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Nasal Valve Obstruction

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

Disclosures

• Financial- none • Off-label-none

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

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

Nasal Valve Areas

Gunter,et al- Dallas Rhinoplasty, Vol I

Support Mechanisms

• Major -Lower lateral cartilage

strength -Upper lateral cartilage

attachment [scroll] -Medial crural footplate-

septal • 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

Nasal Obstruction Diagnosis

• History- onset ? fixed ? supine ? • Exam- external deviation? external

collapse? Cottle maneuver? • Exam- internal: septum, turbinates,

valve • Response to Oxymetazoline?

NVC Diagnosis

NVC Diagnosis

Cummings: Otolaryngology—Head and Neck

Surgery, 4th edition. Loop cerumen curette used to displace nasal valve

Non-surgical treatment of NVC

• Dilator strips • Intranasal stents • Filler injections • Radiofrequency lesion of lateral

nasal sidewall

Nasal Obstruction Non Surgical Tx

• Ulfberg and Fenton: Rhinology 1997 • 35 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

Breathe-Right

• Work best in patients with thin skin and flexible nasal sidewall

Nasal Obstruction Non Surgical Tx

• MaClean HA Eur Resp J. 2005;25:521-527

• 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 MaClean HA et al. Effect of Treating Severe

Nasal Obstruction on the Severity of Obstructive Sleep Apnea. Eur Resp J. 2005;25:521-527

Nasal Obstruction Non Surgical Tx

• MaClean HA Eur Resp J. 2005;25:521-527

• 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%

• Concluded that Tx of nasal obstruction improved sleep but did not cure OSA

MaClean HA et al. Effect of Treating Severe Nasal Obstruction on the Severity of Obstructive Sleep Apnea. Eur Resp J. 2005;25:521-527

Intranasal stents

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

Valve collapse-Spreader Grafts

Gunter,et al- Dallas Rhinoplasty, Vol I

Nasal Vault - Narrow Middle Third

Spreader Grafts

Adamson- Operative Tech in Otol

Inverted V Deformity

• Short Nasal Bones

• Over-resection • Collapse of vault

Autospreader Grafts • Dorsal septum reduced • Upper lateral preserved and scored,

then turned in and sutured • Avoids graft harvest

Most, S JAMA FPS July 2011 Wurm, J FPS Dec 2013

Combined with suturing techniques

• Wurm et al FPS Dec 2013- A New Classification of Spreader Flap Techniques

Flaring Sutures

• Placement varies

• Can be used with other techniques such as spreader grafts

Batten Graft- Internal valve

Gunter,et al- Dallas Rhinoplasty, Vol I

Batten Grafts Success • Sufyan etal. JAMA FPS May 2013 • 126 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

Batten Graft- External valve

Gunter,et al- Dallas Rhinoplasty, Vol I

Alar rim grafts

Boahene and Hilger Arch FPS 2009 (11)

Butterfly Graft

Stacey et al. Ann Plast Surg 2009;63: 280–284)

• Stacey et al: at least as good as spreader grafts

• Does lead to some supratip fullness

Nasal Valve Collapse-Tx

• Implants

Paradoxical curvature- turnover graft

Behrbohm,Tardy- Essentials of Septorhinoplasty

Nasal Valve Suspension Sutures

• Paniello described ’96

• Tends to cut through over time and lose effectiveness

• Helpful in facial paralysis patients

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.

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 2008 139: 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.

Clinical consensus statement: Diagnosis and management of nasal valve compromise

Otolaryngology–Head and Neck Surgery (2010) 143, 48-59 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

Coding • 30465- Surgical Repair of Vestibular Stenosis MCR Allowable = 919 $

• 30420- Rhinoplasty with Major Septal Repair MCR Allowable = 1280 $

• 20912- Harvest Cartilage Graft from Septum MCR Allowable = 453 $

• 21235- Harvest Cartilage Graft from Ear MCR Allowable = 534 $

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

Nasal Valve Obstruction

QUESTIONS?

Nasal Valve Obstruction

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