Is nasal surgery an effective treatment for obstructive sleep apnea?

Outcome of Continuous Positive Airway Pressure Adherence Based on Nasal Endoscopy and the Measurement of Nasal Patency-A Prospective Study

The gold standard for treating obstructive sleep apnea in adults is continuous positive airway pressure (CPAP). However, it can be difficult to convince patients to adhere to this therapy. The aim of this study was to determine the relationship between nasal endoscopy findings/nose patency and CPAP adherence. Material and methods: A cohort of 450 consecutive patients suspected of having OSA were prospectively enrolled. For further analyses, 47 OSA patients undergoing CPAP treatment were selected (13 females and 34 males, average age, 65.3 years, BMI 34.1, apnea-hypopnea index. AHI 51.0). The patients were divided into two groups: patients with good CPAP adherence (n = 35) and patients who did not adhere to CPAP therapy (n = 12). The influence of nasal endoscopy and flow measurement on CPAP adherence was explored. Results: We found a statistical independence between adherence to CPAP and AHI (p = 0.124), T90 (p = 0.502), endoscopic findings (p = 0.588) and nasal patency measured by a flowmeter (p = 0.498). Conclusions: In our studied sample, endoscopic findings and nasal patency measured by a flowmeter were not predictors of CPAP non-adherence in the first year of the treatment. Our data show that while an endoscopic finding in the nasal cavity could indicate that a patient has a severe obstruction, compliance with CPAP therapy is not reduced in these patients and neither is it reduced with a decrease in nasal flow, according to our observation.

Aerodynamics Analysis of the Impact of Nasal Surgery on Patients with Obstructive Sleep Apnea and Nasal Obstruction

OBJECTIVE

The purpose of this study was to evaluate the effects of nasal surgery on airflow characteristics in patients with obstructive sleep apnea (OSA) by comparing the alterations of airflow characteristics within the nasal and palatopharyngeal cavities.

METHODS

Thirty patients with OSA and nasal obstruction who underwent nasal surgery were enrolled. A pre- and postoperative 3-dimensional model was constructed, and alterations of airflow characteristics were assessed using the method of computational fluid dynamics. The other subjective and objective clinical indices were also assessed.

RESULTS

By comparison with the preoperative value, all postoperative subjective symptoms statistically improved (p < 0.05), while the Apnea-Hypopnea Index (AHI) changed little (p = 0.492); the postoperative airflow velocity and pressure in both nasal and palatopharyngeal cavities, nasal and palatopharyngeal pressure differences, and total upper airway resistance statistically decreased (all p < 0.01). A significant difference was derived for correlation between the alteration of simulation metrics with subjective improvements (p < 0.05), except with the AHI (p > 0.05).

CONCLUSION

Nasal surgery can decrease the total resistance of the upper airway and increase the nasal airflow volume and subjective sleep quality in patients with OSA and nasal obstruction. The altered airflow characteristics might contribute to the postoperative reduction of pharyngeal collapse in a subset of OSA patients.

The influential factors on the morphological changes of upper airway associated with mouth opening

OBJECTIVE

This study aimed to evaluate the influential factors on the morphological changes of upper airway caused by mouth opening (MO).

METHODS

One hundred and thirty-eight obstructive sleep apnea-hypopnea syndrome (OSAHS) patients were enrolled. Anthropometric and demographic data, Friedman tongue position (FTP), and tonsil scores were recorded. Overnight polysomnography and upper airway computed tomography scans under two conditions (mouth closed [MC] and MO) were acquired. Morphological parameters of upper airway were compared between MC and MO. Stepwise multiple linear regression analyses were performed with the variation ratio of upper airway parameters (Para-VRs) from MC to MO as the dependent variable, with age, gender, body mass index, neck circumference, waist circumference, four mandibular indexes, net angle or amount of MO, FTP, and tonsil scores as the independent variables.

RESULTS

Overall analysis and subgroup analyses based on OSAHS severity revealed that the minimal cross-sectional area of oropharyngeal lumen (OXmin) significantly decreased (P < 0.05) with MO, whereas the minimal cross-sectional area of velopharyngeal lumen (VXmin) did not significantly change with MO (P > 0.05). The net angle of MO or amount of MO combined with tonsil scores were identified to have significant positive correlation with EXP (OXmin-VR), [OXmin-VR was logarithmically transformed with an exponential function, EXP(n) = eⁿ ]; FTP appeared to be more related to EXP (VXmin-VR). Mouth opening induced a significant increase VXmin for patient subgroup with FTP grading I and a significant decrease VXmin for patient subgroup with FTP grading IV (P < 0.05).

CONCLUSION

Wider MO combined with larger tonsils lead to narrower oropharyngeal airway. The relative position of tongue to soft palate is the main factor influencing the changes of velopharyngeal lumen with MO.

LEVEL OF EVIDENCE

4 Laryngoscope, 128:2902-2909, 2018.

The role of lateral pharyngoplasty in obstructive sleep apnea syndrome

Recent studies have shown that lateral pharyngoplasty is an effective procedure to correct obstructive sleep apnea. The objective of the paper was to evaluate factors contributing to obstructive sleep apnea syndrome and identify the different severity categories of obstructive sleep apnea that could benefit from lateral pharyngoplasty. We included 60 patients undergoing uvulopalatopharyngoplasty with or without lateral pharyngoplasty from December 1, 2008 to May 31, 2012. Six who did not complete the post-operative survey were excluded. 54 participants were assigned alternatively to either uvulopalatopharyngoplasty alone (control group, n = 29) or to uvulopalatopharyngoplasty with lateral pharyngoplasty (intervention group, n = 25). The reduction of apnea-hypoxia index in the intervention group (49.3%) was higher than it was in the control group (30.4%), but the average value was not statistically significant (p = 0.088). Only patients with moderate obstructive sleep apnea in the intervention group achieved a significant reduction of apnea-hypoxia index (30.7 vs. 10.8%; p = 0.020). Factors such as body mass index, nadir/mean SpO2, snoring index, Epworth sleepiness scale and periodic limb movement index did not change significantly following lateral pharyngoplasty. To evaluate patients' upper airway anatomy, we employed cephalometry, and found that the retroglossal space played a critical role in severe obstructive sleep apnea. Our study showed that only patients in the moderate category can be benefited from adding lateral pharyngoplasty to uvulopalatopharyngoplasty; however, patients in the mild or severe category did not benefit from adding this procedure. This information is vital when considering surgery for patients with obstructive sleep apnea syndrome. Level of evidence Prospective cohort study, Level II.

The effect of nasal surgery on nasal continuous positive airway pressure compliance

OBJECTIVES/HYPOTHESIS

Nasal continuous positive airway pressure (CPAP) is the standard therapy for sleep apnea; however, compliance rates are historically poor. Among the most commonly cited reasons for nonadherence is nasal obstruction. Our study sought to examine if nasal surgery actually increases CPAP compliance.

STUDY DESIGN

Prospective case series.

METHODS

Nasal CPAP-intolerant obstructive sleep apnea (OSA) patients, with documented nasal obstruction, underwent septoplasty plus inferior turbinoplasty. Preoperative and postoperative data were collected on CPAP usage per night and subjective nasal obstruction with the Nasal Obstruction Symptom Evaluation (NOSE) Scale questionnaire.

RESULTS

Eighteen patients met inclusion criteria and underwent septoplasty. CPAP usage increased significantly from 0.5 hours per night preoperatively to 5 hours per night postoperatively (P < .05). Subjective nasal obstruction on the NOSE Scale decreased from 16.1 preoperatively to 5.4 following surgical intervention (P < .05). CPAP pressure decreased from 11.9 preoperatively to 9.2 after surgery, with a trend toward significance (P = .062).

CONCLUSIONS

This study demonstrates improved CPAP compliance rates following septoplasty in OSA patients with nasal obstruction. Correction of nasal obstruction should be offered in nasal CPAP-intolerant individuals to improve CPAP compliance.