Is Computed Tomography Imaging of Deviated Nasal Septum Justified for Obstruction Confirmation?

Third-party payers request objective confirmation of the nasal septum deviation (NSD) severity by computed tomography (CT) before authorizing financial support for septoplasty. Previous studies have provided contradictory results related to the link between obstruction severity and CT-measured angle of the NSD. The aim of this study was to investigate whether the diverse CT morphology of NSDs (including previously neglected types and shapes) could predict obstruction severity. The study included 225 patients with NSD. The CT morphology of the septum was analyzed using 5 different classifications of NSD that are commonly used in the clinical practice and research. The angle of NSD was also measured. Nasal obstruction was assessed by the Nasal Obstruction Symptom Evaluation (NOSE) questionnaire. A relationship between CT morphology and the angle of the NSD and NOSE scores was analyzed using appropriate regression models. Patients with NSDs located in the anterior part of the septum always have some degree of nasal obstruction, while those with posterior NSDs did not necessarily report obstruction symptoms no matter how complicated NSD they have. Regression analysis did not reveal any causal relationship between NOSE scores and CT morphology and the angle of NSD. The presence of spurs and whether they divide nasal passages have no statistically significant predictive effect on the obstruction severity. The CT morphology and the angle of the NSD could not predict severity of the nasal obstruction. Requesting CT examination just to objectively confirm nasal obstruction is not justified.

The relationship between the Ottawa Valve Collapse Scale (OVCS) and clinical outcomes in septoplasty patients.

The Ottawa Valve Collapse scale (OVCS) was developed to classify the severity of nasal valve collapse (NVC) in patients with nasal obstruction. The goal of this study was to determine, in patients who have nasal obstruction due to a septal deviation, whether those with a higher OVCS grade will have a reduced improvement in patient-centered clinical outcomes at one-year following septoplasty with inferior turbinate diathermy compared to those with a normal or lower OVCS grade. This study was a prospective study of 78 patients who completed an assessment using the NOSE questionnaire before and at one-year following the surgical intervention. A repeated-measures ANOVA was used to asses for differences in scores between OVCS groups. There was a significant improvement in NOSE scores one year post-septoplasty (p < 0.01). There was no difference in NOSE score improvement when comparing the grades of the OVCS at one-year (F = 0.09, p = 0.968). Though the OVCS was designed to categorize the severity of NVC preoperatively, there is no evidence that it is helpful in predicting which patients will demonstrate poor results following septoplasty. Future studies are required to further evaluate the OVCS and whether complimentary assessments will improve its clinical utility.

Aclaración sobre la evaluación de la obstrucción nasal mediante rinomanometría y escalas subjetivas y medición del éxito terapéutico médico y quirúrgico / Comments on the assessment of nasal obstruction with rhinomanometry and subjective scales and outcomes of surgical and medical treatment

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Nasal Base Retraction: A Treatment Algorithm.

BACKGROUND: Nasal base retraction results from cephalic malposition of the alar base in the vertical plane, which causes disharmony of the alar base with the rest of the nose structures. Correcting nasal base retraction is very important for improved aesthetic outcomes; however, there is a limited body of literature about this deformity and its treatment. OBJECTIVES: Create a nasal base retraction treatment algorithm based on a severity classification system. METHODS: This is a retrospective case review study of 53 patients who underwent rhinoplasty with correction of alar base retraction by the senior author (S.T.). The minimum follow-up time was 6 months. Levator labii alaque nasi muscle dissection or alar base release with or without a rim graft on the effected side were performed based on the severity of the alar base retraction. Aesthetic results were assessed with objective grading of preoperative and postoperative patient photographs by two independent plastic surgeons. Functional improvement was assessed with patient self-evaluations of nasal patency. Also, a rhinoplasty outcomes evaluation (ROE) questionnaire was distributed to patients. RESULTS: Comparison of preoperative and postoperative photographs demonstrated that nasal base asymmetry was significantly improved in all cases, and 85% of the patients had complete symmetry. Nasal obstruction was also significantly reduced after surgery (P < 0.001). The majority of patients reported satisfaction (92.5%), with an ROE total score greater than or equal to 20. CONCLUSIONS: New techniques and a treatment algorithm for correcting nasal base retraction deformities that will help rhinoplasty surgeons obtain aesthetically and functionally pleasing outcomes for patients.

The Significance of Rhinologic Evaluation and Pretreatment for Patients Undergoing Two-Jaw Surgery Through Nasotracheal Intubation.

The aim of this study is to determine whether rhinologic preoperative evaluation and pretreatments reduce intranasal trauma and decrease postoperative complications, such as nasal obstruction and epistaxis, in patients undergoing 2-jaw surgery with nasotracheal intubation. This study included 360 patients with malocclusion (Class III) who underwent 2-jaw surgery under general anesthesia via nasotracheal intubation in our hospital from January to December 2013 and categorized into 3 groups. Nasotracheal intubation was performed according to the nasal cavity the patient was able to breathe comfortably (Group I). The site of nasotracheal intubation was decided by 1 rhinologic specialist who evaluated preoperative dental computed tomography (Group II). The site of nasotracheal intubation was decided upon nasal endoscopic findings, dental computed tomography evaluation, and rhinologic pretreatment (Group III).Group II and Group III showed less damage to the nasal mucosa compared with the nasal status of Group I. Upon comparing Group II and Group III, Group III showed better overall status of the nasal mucosa compared with Group II. Visual analogue scale scores for nasal obstruction were pretty similar for all groups on the first postoperative day. In Group III, the nasal mucosa, however, was improved to that of preoperative status on the third postoperative day.In conclusion, it may be useful to pre-evaluate the mucosal and anatomical status of the nasal cavity to select patients requiring rhinologic pretreatment and decide the site for nasotracheal intubation to minimize complications arising from nasotracheal intubation.

Pack free septoplasty: functional outcomes and complications.

OBJECTIVES: This study aims to evaluate the functional outcomes and complications of pack free septoplasty in adults. PATIENTS AND METHODS: Forty-nine consecutive patients (35 males, 14 females; mean age 37.7 years; range 18 to 63 years) who underwent septoplasty in our clinic between January 2011 and June 2013 were prospectively included in the study. Preoperative nasal obstruction was scored using the Nasal Obstruction Symptom Evaluation (NOSE). Nasal obstruction was reevaluated in the first and the third postoperative months. Postoperative complications were recorded. Pre- and postoperative NOSE scores were compared. RESULTS: Recovery rate was 81.63%. There was a statistically significant difference between preoperative NOSE scores and postoperative first and third-month NOSE scores (p<0.05). We observed minor hemorrhage in 17 patients (34.7%), nasal synechiae in three patients (6.1%), and flap overposition in two patients (4.1%). CONCLUSION: Pack free septoplasty performed with transseptal suture technique is effective in the treatment of septum deviation and may be performed confidently in septum surgery.

Comparison of Clinical Results in Nasal Tip Augmentation Either Via Face to Face or Back to Back Technique With Autogenous Auricular Conchal Cartilage.

OBJECTIVE: To compare the objective and subjective findings between patients who underwent nasal tip augmentation surgery via two different methods using autogenous auricular conchal cartilage. MATERIALS AND METHODS: This study included the data of 21 patients who underwent nasal tip augmentation surgery. The patients were randomly divided in two groups according to the technique used to form a double layer columellar strut graft; either face to face (group 1) and back to back (group 2). All patients were assessed via nasal obstruction symptom evaluation scale (NOSE) and via acoustic rhinometry and rhinomanometry at preoperative and postoperative 1st and 6th months. RESULTS: There was statistically significant improvement in symptom score in both patient groups with no difference inbetween. Total nasal resistance decreased nonsignificantly at the end of 6th month in both groups; 13.1 Pa/cm3 to 8.6 Pa/cm3 and 10.3 Pa/cm3 to 9.5 Pa/cm3 respectively. There was no significant increment in MCA values for both groups except left MCA1. CONCLUSIONS: We achieved good results in tip augmentation via both techniques. An autogenous conchal cartilage is a good alternative to replace lacking caudal septal cartilage. It provides safe and stable support to the nasal tip. However, further comprehensive studies with larger sample size and long follow-up are required to elucidate any difference between these two techniques.

External Nasal Valve Efficacy Index: a simple test to evaluate the external nasal valve.

Many methods and techniques have been proposed for the assessment of the nasal valve, most requiring special equipment. Furthermore the main focus has been on the internal valve, while the role of the external nasal valve (ENV) has usually been underestimated. An index to assess ENV is presented herein. Two photographs of the basal view of the nose are taken, one in the resting position and the other after deep inspiration. These two life-size views are used to calculate the External Nasal Valve Efficacy Index (ENVE Index). Using simple software, the surface area of the nostril in the resting view (A) and breathing view (B) is measured. The ENVE Index is calculated by dividing the deep inspiration surface area by the resting surface area (B/A). The clinical indications for the use of the ENVE Index include rhinoplasty treatment planning, postoperative evaluation to assess the effects of surgery with regard to improvement or deterioration of the airway, and orthognathic surgery and the planning of appropriate postoperative care (such as elastic or intermaxillary fixation) according to the airway patency. The ENVE Index is a relatively simple, reproducible, and documentable test. This index can help the surgeon to make better decisions during treatment planning and postoperative care.

Development of a severity classification system for subjective nasal obstruction.

IMPORTANCE: Nasal airway obstruction is a common presenting symptom in otolaryngology and facial plastic surgery practices, and the potential for multiple contributing causes requires extensive evaluation. OBJECTIVE: To develop a classification system for nasal obstruction using a subjective, validated quality-of-life instrument. DESIGN, SETTING, AND PARTICIPANTS: Retrospective study of patients' responses on the Nasal Obstruction Symptom Evaluation (NOSE) instrument performed from July 2011 through May 2012. All patients were seen at a university-based tertiary medical center. MAIN OUTCOMES AND MEASURES: Scores from patients with or without nasal obstruction were used to develop a classification system after receiver operating characteristic curve analysis. The classification subdivides nasal obstruction scores into a range of defined classes. RESULTS: Data analysis was performed using results from 345 patients. A score of 30 on the NOSE survey best differentiated patients with and without nasal obstruction. This threshold also provided intervals used to define the other class ranges. Patients were categorized as having mild (range, 5-25), moderate (range, 30-50), severe (range, 55-75), or extreme (range, 80-100) nasal obstruction, depending on responses on the NOSE survey. CONCLUSIONS AND RELEVANCE: The NOSE scale is an important tool for gauging symptoms in patients with nasal obstruction. The proposed classification system will improve patient care by providing a framework for the severity of their symptoms and helping them understand potential treatment effects. If the classification is used in future outcomes research, it will allow physicians to better understand the study patient population and the effect of treatment on each severity class. LEVEL OF EVIDENCE: NA.

Effects of radiofrequency and intranasal steroid treatments on respiratory and olfactory functions in nasal obstruction.

OBJECTIVE: This study aimed to compare the effectiveness of radiofrequency ablation (RFA) and intranasal steroid (INS) treatments on respiratory and olfactory functions in patients with inferior concha hypertrophy and chronic nasal obstruction. STUDY DESIGN AND SETTING: This was a prospective clinical trial performed at a tertiary referral center. METHODS: We assessed patients with nasal obstruction between July 2011 and February 2012. The severity of the nasal obstruction in both groups was determined before treatment and 3 months after using a visual analog scale. For the purpose of an objective test, assessment was performed by the acoustic rhinometry. Using Sniffin' Sticks for test odor identification, the discrimination and thresholds were assessed in both groups. RESULTS: The visual analog scale score after treatment was significantly lower in each group. Radiofrequency ablation treatment significantly improved the right minimal cross-sectional area 1 (MCA1), mean MCA1, and volume 1, as well as the right MCA2, mean MCA2, volume 2, and total volume. In the INS group, improvement was detected for the left MCA1, mean MCA1, and volume 1. Minimal cross-sectional area 2, volume 2, and total volume improved significantly after RFA treatment, but not after INS treatment. CONCLUSIONS: Although RFA may be more effective in the posterior region of the nasal cavity, INS and RFA used in the treatment of inferior concha hypertrophy both had favorable effects on respiratory function. Intranasal steroid treatment provided improved discrimination and total score values, whereas RFA treatment improved only odor identification.

Nasal airway function after maxillary surgery: a prospective cohort study using the nasal obstruction symptom evaluation scale.

PURPOSE: To examine nasal airway function using a disease-specific quality-of-life survey instrument in subjects undergoing Le Fort I osteotomy without simultaneous rhinosurgical procedures. MATERIALS AND METHODS: We conducted a prospective cohort study of nasal airway function in consecutive Le Fort I osteotomy patients, who had not received simultaneous rhinosurgical procedures, between 2007 and 2008 at Kaiser Permanente Oakland Medical Center. We administered the Nasal Obstruction Symptom Evaluation (NOSE) survey before and 3 months after surgery. Clinical and radiographic examinations were performed, and the relevant medical and demographic factors were analyzed. RESULTS: The initial study sample comprised 55 patients, of whom 5 were excluded. Of the remaining 50 patients (median age 21 years, 60% women), the maxilla was advanced (median 4 mm, interquartile range 3 to 5) with minimal vertical change. During the follow-up period (median 5.5 months), significant improvement was seen in the NOSE scores for the cohort, with a median decrease of 10 units (P = .0005). Patients with moderate nasal obstruction (preoperative NOSE score >25) had the greatest improvement (P < .001). Those with severe nasal obstruction (preoperative NOSE score >50) improved, however, this did not reach statistical significance (P < .0625). The NOSE scores worsened in 10 patients; of these, 6 had minimal change. However, 4 had significant worsening, with 2 having symptomatic complaints. No predictor variables were identified in this small subgroup; however, individual case analyses revealed 1 subject with postoperative turbinate inflammation on the side of maxillary segmentalization and 1 had nasal septal buckling. CONCLUSIONS: Our overall findings have suggested that nasal airway function improved after maxillary advancement and that subjects with greater preoperative NOSE scores (>25) were more likely to experience relief of nasal obstructive symptoms.

Proposal of a presurgical algorithm for patients affected by obstructive sleep apnea syndrome.

PURPOSE: To propose an algorithm for the preoperative management of patients with obstructive sleep apnea syndrome (OSAS) and review the surgical outcomes in such patients. MATERIALS AND METHODS: This prospective cohort study involved 71 patients with OSAS who underwent presurgical upper airway endoscopy and cephalometry before being assigned to treatment categories based on the site(s) of obstruction, the pattern of collapse, the characteristics of the soft tissue, the air space between the base of the tongue and the posterior wall of the pharynx, and the severity of OSAS. Six months after surgery, they were followed up using polysomnography and the Epworth Sleepiness Scale. The pre- and postsurgical data were compared using a paired Student t test. RESULTS: The mean preoperative apnea/hypopnea index of the 71 patients (61 male and 10 female) was 40.98 events/hour (range, 14.7 to 87.6 events/hr), and the mean postoperative apnea/hypopnea index was 13.96 events/hour (range, 0 to 20 events/hr). The difference was statistically significant (P < .001). CONCLUSIONS: This algorithm was developed on the principle that every patient with OSAS should be considered individually. In the authors' opinion, taking into account the number, site(s), pattern, and degree of the collapse/obstruction is a reasonable means of ensuring the correct diagnosis and treatment.

The efficiency of Nose Obstruction Symptom Evaluation (NOSE) scale on patients with nasal septal deviation.

OBJECTIVE: The aim in this study was to evaluate the efficiency of Nasal Obstruction Symptom Evaluation (NOSE) scale for septoplasty (without turbinate reduction) in comparison with other examination methods. METHODS: Prospective observational study was undertaken in otolaryngology department of university hospital. NOSE scale for quality of life assessment, visual analog scale for examination findings, acoustic rhinometry and coronal computed tomography were performed before and after septoplasty. The efficiency of NOSE scale to assess for septoplasty results and the correlation between NOSE scores and other techniques was analyzed. RESULTS: Twenty-seven patients underwent septoplasty; there was a very significant improvement in mean NOSE scores of patients (60.2 versus 11.28, p<0.01). There was no correlation between NOSE scores and acoustic rhinometry. Correlation was found between NOSE scores and examination and computed tomography findings (p<0.05). CONCLUSION: NOSE scale that is well correlated with examination findings and computed tomography, is very useful tool to evaluate the effectiveness of pure septoplasty.

Nasal strips for evaluating and classifying valvular nasal obstruction.

BACKGROUND: A normal-appearing upper lateral cartilage (ULC) or lower lateral cartilage (LLC) may be functionally abnormal. The Cottle sign estimates obstruction but not its exact location. A test is needed that evaluates the ULC and LLC separately. METHODS: The study included 30 patients with airway obstruction symptoms and signs referable only to the nasal valves. They received a Cottle test and a Breathe-Rite nasal strip to the middle third of the nose and again to the lower third (the rims). The patients were asked whether the strip made their inspiration better, worse, or no different and classified as BR 0 (no airway obstruction due to ULC/LLC dysfunction), BR I (improvement with the strip on the ULC), BR II (improvement with the strip on the LLC), or BR III (improvement with strips on both the ULC and the LLC, independently). All the patients underwent surgery involving spreader grafts, lateral crural struts, suture techniques, and the like. Correlations were sought between the BR classification, Cottle sign, and physical integrity of the ULC/LLC. RESULTS: A total of 12 patients required internal valve correction, whereas 8 required external valve correction, and 10 required correction of both. The Cottle test was nonspecific because most patients in all the groups exhibited a positive Cottle. However, the BR classification was specific, correlating with functional outcomes for 27 of the 30 patients. The McNemar test showed a significant correlation (Χ(2) = 9.09091; P = 0.00257) between physical finding and BR score. CONCLUSIONS: Inspiratory nasal function (related to ULC/LLC cartilages) is easily classified using nasal strips. The BR test is more specific and powerful than the Cottle test.

Nasal obstruction and high Mallampati score as risk factors for Obstructive Sleep Apnea.

UNLABELLED: Respiratory sleep disorders are strongly associated with upper airway patency. Nasal obstruction is associated with higher incidences of sleep apnea, primarily by increasing the negative pressure on the airway during inspiration. AIMS: To evaluate the influence of nasal obstruction in the worsening of sleep apnea in patients with OSA and a high score on the modified classification of Mallampati. MATERIALS AND METHODS: We evaluated and classified 206 patients complaining of snoring, and with a past suggestive of OSA through the Modified Mallampati score, Friedman, nasal obstruction and the severity of OSA by AHI. RESULTS: 168 patients who underwent polysomnography were included. Cross-plotting was made comparing the modified Mallampati score, nasal obstruction and AIH. The odds ratio between high Mallampati score and AHI was OR = 5.053, 95% CI = 1.458 to 7.517 (p = 0.0071). High Mallampati score associated with nasal obstruction was correlated with OSAS (p = 0.0227). However the influence of nasal obstruction on the relationship of high Mallampati score and OSA was not significant: OR = 2.850, 95% CI = 0.992 to 8.189. CONCLUSION: The combination of high Mallampati score and nasal obstruction represents a greater risk factor for worsening of OSA.

Obstrução nasal e alto escore de Mallampati como fatores de risco associados para Apneia Obstrutiva do Sono / Nasal obstruction and high Mallampati score as risk factors for Obstructive Sleep Apnea

Os distúrbios respiratórios do sono estão associados à perviedade das vias aéreas superiores. Obstrução nasal é associada com o aumento de eventos de apneia do sono, principalmente pelo aumento da pressão negativa imposta às vias aéreas durante a inspiração. OBJETIVO: Avaliar a influência da obstrução nasal associada à classificação modificada de Mallampati na gravidade da SAOS. MATERIAIS E MÉTODOS: Foram avaliados e classificados 206 pacientes com queixa de roncos e história sugestiva de SAOS através do Escore Modificado de Mallampati, Friedman, obstrução nasal e quanto à gravidade da SAOS pelo IAH. RESULTADOS: Foram incluídos 168 pacientes que se submeteram ao estudo de polissonografia no laboratório de sono. Uma crostabulação foi feita entre o escore modificado de Mallampati, obstrução nasal e o IAH. O Oddis Ratio entre alto escore de Mallampati e IAH foi OR=5,053, IC 95 por cento=1,458 - 7,517(p = 0,0071). Alto Mallampati associado com obstrução nasal se correlacionam com SAOS (p=0,0227). Entretanto, a influência da obstrução nasal sobre a relação do alto escore de Mallampati e SAOS não foi significativa OR = 2,850, IC 95 por cento=0,992 - 8,189. CONCLUSÃO: A associação de alto escore de Mallampati e obstrução nasal é fator de risco para agravamento da SAOS.

Respiratory sleep disorders are strongly associated with upper airway patency. Nasal obstruction is associated with higher incidences of sleep apnea, primarily by increasing the negative pressure on the airway during inspiration. AIMS: To evaluate the influence of nasal obstruction in the worsening of sleep apnea in patients with OSA and a high score on the modified classification of Mallampati. MATERIALS AND METHODS: We evaluated and classified 206 patients complaining of snoring, and with a past suggestive of OSA through the Modified Mallampati score, Friedman, nasal obstruction and the severity of OSA by AHI. RESULTS: 168 patients who underwent polysomnography were included. Cross-plotting was made comparing the modified Mallampati score, nasal obstruction and AIH. The odds ratio between high Mallampati score and AHI was OR = 5.053, 95 percent CI = 1.458 to 7.517 (p = 0.0071). High Mallampati score associated with nasal obstruction was correlated with OSAS (p = 0.0227). However the influence of nasal obstruction on the relationship of high Mallampati score and OSA was not significant: OR = 2.850, 95 percent CI = 0.992 to 8.189. CONCLUSION: The combination of high Mallampati score and nasal obstruction represents a greater risk factor for worsening of OSA.

Puesta al día en manejo de la obstrucción nasal por colapso valvular / Update in nasal obstrucción management caused by valvular collapse

La estenosis de la válvula nasal aparece como una complicación frecuente de rinoplastfa o traumatismo nasal. Existen diferentes técnicas para corregir el colapso de la válvula nasal; generalmente se utilizan injertos de tejido, que en algunas ocasiones son insuficientes para resolverla alteración y mejorar la función respiratoria. La válvula nasal funciona en base a la resistencia de la ley Starling, que consiste en un tubo semirrígido con un segmento flexible; cuando la presión inspirada excede un nivel crítico, éste se colapsa y provoca la alteración en su fisiología; por tanto, es necesario cierto grado de rigidez en el componente lateral nasal para evitar el colapso durante la inspiración. Cuando se ve afectado su funcionamiento causa frecuentemente obstrucción nasal.

Nasal valve stenosis commonly presents as a postoperative complication of rhinoplasty or facial trauma. Various techniques have been reported to correct nasal valve stenosis through the use of methods that support the nasal valve with cartilage, rib graft, although these tissues are not useful in some cases to improve the nasal breathing. The nasal valve functions as the law Starling resistor, which is a semirigid tube with a flexible segment, when the inspired partial pressure exceeds a critical level, it collapses and causes nasal obstruction, and therefore need some degree of rigidity in nasal lateral component to avoid collapse during inspiration. When the nasal valve is affected frequently causes nasal obstruction.