loop cerumen curette used to displace nasal valve

10 Non-surgical treatment of NVC Dilator strips Intranasal stents Filler injections Radiofrequency lesion of lateral nasal sidewall

11 Nasal Obstruction Non Surgical Tx Ulfberg and Fenton: Rhinology pts, AHI <5, M,F, primary snorers, nasal obstruction Survey by bed-partner re: snoring ESS Significant decrease in snoring, dry mouth and ESS score after Breathe Right use

12 Breathe-Right Work best in patients with thin skin and flexible nasal sidewall

13 Nasal Obstruction Non Surgical Tx MaClean HA Eur Resp J. 2005;25: MaClean HA et al. Effect of Treating Severe Nasal Obstruction on the Severity of Obstructive Sleep Apnea. Eur Resp J. 2005;25: Randomised single blind placebo and sham controlled crossover study 10 patients with OSA and nasal obstruction (turbinate hypertrophy documented by exam) PSG, both oxymetazoline nose spray and Breathe Right strip vs saline and tape (sham) Posterior active rhinomanometry upright and supine

14 Nasal Obstruction Non Surgical Tx MaClean HA Eur Resp J. 2005;25: Nasal Resistance decreased profoundly with active Tx Oral fraction of inhaled ventilation decreased from 39 to 8 with active Tx AHI decreased by an average of 12 points, but only 1 fell below 15 Sleep architecture improved with REM % moving from 9% to 16% MaClean HA et al. Effect of Treating Severe Nasal Obstruction on the Severity of Obstructive Sleep Apnea. Eur Resp J. 2005;25: Concluded that Tx of nasal obstruction improved sleep but did not cure OSA

15 Intranasal stents

16 Surgical interventions for nasal valve collapse Spreader grafts Autospreader flaps Crural turnover Batten grafts Lateral crural strut grafts Butterfly grafts Porous polyethylene implants (various) Suture suspension Crural flaps Crural repositioning (Alar stent) Cephalic turn-in flaps Intranasal Z plasty Alar rim grafts

17 Valve collapse-spreader Grafts Gunter,et al- Dallas Rhinoplasty, Vol I

18 Nasal Vault - Narrow Middle Third

19 Spreader Grafts Adamson- Operative Tech in Otol

20 Inverted V Deformity Short Nasal Bones Over-resection Collapse of vault

21 Autospreader Grafts Dorsal septum reduced Upper lateral preserved and scored, then turned in and sutured Avoids graft harvest Wurm, J FPS Dec 2013 Most, S JAMA FPS July 2011

22 Combined with suturing techniques Wurm et al FPS Dec A New Classification of Spreader Flap Techniques

23 Flaring Sutures Placement varies Can be used with other techniques such as spreader grafts

24 Batten Graft- Internal valve Gunter,et al- Dallas Rhinoplasty, Vol I

25 Batten Grafts Success Sufyan etal. JAMA FPS May pts with NAO Tx with Alar Batten Graft s etc NOSE survey 97% reported significant improvement at 1 year Only 8/126 (6%) restarted nasal steroids postop

26 Batten Graft- External valve Gunter,et al- Dallas Rhinoplasty, Vol I

27 Alar rim grafts Boahene and Hilger Arch FPS 2009 (11)

28 Butterfly Graft Stacey et al: at least as good as spreader grafts Does lead to some supratip fullness Stacey et al. Ann Plast Surg 2009;63: )

29 Nasal Valve Collapse-Tx Implants

30 Paradoxical curvature- turnover graft Behrbohm,Tardy- Essentials of Septorhinoplasty

31 Nasal Valve Suspension Sutures Paniello described 96 Tends to cut through over time and lose effectiveness Helpful in facial paralysis patients

32 How do you know if it works? Zoumalan et al. Intraoperative Suction - Suction Assisted Evaluation of the Nasal Valve in Rhinoplasty. Arch Facial Plast Surg. 2012;14(1):34-38 Measured displacement of point of maximum depression before and after surgical tx.

33 Does it work? John S. Rhee, Jill M. Arganbright, Brian T. McMullin and Maureen Hannley Evidence supporting functional rhinoplasty or nasal valve repair: A 25-year systematic review. Otolaryngology -- Head and Neck Surgery : 10 CONCLUSION There is substantial level 4 evidence to support the efficacy of modern-day rhinoplasty techniques for treatment of nasal obstruction due to nasal valve collapse. More recent studies have incorporated validated patient-reported outcome measures, with more rigorous statistical analysis. Future study design improvements include the use of comparison cohorts and incorporation of standardized objective outcome measures.

34 Clinical consensus statement: Diagnosis and management of nasal valve compromise Otolaryngology Head and Neck Surgery (2010) 143, John S. Rhee, MD, MPH, Edward M. Weaver, MD, MPH, Stephen S. Park, MD, Shan R. Baker, MD, Peter A. Hilger, MD, J. David Kriet, MD, Craig Murakami, MD, Brent A. Senior, MD, Richard M. Rosenfeld, MD, MPH, and Danielle DiVittorio, NVC is a distinct clinical entity NVC can be caused by: Alar or sidewall collapse, septal deviation, columellar deformity, turbinate hypertrophy, ptotic nasal tip Dx is by exam and Cottle type maneuvers and response to strips- adjunctive tests such as radiographs, rhinomanometry etc were not helpful, but photography is helpful for documentation of deformities and endoscopy may be helpful to rule out other causes. Treatment is surgical QOL measures such as NOSE are valid indicators of patient reported success Coding and billing is confusing

35 Coding Surgical Repair of Vestibular Stenosis MCR Allowable = 919 $ Rhinoplasty with Major Septal Repair MCR Allowable = 1280 $ Harvest Cartilage Graft from Septum MCR Allowable = 453 $ Harvest Cartilage Graft from Ear MCR Allowable = 534 $

36 Conclusions NVC is common and treatable by both non-surgical and surgical means There is evidence to support the efficacy of a variety of functional rhinoplasty procedures in the treatment of NVC

37 Nasal Valve Obstruction QUESTIONS?

38 Nasal Valve Obstruction J RANDALL JORDAN, MD, FACS Facial Plastic Surgery Department of Otolaryngology and Communicative Disorders University of Mississippi Medical School