Nasal Procedures for Obstructive Sleep Apnea

The nose is the primary entry point to the airway.  All the hard work preparing air for gas exchange in the lung takes place in the small space that comprise your nasal cavity.  The air is humidified, filtered and conditioned as needed.  Since the nose is your default breathing passage, this is where we often start the conversation when it comes to dealing with “sleep surgery”.  Furthermore, relieving nasal issues can improve daytime symptoms, night time symptoms and CPAP related symptoms, depending on the problems seen in the anatomy.

There are procedures available to help control obstructive sleep apnea and snoring.  These include hard tissue reconstruction (restoring a deviated nasal septum, straightening out distorted nasal bones) and soft tissue reduction (turbinoplasties, removing adenoids).  The rule of thumb is that hard tissue reconstruction requires a general anesthetic while soft tissue reductions may be done under local anesthetic, depending on what is necessary.

Septal Reconstruction

Septal reconstruction involves making an incision in the nasal passage, lifting the linings to expose the bony/cartilage complex, and then manipulating that tissue in such a way as to make a straight wall separating the two nasal passages.  This promotes laminar flow within the nose, improving airflow and decreasing the drying effect of turbulent airflow in the nose.  This drying effect is accentuated with CPAP use if the septum is crooked.

Nasal Valve Stabilization

Sometimes, the outer wall of the nostril collapses inwards with deep inspiration, near the junction of the nostril and the face.  Sometimes, while the skin might look normal in this area, we can see some internal collapse.  We can improve the airflow in this area with a stabilization procedure that can definitely widen the nasal valve and stabilize it against collapse when you need it most.

Turbinate Reduction (Turbinoplasty, Coblation, Radiofrequency reduction)

This is the most common procedure done for improvement of nasal airflow, particularly when prescribed nasal steroids have failed.  The nasal turbinates are three projections from the side wall of the nasal passage on each side, labelled as superior, middle and inferior.  They act as means to direct airflow from the nostril to the back of the nose towards the lower airway.

The inferior turbinate is the workhorse of the nose.  The largest of all three turbinates on each side, its surface lining imparts moisture and warmth to the air we breathe in and secretes a light mucous that traps viruses and bacteria that could otherwise arrive at in the lungs and cause illness.  The thick nasal lining covers a thin shelf of bone that projects out from the bone of the nasal passage.  That nasal lining can grow as a consequence of repeated illness, allergies, smoking, or even age.  Avoidance (smoking cessation, dust covers on beds), prescribed nasal steroids and saline douches are first line therapy to help treat this common problem.  However, if these fail, then we rely on turbinate reduction and lateralization for more definitive management.

The theory is to apply radio frequency to create some internal scarring, causing the turbinate to shrink from the inside. In this way, the outer lining is preserved for good hydration, but the total surface area is smaller leading to less mucous production.  We also apply pressure to the turbinate bone to fracture it at the root to push it over towards the side.  This procedure is well tolerated, and can be done in the space of 45 minutes with local anesthetic.  There is no bruising or swelling on the face after this procedure, and there is minimal risk of bleeding in the recovery period.

If you are considering nasal surgery, the aim should be first to improve nasal airflow, then to improve snoring.  Some people only get nasal obstruction lying in bed; turbinate reduction with or without septal surgery will improve this congestion.  If you can breathe through your nose in bed, less mouth breathing will lead to less snoring.

CPAP users with increased nasal congestion after long term therapy will often respond well to turbinate reduction procedures.  Check with your physician if you are experiencing this problem.