Extracorporeal septoplasty- correcting the difficult septal deformity

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 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
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;25:521527
• 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;25:521527
• 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;25:521-527
• Concluded that Tx of nasal obstruction
improved sleep but did not cure OSA
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: at least as
good as spreader grafts
• Does lead to some
supratip fullness
Stacey et al. Ann Plast Surg 2009;63: 280–284)
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