The Nose in OSA Soup to Nuts Edward M. Weaver, MD, MPH University - - PowerPoint PPT Presentation

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The Nose in OSA Soup to Nuts Edward M. Weaver, MD, MPH University - - PowerPoint PPT Presentation

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The Nose in OSA Soup to Nuts Edward M. Weaver, MD, MPH University of Washington Harborview Medical Center Seattle VA Medical Center Acknowledgments This material is the result of work supported in part by resources from the VA Puget

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The Nose in OSA – Soup to Nuts

Edward M. Weaver, MD, MPH

University of Washington Harborview Medical Center Seattle VA Medical Center

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Acknowledgments

  • This material is the result of work supported in

part by resources from the VA Puget Sound Health Care System, Seattle, Washington.

  • Dr. Weaver is a staff physician, surgery service

line, Dept of Veterans Affairs Medical Center, Seattle, Washington.

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Disclosures

  • No industry disclosures
  • No off label therapies
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Notes

  • Adults
  • Split audience:

– Otolaryngologists – Others

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Topics

  • Significance of nasal obstruction and

treatment in OSA

  • Nasal evaluations, findings, therapies
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Upper Airway Anatomy

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Nasal Obstruction à Mouth Opening à

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Nasal Obstruction & CPAP Use

Nasal obstruction â CPAP use. Nasal treatment á CPAP use.

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r = 0.34 p < 0.01

Figure 5 Nasal Minimum Cross-sectional Area (cm2)

CPAP Use (hrs/nt)

Li, Sleep 2005; 28:1554-9

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Camacho, Sleep 2015; 38:279-86

Outcome Pre-Nasal Post-Nasal Pressure (cm) 11.6 ± 2.2 9.5 ± 2.0 Acceptance 39% 90% Use (hr/nt) 3.0 ± 3.1 5.5 ± 2.0 All p<0.001 *Beware *

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Topics

  • Significance of nasal obstruction and

treatment in SDB

  • Nasal evaluations, findings, therapies
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  • 1. Subjective
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Subjective Instruments

  • Nasal Obstruction Symptom

Evaluation (NOSE) Scale

  • Nasal Obstruction VAS

Stewart, OtoHNS 2004; 130:157-63 Stewart, OtoHNS 2004; 130:283-90

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  • 2. Nasal Valve
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  • Point of greatest resistance

– Regulates airflow – Valve disorders important

Nasal Valve

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Nasal Valve

Septum Turbinate Upper lateral cartilage

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Rhee, OtoHNS 2010; 143:48-59

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Nasal Valve Collapse

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Cottle Test

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Nasal Pillows

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Nasal Dilator Strip

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Nasal Dilator Insert

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Nasal Medication

  • Treat intranasal congestion
  • ↑ nasal caliber → ↓ neg force

– Bernoulli’s Law

  • Indirect effect on valve collapse
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Otolaryngology Consultation

  • Nasal airway evaluation
  • Surgery evaluation
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  • 3. Nasal Cavity
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Nasal Cavity Exam

  • Speculum & headlight
  • Septum
  • Turbinates*
  • Allergy*
  • Polyps*

*Medically treatable (partial)

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Nasal Valve Septum

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Septum Treatment

  • Surgical: Septoplasty
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Pre-Op Post-Op Septoplasty

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Turbinate Valve

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Turbinate Treatment

  • Irritant avoidance
  • Elevate head of bed
  • CPAP heated humidity
  • Nasal saline
  • Medications:

– Nasal steroid – Anti-histamine – Oral decongestant – Nasal decongestant

  • Surgery: Turbinate reduction
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Turbinate Reduction

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Turbinate Reduction

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Poiseuille’s Law

Radius4

Flow = ———— x η Length

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Allergy Treatment

  • Allergen avoidance
  • Nasal saline
  • Medications:

– Nasal steroid – Oral anti-histamine – Nasal anti-histamine – Nasal leukotriene modifiers

  • Desensitization therapy
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Polyp Treatment

  • Allergy treatment
  • Oral steroid
  • Surgery:

– Endoscopic Polypectomy

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  • 4. Nasal Structure
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Nasal Deformity Treatment

  • Surgical
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Columellar Reduction

Pre-Op

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Columellar Reduction

Post-Op

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Men 22 ± 2 mm Women 21 ± 2 mm

Erdem, Am J Rhinol 2004; 18:57-62

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Aperture Widening

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Weaver, Op Tech Oto 2012; 23:67-71

Nasal Valve Stabilization

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Topics

  • Nasal airway significant
  • Nasal evaluation

– Everyone can do basic evaluation – Otolaryngology for advanced eval

  • Nasal therapy

– Medications safe & available – Often helpful – Surgical treatment backup

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The Nose and OSA – Soup to Nuts

REFERENCES 1. Lee SH, Choi JH, Shin C, Lee HM, Kwon SY, Lee SH. How does open-mouth breathing influence upper airway anatomy? Laryngoscope 2007;117(6):1102-6. 2. Li HY, Engleman H, Hsu CY, et al. Acoustic reflection for nasal airway measurement in patients with obstructive sleep apnea- hypopnea syndrome. Sleep 2005;28(12):1554-9. 3. Camacho M, Riaz M, Capasso R, et al. The effect of nasal surgery on continuous positive airway pressure device use and therapeutic treatment pressures: A systematic review and meta-analysis. Sleep 2015;38(2):279-86. 4. Stewart MG, Witsell DL, Smith TL, Weaver EM, Yueh B, Hannley MT. Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) Scale. Otolaryngology-Head & Neck Surgery 2004;130(2):157-63. 5. Stewart MG, Smith TL, Weaver EM, et al. Outcomes after nasal septoplasty: Results from the Nasal Obstruction Septoplasty Effectiveness (NOSE) study. Otolaryngol Head Neck Surg 2004;130(3):283-90. 6. Rhee JS, Weaver EM, Park SS, et al. Clinical consensus statement: Diagnosis and management of nasal valve compromise. Otolaryngol Head Neck Surg 2010;143:48-59. 7. Erdem T, Ozturan O, Erdem G, Akarcay M, Miman MC. Nasal pyriform aperture stenosis in adults. Am J Rhinol 2004;18(1):57-62. 8. Weaver EM. Nasal valve stabilization. Operative Techniques in Oto 2012;23:67-71.