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

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 Sound Health Care System, Seattle, Washington. • Dr. Weaver is a staff physician, surgery service line, Dept of Veterans Affairs Medical Center, Seattle, Washington.

Disclosures • No industry disclosures • No off label therapies

Notes • Adults • Split audience: – Otolaryngologists – Others

Topics • Significance of nasal obstruction and treatment in OSA • Nasal evaluations, findings, therapies

Upper Airway Anatomy

Nasal Obstruction à Mouth Opening à

Nasal Obstruction & CPAP Use Nasal obstruction â CPAP use. Nasal treatment á CPAP use.

r = 0.34 CPAP Use p < 0.01 (hrs/nt) Nasal Minimum Cross-sectional Area (cm 2 ) Figure 5 Li, Sleep 2005; 28:1554-9

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 *Beware All p<0.001 Camacho, Sleep 2015; 38:279-86

Topics • Significance of nasal obstruction and treatment in SDB • Nasal evaluations, findings, therapies

1. Subjective

Subjective Instruments • Nasal Obstruction Symptom Evaluation (NOSE) Scale • Nasal Obstruction VAS Stewart, OtoHNS 2004; 130:157-63 Stewart, OtoHNS 2004; 130:283-90

2. Nasal Valve

Nasal Valve • Point of greatest resistance – Regulates airflow – Valve disorders important

Nasal Valve Upper lateral cartilage Septum Turbinate

Rhee, OtoHNS 2010; 143:48-59

Nasal Valve Collapse

Cottle Test

Nasal Pillows

Nasal Dilator Strip

Nasal Dilator Insert

Nasal Medication • Treat intranasal congestion • ↑ nasal caliber → ↓ neg force – Bernoulli’s Law • Indirect effect on valve collapse

Otolaryngology Consultation • Nasal airway evaluation • Surgery evaluation

3. Nasal Cavity

Nasal Cavity Exam • Speculum & headlight • Septum • Turbinates* • Allergy* • Polyps* *Medically treatable (partial)

Nasal Valve Septum

Septum Treatment • Surgical: Septoplasty

Pre-Op Post-Op Septoplasty

Valve Turbinate

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

Turbinate Reduction

Turbinate Reduction

Poiseuille’s Law Radius 4 Flow = ———— x η Length

Allergy Treatment • Allergen avoidance • Nasal saline • Medications: – Nasal steroid – Oral anti-histamine – Nasal anti-histamine – Nasal leukotriene modifiers • Desensitization therapy

Polyp Treatment • Allergy treatment • Oral steroid • Surgery: – Endoscopic Polypectomy

4. Nasal Structure

Nasal Deformity Treatment • Surgical

Columellar Reduction Pre-Op

Columellar Reduction Post-Op

Men 22 ± 2 mm Women 21 ± 2 mm Erdem, Am J Rhinol 2004; 18:57-62

Aperture Widening

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

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

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.