Obstructive sleep apnea

NASAL OBSTRUCTION FROM
ENT / FACIAL PLASTIC
SURGEON’S PERSPECTIVE
SANG W. KIM, MD
DIPLOMATE, AMERICAN ACADEMY OF OTOLARYNGOLOGY
MEMBER, AMERICAN ACADEMY OF FACIAL PLASTIC AND
RECONSTRUCTIVE SURGERY
ASSOCIATE MEMBER, INTERNATIONAL SOCIETY OF HAIR
RESTORATION SURGERY
Overview
• Anatomy of the nasal airway
• Physiology of the nasal airway
• Evaluation of nasal obstruction
o Objective measurements
o Subjective measurements
• Etiology
• Special conditions
o Aging nose
o Obstructive sleep apnea
• Management
• Case studies
External anatomy of nose
Grotting, ed. Seconadry Rhinoplasty. 1996
External anatomy of nose
Grotting, ed. Seconadry Rhinoplasty. 1996
External anatomy of nose
Grotting, ed. Seconadry Rhinoplasty. 1996
Internal anatomy of nose : Nasal septum
• Midline supportive
structure of the nose
• 5 structures of septum
o Septal cartilage
o Crest of maxillary and
palatine bones
o Perpendicular plate of
ethmoid bone
o Vomer.
Daniel RK, Mastering rhinoplasty
Internal anatomy of nose : Nasal turbinates
• Lateral wall of the
nasal cavity
Soft tissue
Ciliated respiratory
epithelium, Goblet cells, and
rich vascular bed.
Bony infolding of the
maxilloturbinal ridge
Internal anatomy of nose : Nasal turbinates
• Engorgement of mucosa / LP
• Chronic turbinate enlargement results in deposition of collage
in nasal mucosa, glandular hyperplasia, and irreversible
mucoperiosteal hypertrophy
Rohrich, Plasti Reconstr Surg. 136: 607e, 2015
Inferior turbinate
Internal anatomy of nose : Nasal turbinates
Functions
o Filtration > 30um
o Warm the incoming air 87-98.6 F
o Humidify up to 95%
Rohrich; Plast Reconstr Surg 2001
External and internal nasal valves
External nasal valves
o Caudal septum
o Strength and shape of the lower lateral cartilages
o Strength and shape of the soft tissue alae
Daniel RK, Mastering rhinoplasty
External nasal valves
o Caudal septum
o Strength and shape of the lower lateral cartilages
o Strength and shape of the soft tissue alae
Daniel RK, Mastering rhinoplasty
External nasal valves
Collapse of the nostril margin on moderate to deep
inspiration. “alar collapse”
Internal nasal valves
o Dorsal septum
o Strength and shape of the upper lateral cartilages
o Anterior head of the inferior turbinates
Daniel RK, Mastering rhinoplasty
Internal nasal valves
o Dorsal septum
o Strength and shape of the upper lateral cartilages
o Anterior head of the inferior turbinates
Daniel RK, Mastering rhinoplasty
Internal nasal valves
• Dynamic INV insufficiency :
Medialization of caudal margin of upper
lateral cartilage due to negative pressure
during inspiration
• Static INV insufficiency :
Pinching or medial collapse of the supra-alar
region at rest
Internal nasal valves
• Dynamic INV insufficiency :
Medialization of caudal margin of upper
lateral cartilage due to negative pressure
during inspiration
• Static INV insufficiency :
Pinching or medial collapse of the supra-alar
region at rest
Physiology of the nasal valves
• Static nasal valve problem
o Poiseuille’s Law
• Narrowest point within the airway will have the biggest
impact in terms of airway resistance
http://hyperphysics.phy-astr.gsu.edu/hbase/ppois2.html
Physiology of the nasal valves
• Dynamic nasal valve problem
o Bernoulli Principle and the Starling Resistor
Narrow segment → ↑ Flow velocity → ↓ Internal pressure
→ Dynamic collapse within the segment
www. physrev.physiology.org; www.premedhq.com/bernoullis-equation
Common causes for nasal airway
obstruction
Congenital
Acquired
Structural
Trauma
Iatrogenic
Aging process
Autonomic
Vasomotor rhinitis
Sexual stimulation
Emotions
Environmental
Allergic rhinitis
Dust
Tobacco
Recreational drugs
Medical
Inflammatory
Pregnancy
Hyperthyroid
Rhinitis Medicamentosa
Problematic external nasal valve
configurations
Daniel RK, Mastering rhinoplasty
Problematic internal nasal valve
configurations
Daniel RK, Mastering rhinoplasty
Clinical evaluation
•
History
Clinical evaluation
•
History
How long have you experienced these symptoms?
Are these Seasonal or Throughout the year?
Which side of the nose is more obstructed?
Do you ever get runny and itch eyes and/or nose?
Have you ever had any nasal surgery or trauma to the face?
Do you breathe through mouth during activity?
Do you snore at night?
Are you bothered by the external appearance of the nose?
Do you use nasal spray medicine?
Do you use allergy medicine? How often? How long?
Have you used Breathe-right strip?
Clinical evaluation
•
History
•
Exam – external and
internal nasal exam
Clinical evaluation
•
History
•
Exam – external and
internal nasal exam
Fung E Plast Surg Intern 2014
Clinical evaluation
•
History
•
Exam – external and
internal nasal exam
•
Nasal endoscope exam
– rule out mass, polyp,
inflammatory disease
Daniel RK, Mastering rhinoplasty; Ch6
Clinical evaluation
•
History
•
Exam – external and
internal nasal exam
•
Nasal endoscope exam
– rule out mass, polyp,
inflammatory disease
•
Topical decongestant
then reassess nasal
airway obstruction
Fung E Plast Surg Intern 2014
Clinical evaluation
•
History
•
Exam – external and
internal nasal exam
•
Nasal endoscope exam
– rule out mass, polyp,
inflammatory disease
•
Topical decongestant
then reassess nasal
airway obstruction
•
CT imaging – optional
Clinical evaluation
•
History
•
Exam – external and
internal nasal exam
•
Nasal endoscope exam
– rule out mass, polyp,
inflammatory disease
•
Topical decongestant
then reassess nasal
airway obstruction
•
Trial of medical tx and
BRS
Modified Cottle maneuver can predict
nasal valve surgery outcome.
Fung E Plast Surg Intern 2014
Objective measurement of nasal airway
Acoustic rhinometry
Measures cross-sectional area
based on impedence of sound
wave.
Mohammed Clin Exp Otorhinolaryngol 2012
Validated Quality-of-life survey
instruments
• NOSE
o Validated, reliable survey measurement instrument that evaluate nasal
obstruction as it affects QOL.
• SOS
o Evaluates duration, severity, frequency, and consequences of problem
associated with Sleep Disordered Breathing (OSA) and snoring in particular
• ESS
o Evaluates excessive daytime sleepiness
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Sino-nasal Outcome Tool (SNOT-20)
Allergy Outcome Survey (AOS)
CSS (Chronic sinusitis Survey)
Rhinosinusitis Disability Index (RSDI)
Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ)
Special considerations
• Aging nose
• Nasal airway and
obstructive sleep
apnea
Aging nose : anatomic changes
• Structural changes with the aging nose
o Downward migration of lateral crura due to weakening of scroll area
between ULC and LLC
o Weakening of suspensory ligament support
o Maxillary bone changes (widening of the pyriform aperture and maxillary
alveolar hypoplasia)
Rohrich RJ Plast Reconstr Surg 114: 1936, 2004
Aging nose : physiologic changes
• Septal abnormality and inferior turbinate enlargement
• Drooping nasal tip results in a more superior redistribution of
airflow
• Internal nasal valve collapse secondary to downward
migration and separation of upper and lower lateral cartilages
Nasal airway and obstructive sleep apnea
Connection between OSA and nasal airway
obstruction has been described in many ways
1. Starling resistor model
↑ Nasal airway resistance →
↑ negative pressure in oropharynx leading to collapse
2. Unstable oral airway proposition
3. Nasal ventilatory reflex
4. Production of NO
Nasal airway and obstructive sleep apnea
Connection between OSA and nasal airway
obstruction has been described in many ways
1. Starling resistor model
↑ Nasal airway resistance →
↑ negative pressure in oropharynx leading to collapse
2. Unstable oral airway proposition
Obligatory mouth breathing during sleep is 2.5x higher in airway
resistance than normal nasal airway
3. Nasal ventilatory reflex
4. Production of NO
Nasal airway and obstructive sleep apnea
Connection between OSA and nasal airway
obstruction has been described in many ways
1. Starling resistor model
↑ Nasal airway resistance →
↑ negative pressure in oropharynx leading to collapse
2. Unstable oral airway proposition
Obligatory mouth breathing during sleep is 2.5x higher in airway
resistance than normal nasal airway
3. Nasal ventilatory reflex
∆Nasal receptor modulates muscle tone, breathing frequency, and minute
ventilation
4. Production of NO
Meta-analysis – Does nasal airway
surgery help patients with obstructive
sleep apnea?
54 articles  2 RTC, 7 Prospective, 1 Retrospective studies
Nasal surgery improves Epworth Sleepiness score (ESS), and
Respiratory disturbance index (RDI), but not Apnea-hypopnea index (AHI)
Meta-analysis – Does nasal airway
surgery help patients with obstructive
sleep apnea?
Functional septorhinoplasty improves
PSG score in non-obese, OSA patients
26 consecutive adult patient with BMI < 30
AHI improved 57%
(22.5 > 9.6)
NOSE score improved 63%
(92 >34)
Surgical treatment
• Opening maneuver
• Strengthening maneuver
Conde Nast Collection
Surgical treatment algorithm
Case 1: Primary functional rhinoplasty
Case 1: Primary functional rhinoplasty
Open approach – exposing nasal
structures
Open approach - exposure of dorsal
septum
Open approach - deviated dorsal septum
Case 1: Primary functional rhinoplasty
Plan:
1. Straighten the dorsal septum
2. Reduce the inferior turbinates
3. Widen internal nasal valve angle
Septoplasty
• First described in 1882 by Ingals,
later modified by Freer in 1902
and Killian in 1904.
• Indication for septoplasty
o Obstruction from deviated septum
o Improve access for surgery
o Autologous donor for cartilage
Septoplasty
• Technique
o Submucous resection
o Altering cartilage through Crosshatching, vertical and horizontal strip
excision
o Swing door
o Dorsal septum resection for tension
nose
o Extracorporeal septoplasty +/Replacement with PDS plate
Persistent nasal obstruction after
septoplasty
Success rate of septoplasty ranges between 43-85% based on subjective
survey and objective acoustic rhinometry studies (Chambers; JAMA
Facial Plastic 2015)
51% of revision septoplasty underwent nasal valve repair procedure
(Becker; Am J Rhinol 2008)
Why is nasal valve repair not considered during initial surgery?
o Simply overlooked by otolaryngologyst “uncertainty and unease
of sorts in defining the nasal valve component regions” (Wexler
Am J Rhinol 2004)
o Septal deviation was masking the underlying nasal valve
insufficiency
o Aging process and resultant weakening of cartilage and ligament
– delayed nasal valve insufficiency over time.
Prospective study; N=40
NOSE score 83 > 30 after nasal
valve repair
Spreader grafts for internal nasal valve
Septal cartilage is used to create spreader
grafts
While septal cartilage is ideal, auricular
cartilage can be used.
Arch Facial Plast Surg. 2004;6(1):36-40. doi:10.1001/archfaci.6.1.36
Spreader graft widens the internal nasal valve area, while strengthening
and straightening the middle vault of the nose.
Flair Suture Technique further
opens the nasal valve
Schlosser, Park; Arch Facial Plast Surg 1999
Schlosser, Park; Arch Facial Plast Surg 1999
Case 2: Revision functional rhinoplasty
Unilateral spreader graft (Right), Alar batten graft (Right), Septal
Cartilage harvest, inferior turbinate reduction
Case 2: Revision functional rhinoplasty
Unilateral spreader graft (Right), Alar batten graft (Right), Septal
Cartilage harvest, inferior turbinate reduction
Case 2: Revision functional rhinoplasty
Alar Batten Graft
Toriumi D Arch Otolaryngol Head Neck Surg 1997
Case 2: Revision functional rhinoplasty
Buckled lower cartilage, inward collapsed upper lateral cartilage
Unilateral spreader graft (Right), Alar batten graft (Right), Septal
Cartilage harvest, inferior turbinate reduction
Case 2: Revision functional rhinoplasty
Case 3: Revision functional rhinoplasty
Case 3: Butterfly graft, unilateral
spreader, tip graft
Case 3: Butterfly graft, unilateral
spreader, tip graft
Case 4: Septoplasty with valve
repair using alar batten grafts
Louis Henry Sullivan
1856-1924
Father of modernism and
American architecture
It is the pervading law of all things organic and inorganic, of all things physical
and metaphysical, of all things human, and all things super-human, of all true
manifestations of the head, of the heart, of the soul, that the life is recognizable in
its expression, that form ever follows function. This is the law.
Key points
•
Form follows function. If the nose has external deformity, it may have internal
dysfunction.
•
Careful history and examination will help identify patients with nasal obstruction
•
Nasal valve is a site where up to 50% of upper airway resistance can take place
•
There are two distinct nasal valves (internal and external) and the problem may be
static at rest and/or dynamic during inspiration.
•
For patients with OSA, nasal airway should be carefully assessed. If indicated, they
will benefit from surgical repair.
•
Traditional septoplasty and turbinate reduction may not be adequate treatment
for some patients presenting with nasal valve dysfunction.
•
Goal of functional rhinoplasty is to open and strengthen the dysfunctional nasal
valve.
Thank you
Sang W Kim, MD
Syracuse Facial Plastic and Cosmetic Surgery
CNY Family Care Building
4939 Brittonfield Pkwy East Syracuse NY 13057
Office: 315-471-8404
Cell: 315-400-2555
SangKim@NaturalFaceCenters.com
www.NaturalFaceCenters.com
References
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Rohrich et al, Rhinoplasty with advancing age. Plast Reconstr Surg 2004
Becker et al, Revision septoplasty: review of sources of persistent nasal obstruction. Am J Rhinol 2008
Karlsson et al, Septoplasty with concomitant inferior turbinate reduction reduces the need for revision procedure. Rhinol 2015
Erickson et al, Acoustic rhinometry and video endoscopic scoring to evaluate post operative outcomes in endonasal
spreader graft surgery with septoplasty and turbinoplasty for nasal valve collapse. Otolaryngol Head Neck 2016
Leitzen, et al. Correlation between nasal anatomy and objective obstructive sleep apnea severity. Otolaryngol Head Neck
2014
Lindsay RW. Disease-specific quality of life outcomes in functional rhinoplasty. Laryngoscope 2012
Chambers et al. Evaluation of improvement in nasal obstruction following nasal valve correction in patients with history of
failed septoplasty JAMA Facial Plastic Surg 2015
Ishii et al. Does nasal surgery improve OSA in patients with nasal obstruction and OSA? A meta-analysis Otolaryngol Head
Neck Surg 2015
Fung et al, Effectiveness of modified cottle maneuver in predicting outcomes in functional rhinoplasty. Plastic Surg Intern 2014
Lee J, Constantinides M. Trends in functional rhinoplasty 2008. Current Op Otolaryngol Head Neck Surg 2009
Simon P, Sidle D. Augmenting the nasal airway: beyond septoplasty. Am J Rhinol Allergy 2012
Lee, MK, Most SP. Evidence-based medicine rhinoplasty. Facial Plast Surg Clin N Am 2015
Shuaib et al. Can functional septorhinoplasty independently treat obstructive sleep apnea? Plast Reconstr Surg 2015
Gillman et al. Revision septoplasty: a prospective disease-specific outcome study. Laryngoscope 2013
Beck DO, Kenkel JM. Evidence based medicine Rhinoplasty. Plast Reconstr Surg 2014
Stewart et al. Development and validation of the nasal obstruction symptom evaluation scale Otolaryngol head Neck Surg
2004
Rohrich et al. Closed microfracture technique for surgical correction of inferior turbinate hypertrophy in rhinoplasty: safety
and technical consideration Plast Reconstr Surg 2015
Angelos et al. Contemporary review of rhinoplasty. Arch Facial Plast Surg 2012
Toriumi et al. Use of alar batten grafts for correction of nasal valve collapse. Arch Otolaryngol head Neck Surg 1997
Rohrich et al. Rationale for submucous resection of hypertrophied inferior turbinates in rhionplasty: an evolution. Plast
Reconstr Surg 2001