Obstructive sleep apnea
Transcription
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 • • • • • 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 [email protected] www.NaturalFaceCenters.com References • • • • • • • • • • • • • • • • • • • • 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
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