Introduction
Nasal valve collapse (NVC) is a common cause of nasal airway obstruction, with substantial morbidity.1 NVC can occur either at the level of the external nasal valve or at the internal nasal valve.2 NVC or narrowing often occurs concomitantly with septal deviation and inferior turbinate hypertrophy (ITR).3 Recently, a major insurer instituted a policy not authorizing repair of nasal vestibular stenosis (RNVS) unless prior septoplasty had been performed. This study investigates effectiveness of prior septoplasty in patients with likely NVC requiring RNVS.
Methods
This study was approved by the Sanford University Institutional Review Board.
Insurance claims data between 2007 and 2021 were obtained from the Merative™ Marketscan® Research Databases that includes national census-designated regions, and data from private insurance types (Table 1).4 As the ICD9/10 code for NVC (478.19/J34.89) is ill-defined, we utilized CPT codes (Supplementary Table S1) to isolate patients who underwent RNVS with or without extranasal rib/ear cartilage graft as a proxy for NVC and then identified nasal surgeries before their RNVS procedure.
Table 1.
Characteristics of repair of nasal vestibular stenosis patients
| Characteristic | RNVS without extra nasal graft, N = 12,304 | RNVS with extra nasal graft, N = 1591 | p |
|---|---|---|---|
| Age, mean (SD) | 40.2 (13.2) | 44.2 (12.5) | <0.001 |
| Gender, n (%) | |||
| Male | 6270 (51.0) | 694 (43.6) | <0.001 |
| Female | 6034 (49.0) | 897 (56.4) | |
| Age group, (years) n (%) | |||
| 18–34 | 4571 (37.2) | 395 (24.8) | <0.001 |
| 35–44 | 2802 (22.8) | 347 (21.8) | |
| 45–54 | 2744 (22.3) | 446 (28.0) | |
| 55+ | 2187 (17.8) | 403 (25.3) | |
| Region, n (%) | |||
| Northeast | 2332 (19.0) | 203 (12.8) | <0.001 |
| North central | 3044 (24.7) | 346 (21.7) | |
| South | 4386 (35.6) | 694 (43.6) | |
| West | 2443 (19.9) | 325 (20.4) | |
| Unknown | 99 (0.8) | 23 (1.4) | |
| Insurance type, n (%) | |||
| Comprehensive | 234 (1.9) | 26 (1.6) | 0.001 |
| EPO | 227 (1.8) | 48 (3.0) | |
| HMO | 1280 (10.4) | 181 (11.4) | |
| POS ± capitation | 1217 (9.9) | 125 (7.9) | |
| PPO | 7600 (61.8) | 1001 (63.0) | |
| CDHP | 842 (6.8) | 87 (5.5) | |
| HDHP | 904 (7.3) | 122 (7.7) | |
CDHP, Consumer Directed Health Plan; EPO, Exclusive Provider Organization; HDHP, High Deductible Health Plan; HMO, Health Maintenance Organization; POS, Point-of-sale; PPO, Preferred Provider Organization; RNVS, repair of nasal vestibular stenosis.
Patients under 18 years of age or with missing demographic data were excluded from this study. For demographic analysis, a Student's t-test (continuous variables) and chi-squared test (categoric variables) were utilized and a chi-squared test was used for prior septoplasty history analysis. p < 0.05 was considered significant.
Results
Among 13,895 patients who underwent RNVS, 1591 (11.5%) required an extranasal cartilage graft (Table 1). Compared with patients who underwent RNVS without a graft, patients who required a graft were older (44.2 years old vs. 40.2 years old; p < 0.001), and a higher proportion of these patients were female (56.4% vs. 49.0%; p < 0.001). In addition, a higher proportion of patients who required an extranasal graft during their RNVS procedure were from the south and west regions (p < 0.001) and were enrolled in Exclusive Provider Organization/Health Maintenance Organization/Preferred Provider Organization insurance plans (p = 0.001).
Patients who underwent isolated septoplasty (with or without ITR) before their RNVS surgery were more likely to require an extranasal graft during their RNVS procedure than patients with no history of isolated septoplasty (23.1% vs. 11.2%; p < 0.001) (Table 2).
Table 2.
Chi-squared analysis of septoplasty history in repair of nasal vestibular stenosis patients
| Prior nasal procedure |
Count (%)
|
|
|
|---|---|---|---|
| RNVS without extra nasal graft | RNVS with extra nasal graft | p | |
| No septoplasty history | 12,101 (88.8) | 1530 (11.2) | <0.001 |
| Septoplasty ± ITR | 203 (76.9) | 61 (23.1) | |
ITR, inferior turbinate hypertrophy.
Discussion
This retrospective database study found that a minority of RNVS patients require an extranasal cartilage graft during their procedure. However, having prior isolated septoplasty (with or without ITR) was shown to increase the rate of requiring extranasal grafts for subsequent RNVS procedures. Although the majority of nasal obstruction patients undergo septoplasty, previous work5 has shown that nasal obstruction patients with NVC often have decreased benefit from septoplasty alone.3
Our findings demonstrate that patients with NVC who undergo RNVS procedure who had a prior isolated septoplasty have an increased risk of requiring an extranasal cartilage graft during their subsequent RNVS procedure. Therefore, patients who present with NVC would benefit from complete treatment, such as RNVS and septoplasty ± ITR initially, rather than trying to correct nasal obstruction using septoplasty ± ITR without performing an RNVS.
Our study is limited by the use of private insurance claims data that are subject to provider coding errors and may not be generalizable to publicly or uninsured populations. In addition, RNVS may also be used to treat stenosis related to cleft lip, trauma, or infection, in addition to NVC6; therefore, using RNVS procedures as a proxy for NVC may result in including patients who do not have NVC. Lastly, due to the lack of a CPT code for cadaveric cartilage grafts, which are commonly used in RNVS procedures, these grafts were not captured in this claims database. Overall, however, our study suggests that patients with NVC who had undergone prior septoplasty, with or without ITR, have an over two-fold risk of requiring an extranasal cartilage graft when undergoing subsequent NVC repair.
Authors' Contributions
A.G. contributed to methodology, software, validation, formal analysis, investigation, data curation, writing—original draft, writing—review and editing, and visualization. E.X.W. was involved in methodology, formal analysis, and writing—review and editing. C.K. carried out conceptualization, methodology, formal analysis, writing—review and editing, and supervision. G.M.Y. carried out software and data curation. J.P.S. took care of software and data curation. S.P.M. was in charge of conceptualization, methodology, writing—review and editing, supervision, and project administration. All authors approve the current version of this article.
Disclaimer
The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.
Data Availability
Data for this project were accessed using the Stanford Center for Population Health Sciences Data Core.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
The PHS Data Core is supported by a National Institutes of Health National Center for Advancing Translational Science Clinical and Translational Science Award (UL1TR003142) and from Internal Stanford funding.
Supplementary Material
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Data for this project were accessed using the Stanford Center for Population Health Sciences Data Core.