Polysomnographic effects of nasal surgery for snoring and obstructive sleep apnea

Role of Nasal Surgery in Adult Obstructive Sleep Apnea: A Systematic Review

Objective  To perform a systematic review to determine if isolated nasal surgery has any impact on subjective or objective parameters in adult obstructive sleep apnea (OSA) patients. Materials and Methods  From December 2022 to March 2023, we conducted a search on the PubMed, Cochrane, Scopus, and Web of Science databases. Two independent investigators performed a study selection according to the established criteria, as well as data collection, including the study design, the subjective and objective parameters addressed, the type of intervention, and the outcomes, considering the methodological quality and risk of bias. Results  In total, 25 studies met the selection criteria, and they showed that there is a significant improvement in sleep quality, sleepiness, nasal resistance, and snoring after isolated nasal surgery. Still, there is no relevant modification of other polysomnographic parameters. It also reduces the required titration pressures of continuous positive airway pressure (CPAP) and increases the duration of its use. Conclusion  Isolated nasal surgery is not a primary treatment for OSA. Still, it improves the subjective parameters and can lead to CPAP therapy success by enhancing its effectiveness and long-term compliance.

Polysomnographic Assessment on Osahs Outcomes in Patients with Nasal Obstruction Undergoing Septoplasty with Partial Inferior Turbinectomy

The relationship between nasal obstruction and obstructive sleep apnea has raised interest among otolaryngologists since years. There are studies that suggest that surgical correction of nasal obstruction improves sleep quality and reduces symptoms of sleep apnea. This lead to our study to understand the effect of nasal surgery on obstructive sleep apnea hypopnea syndrome (OSAHS).

AIM

To assess the effect of nasal surgery in improvement in Obstructive Sleep Apnoea Hypopnoea Syndrome in patients with nasal obstruction by Polysomnography (PSG).

MATERIAL AND METHODS

This study included 30 patients with nasal obstruction who underwent septoplasty and/or turbinate reduction procedure with pre and post operative assessment of respiratory distress index (RDI) including apnoea hypopnoea index (AHI), obstructive apnoea index (OAI), Snoring Index (SI) using polysomnography (PSG).

RESULT

Nasal correction surgery showed statistically significant improvement (p-value < 0.001) in RDI from 13.66 to 6.66, OAI from 6.34 to 3.18 and Snoring Index from 161.77 to 62.23 as assessed by polysomnography. There was statistically significant improvement in minimal saturation levels (during sleep) and positional sleep apnoea.

CONCLUSION

Isolated nasal surgery like septoplasty and/or turbinate reduction improved sleep parameters and alleviated OSA symptoms in patients with static nasal obstruction and obstructive sleep apnoea/hypopnoea syndrome. However, patients with multilevel or dynamic airway obstruction may need further intervention.

Can functional septoturbinoplasty, with or without nasal valve suspension suture (FSTVS), alter the initial findings of drug-induced sleep endoscopy (DISE) in patients with obstructive sleep apnea syndrome (OSAS)?

BACKGROUND

Drug-induced sleep endoscopy (DISE) is routinely performed to assess the upper airway collapse in patients with obstructive sleep apnea syndrome (OSAS). Its purpose is to identify cases of multilevel collapse, which helps to determine the appropriate surgical approach. The current proposal to analyze the functional septoturbinoplasty with or without nasal valve suspension suture (FSTVS) has the potential to change the original findings of DISE in OSAS patients who were initially planned for one-stage multilevel surgery based on the pre-FSTVS DISE results.

STUDY DESIGN

Prospective study.

METHODS

All OSAS patients with moderate to severe symptoms who underwent DISE pre-FSTVS and noticed multilevel collapse were subjected to post-FSTVS re-evaluation using DISE at three-month intervals.

RESULT

This study included a total of thirty-two patients, with males outnumbering females in a ratio of 15:1. The average age of the patients was 38.88 years (standard deviation, SD ± 10.12), and the mean body mass index (BMI) was 28.66 (SD ± 3.73). Significant improvements (p = 0.0417) were observed in both pre- and post-FSTVS measurements at three-month intervals, as well as in the Epworth sleepiness score (ESS). Enhancements in the apnea-hypopnea index (AHI) and snoring event post-FSTVS were also observed. Around 50% of the patients exhibited concentric collapse at the velum, lateral collapse at the oropharynx, and anteroposterior (AP) collapse at the tongue base. Post-FSTVS, the dynamics at the velum were modified by 23.33%, at the oropharynx by 10%, at the tongue base by 11.76%, and at the epiglottis by 23.07%. One patient who did not experience collapse at the tongue base pre-FSTVS exhibited partial collapse after the procedure. Moreover, all cases of complete AP collapse of the epiglottis changed to partial collapse.

CONCLUSION

Our study confirms that FSTVS may offer a simpler and more accessible approach for patients with OSAS. It is a viable option to consider even prior to DISE in clinical anticipated multilevel collapse. By conducting DISE at intervals subsequent to addressing nasal resistance through surgery, valuable insights can be obtained regarding the collapsibility of the upper airway. These findings can guide surgical interventions, ultimately resulting in improved outcomes for patients.

Association between nasal septum deviation and transverse maxillary development: A retrospective cross-sectional study

INTRODUCTION

The few studies investigating the relationship between nasal septum deviation (NSD) and maxillary development, using different assessment methods and the age of subjects, reported contradicting results.

METHODS

The association between NSD and transverse maxillary parameters was analyzed using 141 preorthodontic full-skull cone-beam computed tomography scans (mean age, 27.4 ± 9.01 years). Six maxillary, 2 nasal, and 3 dentoalveolar landmarks were measured. The intraclass correlation coefficient was used to assess intrarater and interrater reliability. The correlation between NSD and transverse maxillary parameters was analyzed using the Pearson correlation coefficient. Each transverse maxillary parameter was compared among 3 groups of different degrees of severity using the analysis of variance test. Transverse maxillary parameters were also compared between the more and less deviated nasal septum sides using the independent t test.

RESULTS

A correlation between deviated septal width and palatal arch depth (r = 0.2, P <0.013) and significant differences in palatal arch depth (P <0.05) among 3 NSD severity groups classified with deviated septal width was noted. There was no correlation between septal deviated angle and transverse maxillary parameters and no significant difference for transverse maxillary parameters among the 3 groups of NSD severity classified by septal deviated angle. No significant difference in transverse maxillary parameters was found when comparing the more and the less deviated sides.

CONCLUSIONS

This study suggests that NSD can affect palatal vault morphology. The magnitude of NSD may be a factor associated with transverse maxillary growth disturbance.

Clinical Practice Guideline: Clinical Efficacy of Nasal Surgery in the Treatment of Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a common disorder characterized by upper airway obstruction during sleep. To reduce the morbidity of OSA, sleep specialists have explored various methods of managing the condition, including manifold positive airway pressure (PAP) techniques and surgical procedures. Nasal obstruction can cause significant discomfort during sleep, and it is likely that improving nasal obstruction would enhance the quality of life and PAP compliance of OSA patients. Many reliable studies have offered evidence to support this assumption. However, few comprehensive guidelines for managing OSA through nasal surgery encompass all this evidence. In order to address this gap, the Korean Society of Otorhinolaryngology-Head and Neck Surgery (KORL-HNS) and the Korean Society of Sleep and Breathing designated a guideline development group (GDG) to develop recommendations for nasal surgery in OSA patients. Several databases, including OVID Medline, Embase, the Cochrane Library, and KoreaMed, were searched to identify all relevant papers using a predefined search strategy. The types of nasal surgery included septoplasty, turbinate surgery, nasal valve surgery, septorhinoplasty, and endoscopic sinus surgery. When insufficient evidence was found, the GDG sought expert opinions and attempted to fill the evidence gap. Evidence-based recommendations for practice were ranked according to the American College of Physicians' grading system. The GDG developed 10 key action statements with supporting text to support them. Three statements are ranked as strong recommendations, three are only recommendations, and four can be considered options. The GDG hopes that this clinical practice guideline will help physicians make optimal decisions when caring for OSA patients. Conversely, the statements in this guideline are not intended to limit or restrict physicians' care based on their experience and assessment of individual patients.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Barbed Pharyngoplasty for Snoring: Does It Meet the Expectations? A Systematic Review

To date, the use of barbed sutures for the surgical management of patients suffering from obstructive sleep apnea and snoring with retropalatal collapse and vibration has significantly increased. A systematic review was carried out, which included clinical studies that used barbed sutures for the treatment of snoring. A qualitative analysis, including six clinical studies, was conducted. Of these, five were studies on barbed pharyngoplasties, and one study involved a minimally invasive surgical procedure. The population consisted of 176 patients, aged 26 to 58 years old. Overall, the included studies showed a mean gain in the snoring Visual Analog Scale of 5.67 ± 1.88, with a mean preoperative value of 8.35 ± 1.17 and a postoperative value of 2.68 ± 1.27. No major complications were described. Given the lack and heterogeneity of this evidence, the conclusion calls for being cautious. In carefully selected snorers and obstructive sleep apnea patients, the use of barbed sutures could represent a valid therapeutic strategy for snoring, ensuring a statistically significant improvement in the subjective parameters. Further studies on a larger scale that assess the role of barbed pharyngoplasties in snoring surgery and more extended follow-up studies are needed in order to confirm these promising results.

Analysis of Lateral Decubitus Position During Sleep in Patients With Obstructive Sleep Apnea Using WatchPAT Device

Background and Objectives

Measurement of sleep parameters in both supine and non-supine positions is important for the diagnosis of positional obstructive sleep apnea (OSA). However, the influence of right and left lateral decubitus positions (RLDP and LLDP, respectively) on sleep parameters is relatively unknown and has not been well investigated. This study was performed to verify the associations between sleep parameters and lateral decubitus sleep position.

Methods

A retrospective study was performed on 38 patients who were diagnosed with OSA and underwent surgical interventions from January 2014 to December 2016. Preoperative sleep parameters were evaluated with WatchPAT, and patients who slept sufficiently in both RLDP and LLDP to accurately analyze sleep parameters were enrolled in the study. Basic clinical data including body mass index (BMI) and nasal endoscopic findings of patients were assessed.

Results

The difference in peripheral arterial tonometry apnea-hypopnea index (pAHI) and PAT respiratory disturbance index (pRDI) between RLDP and LLDP showed no association with the side of deviated nasal septum. Patients with higher BMI showed higher pRDI in LLDP than RLDP (p=0.038). The difference in sleep position percentage between RLDP and LLDP was negatively correlated with the difference in pRDI (p=0.023).

Conclusion

Higher BMI patients with OSA might benefit more from sleeping in RLDP than LLDP. Patients slept longer in the lateral decubitus position that produced lower pRDI. Not only supine and non-supine positions, but also RLDP and LLDP need to be evaluated in patients with OSA.

Evaluation of the clinical efficacy of nasal surgery in the treatment of obstructive sleep apnoea

STUDY OBJECTIVES

The aim of the study was to evaluate the clinical efficacy of nasal surgery in the treatment of obstructive sleep apnoea (OSA) by comparing the improvement of subjective symptoms and objective metrics before surgery and after 6 months of surgery.

METHODS

Patients with the main complaint of nasal congestion combined with habitual snoring who were hospitalized and treated were selected. Patients underwent subjective symptom tests and objective indicator monitoring both before surgery and 6 months after surgery. Comparisons between groups were performed using the independent samples t-test.

RESULTS

Subjective scale evaluations demonstrated that nasal congestion, daytime sleepiness, snoring, nose-related symptoms, and sleep symptoms in patients with simple snoring or with OSA were improved after nasal surgery. Additionally, vitality was improved in all groups except for the patients with simple snoring and emotional consequence was improved in patients with simple snoring and mild OSA. Objective evaluations indicated the apnoea-hypopnoea index (AHI), the thickness of the soft palate, and the maximum cross-sectional area of the sagittal plane of the soft palate decreased after surgery in patients with mild OSA. The lowest blood oxygen concentration (LSaO₂) and anteroposterior diameter of the soft palate increased after surgery in patients with mild OSA. The arousal index also significantly decreased in patients with mild and moderate OSA. The nasal cavity volumes (NCVs) and the nasal minimal cross-sectional areas (NMCAs) of all groups showed significant differences after surgery.

CONCLUSIONS

Nasal surgery can effectively improve nose and sleep symptoms in patients with simple snoring or with OSA. It can significantly reduce the nasal resistance and increase the ventilation volume.

STATEMENT OF SIGNIFICANCE

Obstructive sleep apnoea (OSA) is becoming a global health problem. OSA is associated with several coexisting conditions, reduced health-related quality of life, and impaired work productivity. This study performed nasal surgery on OSA patients with the main complaint of nasal congestion combined with snoring and patients with simple snoring to compare the improvement of subjective symptoms and objective metrics before and after surgery. We found that: (1) symptoms such as nasal congestion, daytime sleepiness or snoring were improved after nasal surgery; (2) the apnoea-hypopnoea index (AHI) and arousal index decreased after surgery in patients with OSA; (3) the nasal and oropharyngeal cavity volumes increased after surgery. These findings suggest that patients with OSA or with simple snoring could benefit from nasal surgery.

Association between septal deviation and OSA diagnoses: a nationwide 9-year follow-up cohort study

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) is a multilevel problematic disease. Major septal deviation (SD) can lead to severe nasal congestion, which, in turn, can lead to sleep apnea. Although SD seems to be related to OSA, very few studies have quantitatively examined this relationship. In this study, we investigate this using a 9-year large-scale cohort study.

METHODS

The SD group was selected out of 1 million individuals randomly extracted by the National Health Insurance Service. The non-SD group was obtained through propensity score matching considering several variables. The primary end point was OSA diagnosis.

RESULTS

The study (SD) group included 11,238 individuals and the non-SD group (control group) included 22,476 persons. The overall hazard ratio for OSA in the SD group was 4.39 (95% confidence interval [CI]: 3.56-5.42). In subgroup analysis, the hazard ratio for OSA of male individuals was 3.77 (95% CI: 2.83-5.03), high economic status was 1.27 (95% CI: 1.05-1.56), metropolitan area was 1.31 (95% CI: 1.07-1.62), young age was 0.79 (95% CI: 0.64-0.98), hypertension was 1.00 (95% CI: 0.37-2.7), and diabetes mellitus was 2.44 (95% CI: 1.15-5.21). In the SD group, the hazard ratio for OSA after septoplasty was 0.71 (95% CI: 0.54-0.94).

CONCLUSIONS

From long-term follow-up, the prevalence of OSA was 4.39 times higher in the SD group compared with the control group. This phenomenon was more pronounced with increasing body mass index and decreased significantly after septoplasty.

CITATION

Yeom SW, Chung SK, Lee EJ, et al. Association between septal deviation and OSA diagnoses: a nationwide 9-year follow-up cohort study. J Clin Sleep Med. 2021;17(10):2099-2106.

Impact of Treatment for Nasal Cavity Disorders on Sleep Quality: Systematic Review and Meta-analysis

OBJECTIVE

To determine the impact of treatment for patients with nasal obstruction secondary to allergic rhinitis (AR) and nasal septal deviation (NSD) on sleep quality.

DATA SOURCES

Primary studies were identified though PubMed, Scopus, Cochrane Library, and Web of Science.

REVIEW METHODS

A systematic review was performed by querying databases for articles published through August 2020. Studies were included that reported on objective sleep parameters (apnea-hypopnea index) and sinonasal and sleep-specific patient-reported outcome measures: Rhinoconjunctivitis Quality of Life Questionnaire, Nasal Obstruction Symptom Evaluation, Epworth Sleepiness Scale (EpSS), and Pittsburgh Sleep Quality Index (PSQI).

RESULTS

The database search yielded 1414 unique articles, of which 28 AR and 7 NSD studies were utilized for meta-analysis. A total of 9037 patients (8515 with AR, 522 with NSD) were identified with a mean age of 35.0 years (35.3 for AR, 34.0 for NSD). Treatment for AR and NSD significantly improved subjective sleep quality. For AR, the EpSS mean difference was -1.5 (95% CI, -2.4 to -0.5; P = .002) and for the PSQI, -1.7 (95% CI, -2.1 to -1.2; P < .00001). For NSD, the EpSS mean difference was -3.2 (95% CI, -4.2 to -2.2; P < .00001) and for the PSQI, -3.4 (95% CI, -6.1 to -0.6; P = .02).

CONCLUSION

Subjective sleep quality significantly improved following treatment for AR and NSD. There were insufficient data to demonstrate that objective metrics of sleep quality similarly improved.

[Results of inferior nasal turbinate reduction in old and very old patients with chronic rhinitis]

BACKGROUND

Symptoms of chronic rhinitis in old and very old populations may result from isolated hyperplasia of nasal inferior turbinates. Turbinoplasty is a possible method of treatment in these individuals. However, preoperative concerns are associated with their poor general condition: tendency to epistaxis, treatment with anticoagulants, hypertension, and less effective healing.

OBJECTIVE

The aim of this study was to determine differences in results of turbinoplasty obtained in old and very old individuals with chronic rhinitis, compared to young and otherwise healthy patients.

MATERIAL AND METHODS

We analyzed records of 130 patients with hyperplasia of the inferior turbinates, who had undergone bipolar diathermy turbinoplasty: 82 individuals aged 18-59 (mean = 33.8; SD = 10.2), 30 patients aged 60-74 (mean = 66.0; SD = 3.7) and 18 participants aged 75 + years (mean = 85.3; SD = 6.5). The patients were questioned about the intensity of their symptoms before and one month after the surgery, using the SNOT-20 questionnaire. The duration of wound healing and satisfaction scores were also noted.

RESULTS

Nasal patency, nasal discharge and post-nasal drip improved in old and very old patients, similarly as in the young ones. Olfactory and taste function improved significantly more in young individuals. Postoperative healing time was significantly longer in very old patients.

CONCLUSIONS

Some results of turbinoplasty in old and very old patients were significantly worse than in young ones.

Nasal Obstruction as a Potential Factor Contributing to Hypoxemia in Obstructive Sleep Apnea

PURPOSE

This study aimed to evaluate the correlation between nasal resistance and oxygen desaturation to better elucidate the role of nasal obstruction in the pathophysiology of obstructive sleep apnea (OSA).

PATIENTS AND METHODS

Eighty-eight OSA patients aged between 22 and 77 years were enrolled in this study. Nasal resistance was measured at pressures of 75, 150, and 300 Pa, with the patients first in the seated position than in the supine position. Relationships between the oximetric variables and nasal resistance in the seated and supine positions were analyzed.

RESULTS

From seated to supine position, a statistically significant increase in nasal resistance was observed at pressures of 75 and 150 Pa (p=0.001 and p=0.006, respectively). Significant positive correlations were noted between nasal resistance in the supine position at 75 Pa (SupineNR75) and oximetry variables, including oxygen desaturation index (ODI, p=0.015) and the percentage of total time with oxygen saturation level lower than 90% (T < 90%, p=0.012). However, significant positive correlations existed only in moderate to severe OSA when the study group was further divided into two subgroups (mild vs moderate to severe OSA). Body mass index (β = 0.476, p<0.001) and SupineNR75 (β = 0.303, p=0.004) were identified as independent predictors for increased ODI.

CONCLUSION

Nasal resistance in the supine position measured at 75 Pa significantly correlated with the severity of oxygen desaturation. Therefore, nasal obstruction may play an important role in the pathophysiology of hypoxemia in OSA patients, especially in patients with moderate to severe OSA.

Rhinologic disease and its impact on sleep: a systematic review

BACKGROUND

Rhinologic disease can be responsible for systemic symptoms affecting mood, cognition, and sleep. It is unclear whether sleep disturbance in specific rhinologic disorders (chronic rhinosinusitis [CRS], rhinitis, and nasal septal deviation [NSD]) is an obstructive phenomenon or due to other mechanisms. In this review we examine the impact of CRS, rhinitis, and NSD on objective and subjective sleep outcome metrics and draw comparisons to normal controls and patients with known obstructive sleep apnea (OSA).

METHODS

A systematic review of 4 databases (PubMed, Scopus, Cochrane Library, and Web of Science) was performed. Studies reporting on objective (apnea-hypopnea index [AHI], respiratory disturbance index [RDI], oxygen nadir) and subjective (Epworth Sleepiness Scale [EpSS], Pittsburgh Sleep Quality Index [PSQI], Fatigue Severity Scale [FSS]) sleep parameters and disease-specific patient-reported outcome measures (PROMs; 22-item Sino-Nasal Outcome Test [SNOT-22], Rhinoconjunctivitis Quality of Life Questionnaire [RQLQ], Nasal Obstruction Symptom Evaluation [NOSE]) were included.

RESULTS

The database search yielded 1414 unique articles, of which 103 were included for analysis. Baseline PROMs were at the high end of normal to abnormal for all 3 conditions: EpSS: CRS (9.8 ± 4.0), rhinitis (9.7 ± 4.3), and NSD (8.9 ± 4.6); and PSQI: CRS (11.0 ± 4.5), rhinitis (6.1 ± 3.7), and NSD (8.6 ± 3.5). Objective measures demonstrated a mild to moderate OSA in the studied diseases: AHI: CRS (10.4 ± 11.5), rhinitis (8.6 ± 8.8), and NSD (13.0 ± 6.9). There were significant differences when compared with reported norms in all measured outcomes (p < 0.001).

CONCLUSION

Sleep quality is impacted by rhinologic (CRS, rhinitis, NSD) disease. There is likely a mild obstructive component contributing to poor sleep, but other contributing factors may be involved.

Does nasal surgery improve multilevel surgical outcome in obstructive sleep apnea: A multicenter study on 735 patients

OBJECTIVE

Does nasal surgery affect multilevel surgical success outcome.

METHODS

Prospective eight country nonrandomized trial of 735 obstructive sleep apnea (OSA) patients, who had multilevel palate and/or tongue surgery, divided into two groups, with or without nose surgery.

RESULTS

There were 575 patients in nose group, 160 patients in no nose group. The mean age for nose group 44.6 ± 11.4, no nose group 44.2 ± 11.8. Mean preoperative BMI for nose group 27.5 ± 3.6, no nose group 27.5 ± 4.1, mean postoperative BMI nose group 26.3 ± 3.7, no nose group 27.1 ± 3.8 (P = .006). Mean preoperative AHI nose group 32.7 ± 19.4, no nose group 34.3 ± 25.0 (P = .377); and mean postoperative AHI nose group 13.5 ± 10.2, no nose group 17.1 ± 16.0 (P = .001). Mean preoperative ESS nose group was 11.3 ± 4.7, no nose group was 10.4 ± 5.4 (P = .051); and mean postoperative ESS nose group was 5.3 ± 3.2, no nose group was 6.7 ± 2.8 (P = .001). The nose group had higher percentage change (adjusted for age, gender, BMI) in AHI (33.7%, 95% CI 14% to 53.5%) compared to the no nose group (P = .001); the nose group also had more percentage change in ESS (37%, 95% CI 23.6% to 50.3%) compared to the no nose group (P < .001). Change in BMI did not affect AHI nor ESS change (Cohen effect 0.03 and 0.14, respectively). AHI change in both groups were also statistically significant in the mild OSA (P = .008) and the severe OSA (P = .01). Success rate of surgery for the nose group 68.2%, while the no nose group 55.0% (P = .002).

CONCLUSION

Combining nose surgery in multilevel surgery improves surgical success.

LEVEL OF EVIDENCE

IIC.

Effect of nasal and sinus surgery in patients with and without obstructive sleep apnea

BACKGROUND

Nasal obstruction is associated with snoring, sleep disordered breathing, and OSA. Abnormal nasal physiology is an important aspect of OSA etiology.

AIMS/OBJECTIVES

To perform a systematic review and meta-analysis to determine if isolated nasal surgery in patients with and without OSA could improve sleep quality after surgery.

MATERIAL AND METHODS

Computerized searches were performed in PubMed, Scopus, google scholar and the Cochrane library through June 2017. Two independent investigators performed the articles searching, screening and the data extraction.

RESULTS

There were 19 studies meeting inclusion and exclusion criteria including a total of 896 patients. These studies were divided into two subgroups depending on diagnosis with and without OSA. In subgroup OSA (n = 14), there was a significant improvement in the pooled results of Epworth Sleepiness Scale (ESS) with isolated nasal surgery. In subgroup without OSA (n = 5), the pooled mean difference of ESS before and after surgery was similar. In each subgroup, there was no significant improvement in the Apnea Hypopnea Index.

CONCLUSIONS

The pooled results showed isolated nasal and sinus surgery for patients with OSA could improve subjective sleep parameters and reduce daytime sleepiness, but had no significant improvements on objective parameters. In patients without OSA, it was ineffective to improve sleep quality.

Establishing a Patent Nasal Passage in Obstructive Sleep Apnea

The role of the nose in the pathophysiology and treatment of sleep-disordered breathing (SDB) has not been fully understood and might have been underestimated. In the Staring resistor model, the nose is regarded as a passive and noncollapsible tube, but recent studies have shown that the nose might participate more in the pathophysiology of SDB as anatomic, neuromuscular, and respiratory factors than previously reported, which might imply the nose is an active noncollapsible tube. The roles of nasal treatments for OSA are not only the reduction of AHI, but also the improvement of subjective symptoms, sleep quality, and CPAP adherence.

Polysomnographic and pulmonary function changes in patients with sleep problems after septoplasty with turbinectomy

OBJECT

To compare Polysomnography and Pulmonary function tests before and after Septoplasty with Turbinectomy in patients complaining of nasal obstruction and sleep problems due to deviated septum with hypertrophic inferior turbinate.

METHODS

90 patients underwent Septoplasty with Turbinectomy due to nasal obstruction and sleep problems involved in this study, their sleep quality evaluated by polysomnography before and after the surgery, their pulmonary functions assessed by spirometry before and after the operation.

RESULTS

The postoperative pulmonary function values; FVC, FEV1, PEFR and postoperative polysomonographic values; AHI, Snoring index/hour, SpaO2 were higher than the preoperative values, and the results were statistically significant (p-values <0.001).

CONCLUSION

Septoplasty with partial inferior turbinectomy might be a useful operation in the management of nasal obstruction and sleep problems that caused by a deviated nasal septum and hypertrophied inferior turbinate.

Moderate OSAS and turbinate decongestion: surgical efficacy in improving the quality of life and compliance of CPAP using Epworth score and SNOT-20 score

SUMMARY

Drug-induced sleep endoscopy (DISE) is an important procedure in diagnostic pathway of patients affected by moderate OSAS. However, the Italian National Health System does not provide any compatible Diagnosis-related-group (DRG) code codification for DISE, which makes it impossible to obtain regional reimbursement. In order to overcome this problem, DISE is usually associated with other codified surgical procedures. The aim of our study is to assess the association of turbinate decongestion (TD) and DISE in order to combine in a single operating session diagnostic and therapeutic procedures. The objective of our work is to assess the role of nasal surgery on symptoms of moderate OSA. Recent studies have confirmed that isolated nasal surgery improves quality of life (QOL), but not the apnoea hypopnoea index (AHI) during polygraph registration. We enrolled 30 patients, aged between 29 and 64 years (mean 50.53 ± 9.20), 26 males and 4 females, with a mean BMI of 26.07 ± 2.81 kg/m², who were affected by moderate OSAS. All patients underwent otolaryngologycal pre-operative evaluation, home respiratory polygraph and subjective evaluation through Sino-Nasal-Outcome Test (SNOT-20) and Epworth Sleepiness Scale (ESS). During the same surgery session, they underwent DISE and TD. Patients were re-evaluated six months later using the same questionnaires. We observed a significant improvement (p #x003C; 0.05) in both the mean ESS index (6.03 ± 2.75 vs 4.16 ± 4.63) and total SNOT score (22.53 ± 12.16 vs 13.23 ± 10.82). Significant differences (p #x003C; 0.05) were also identified for partial SNOT questions 1-11 (9.1 ± 5.11 vs 6.13 ± 4.12) and 11-20 (13.36 ± 10.20 vs 7.13 ± 9.644). The results of the present study confirm that TD alone can improve sleepiness, QOL and nasal symptoms. Thus, in absence of a National Health System recognition for DISE, the association of this procedure with TD can be useful for diagnostic and therapeutic management of OSAS, improving CPAP compliance and adherence, reducing sleepiness, ameliorating nasal symptoms and therefore QOL.

Rhinological interventions for obstructive sleep apnoea - a systematic review and descriptive meta-analysis

OBJECTIVES

Obstructive sleep apnoea is a common chronic sleep disorder characterised by collapse of the upper airway during sleep. The nasal airway forms a significant part of the upper airway and any obstruction is thought to have an impact on obstructive sleep apnoea. A systematic review was performed to determine the role of rhinological surgical interventions in the management of obstructive sleep apnoea.

METHODS

A systematic review of current literature was undertaken; studies were included if they involved comparison of a non-surgical and/or non-rhinological surgical intervention with a rhinological surgical intervention for treatment of obstructive sleep apnoea.

RESULTS

Sixteen studies met the selection criteria. The pooled data suggest that there are reductions in the apnoea/hypopnea index and respiratory disturbance index following nasal surgery. However, the current body of studies is too heterogeneous for statistically significant meta-analysis to be conducted.

CONCLUSION

Nasal surgery may have limited benefit for a subset of patients based on current evidence.

[Treating nasal obstruction in obstructive sleep apnea patients]

The impact of treating nasal obstruction in obstructive sleep apnea (OSA) patients is still intensively discussed at congresses. This is likely due to the highly conflicting results of nasal treatments in regard to restorative sleep on the one hand, and their influence on the severity of OSA on the other. Both conservative and surgical nasal treatments result in a highly significant improvement of sleep quality. Patients' sleep is more restorative, which has a huge impact on several quality of life parameters. In contrast, the impact of conservative and surgical nasal treatments on the severity of OSA measured using the apnea-hypopnea index is very limited, apart from rare exceptions. However, there are preliminary data indicating that successful nasal surgery may facilitate or enable nasal ventilation therapy by lowering the effective pressure.

Clinical Practice Guideline: Improving Nasal Form and Function after Rhinoplasty

Objective Rhinoplasty, a surgical procedure that alters the shape or appearance of the nose while preserving or enhancing the nasal airway, ranks among the most commonly performed cosmetic procedures in the United States, with >200,000 procedures reported in 2014. While it is difficult to calculate the exact economic burden incurred by rhinoplasty patients following surgery with or without complications, the average rhinoplasty procedure typically exceeds $4000. The costs incurred due to complications, infections, or revision surgery may include the cost of long-term antibiotics, hospitalization, or lost revenue from hours/days of missed work. The resultant psychological impact of rhinoplasty can also be significant. Furthermore, the health care burden from psychological pressures of nasal deformities/aesthetic shortcomings, surgical infections, surgical pain, side effects from antibiotics, and nasal packing materials must also be considered for these patients. Prior to this guideline, limited literature existed on standard care considerations for pre- and postsurgical management and for standard surgical practice to ensure optimal outcomes for patients undergoing rhinoplasty. The impetus for this guideline is to utilize current evidence-based medicine practices and data to build unanimity regarding the peri- and postoperative strategies to maximize patient safety and to optimize surgical results for patients. Purpose The primary purpose of this guideline is to provide evidence-based recommendations for clinicians who either perform rhinoplasty or are involved in the care of a rhinoplasty candidate, as well as to optimize patient care, promote effective diagnosis and therapy, and reduce harmful or unnecessary variations in care. The target audience is any clinician or individual, in any setting, involved in the management of these patients. The target patient population is all patients aged ≥15 years. The guideline is intended to focus on knowledge gaps, practice variations, and clinical concerns associated with this surgical procedure; it is not intended to be a comprehensive reference for improving nasal form and function after rhinoplasty. Recommendations in this guideline concerning education and counseling to the patient are also intended to include the caregiver if the patient is <18 years of age. Action Statements The Guideline Development Group made the following recommendations: (1) Clinicians should ask all patients seeking rhinoplasty about their motivations for surgery and their expectations for outcomes, should provide feedback on whether those expectations are a realistic goal of surgery, and should document this discussion in the medical record. (2) Clinicians should assess rhinoplasty candidates for comorbid conditions that could modify or contraindicate surgery, including obstructive sleep apnea, body dysmorphic disorder, bleeding disorders, or chronic use of topical vasoconstrictive intranasal drugs. (3) The surgeon, or the surgeon's designee, should evaluate the rhinoplasty candidate for nasal airway obstruction during the preoperative assessment. (4) The surgeon, or the surgeon's designee, should educate rhinoplasty candidates regarding what to expect after surgery, how surgery might affect the ability to breathe through the nose, potential complications of surgery, and the possible need for future nasal surgery. (5) The clinician, or the clinician's designee, should counsel rhinoplasty candidates with documented obstructive sleep apnea about the impact of surgery on nasal airway obstruction and how obstructive sleep apnea might affect perioperative management. (6) The surgeon, or the surgeon's designee, should educate rhinoplasty patients before surgery about strategies to manage discomfort after surgery. (7) Clinicians should document patients' satisfaction with their nasal appearance and with their nasal function at a minimum of 12 months after rhinoplasty. The Guideline Development Group made recommendations against certain actions: (1) When a surgeon, or the surgeon's designee, chooses to administer perioperative antibiotics for rhinoplasty, he or she should not routinely prescribe antibiotic therapy for a duration >24 hours after surgery. (2) Surgeons should not routinely place packing in the nasal cavity of rhinoplasty patients (with or without septoplasty) at the conclusion of surgery. The panel group made the following statement an option: (1) The surgeon, or the surgeon's designee, may administer perioperative systemic steroids to the rhinoplasty patient.

Correcting Concavity of Rabbit Auricular Cartilage: Comparison of Single Scoring Incisions with Butyl Cyanoacrylate-Aided Techniques

BACKGROUND

The authors present the results of an experimental study in which four different techniques were used for the correction of concave rabbit auricular cartilage.

METHODS

Sixteen New Zealand adult male rabbits were used in the study. Butyl cyanoacrylate-aided cartilage graft fixation and butyl cyanoacrylate-aided bone graft fixation and scoring technique, alone or combined with butyl cyanoacrylate application, were performed to correct the concavity of rabbit auricular cartilage.

RESULTS

Angle measurements showed that all four techniques were efficient for correction of the cartilage concavities. However, the mean postsacrifice angles of the graft fixation groups were significantly higher than those of the other study groups, reflecting the fact that graft fixation with butyl cyanoacrylate application was more efficient for preserving the final cartilage shape. Furthermore, in the ninth month, graft fixation groups had the lowest chondrocyte densities, the highest degree of inflammation, the highest degree of foreign body reaction, and the highest butyl cyanoacrylate density.

CONCLUSIONS

Fibrosis or chondrocyte proliferation on scoring incision lines is not an associated feature of this technique. When the incision depths were standardized, the scoring technique provided efficacy similar to that of the scoring incisions combined with butyl cyanoacrylate application for correction of the cartilage concavity. The scoring incision plus butyl cyanoacrylate group showed less toxicity than the graft fixation groups because of rapid removal of toxic breakdown products. Graft fixation techniques were superior to other corrective procedures with regard to preservation of the final cartilage shape. Although they resulted in greater toxicity, the cartilage correction was not affected unfavorably.

The evaluation of pattern and quality of sleep in patients with chronic rhinosinusitis with nasal polyps

OBJECTIVE

The goal of this study is to evaluate the impact of chronic rhinosinusitis with nasal polyps (CRSwNP) on sleep pattern and sleep quality before and after functional endoscopic sinus surgery using subjective and objective parameters.

METHODS

Twenty-two patients with CRSwNP were evaluated. All subjects underwent assessment by nasal endoscopy, rhinomanometry and computed tomography. Sleep pattern and sleep quality were evaluated by Pittsburgh sleep quality index (PSQI) and polysomnography (PSG). All patients were reassessed 6 months after surgery.

RESULTS

Nasal resistance decreased after the surgery (p<0.001). Postoperative PSQI scores were significantly lower than preoperative scores (p<0.001). The preoperative mean values of total apnea index and apnea-hypopnea index were 25.4 and 13.3, respectively. After surgery, the total apnea and apnea-hypopnea index had decreased significantly to 7.8 and 11.2, respectively (p=0.009 and 0.019, respectively).

CONCLUSION

In patients with CRSwNP, functional endoscopic sinus surgery significantly ameliorates sleep pattern and sleep quality. CRSwNP may be a predisposing factor for sleep related respiratory disorders.

Sleep disruption in chronic rhinosinusitis

INTRODUCTION

Chronic rhinosinusitis (CRS) is a common disease of the upper airways and paranasal sinuses with a marked decline in quality of life (QOL). CRS patients suffer from sleep disruption at a significantly higher proportion (60 to 75%) than in the general population (8-18 %). Sleep disruption in CRS causes decreased QOL and is linked to poor functional outcomes such as impaired cognitive function and depression. Areas covered: A systematic PubMed/Medline search was done to assess the results of studies that have investigated sleep and sleep disturbances in CRS. Expert commentary: These studies reported sleep disruption in most CRS patients. The main risk factors for sleep disruption in CRS include allergic rhinitis, smoking, and high SNOT-22 total scores. The literature is inconsistent with regard to the prevalence of sleep-related disordered breathing (e.g. obstructive sleep apnea) in CRS patients. Although nasal obstruction is linked to sleep disruption, the extent of sleep disruption in CRS seems to expand beyond that expected from physical blockage of the upper airways alone. Despite the high prevalence of sleep disruption in CRS, and its detrimental effects on QOL, the literature contains a paucity of studies that have investigated the mechanisms underlying this major problem in CRS.

Apnea-hypopnea index decreased significantly after nasal surgery for obstructive sleep apnea: A meta-analysis

BACKGROUND

Nasal surgeries have been applied to obstructive sleep apnea (OSA) patients with nasal obstruction for decades. However, the efficiency of nasal surgery in improving OSA remains controversial.The aim of this study was to identify whether isolated nasal surgery can improve apnea-hypopnea index (AHI).

METHODS

Computerized searches were performed in MEDLINE, Web of Science, Cochrane Library, and Scopus from January 1, 2000 to April 30, 2016. A total of 18 articles and 587 participants were included. There were 1 randomized controlled trials, 2 nonrandomized trials, 11 prospective studies, and 4 retrospective studies. Data regarding study design (prospective/retrospective clinical trial, randomized, and controlled), population size, participant characteristics (age, gender, and body mass index), surgical intervention, and outcomes (AHI, Epworth sleep scale [ESS]) was collected.

RESULTS

Statistically significant improvement in AHI (subgroup 1: weighted mean difference [WMD] [95%confidence interval (CI)], -4.17 [-7.62, -0.73]; subgroup 2: WMD [95%CI], -4.19 [-7.51, -0.88]; overall: WMD [95%CI], -4.15 [-6.48, -1.82]) and ESS (subgroup 1: WMD [95%CI], -2.14 [-3.08, -1.19]; subgroup 2: WMD [95%CI], -4.70 [-5.95, -3.44]; overall: WMD [95%CI], -4.08 [-5.27, -2.88]) was revealed.

CONCLUSION

Both AHI and ESS improved significantly after isolated nasal surgery, but the improvement of AHI is slightly significant. Future randomized controlled trials are needed to confirm the long-term benefits of nasal surgery on OSA.

Three-dimensional Evaluation of Nasal Surgery in Patients with Obstructive Sleep Apnea

Background:

Obstructive sleep apnea (OSA) is a common sleep disorder and is characterized by airway collapse at multiple levels of upper airway. The effectiveness of nasal surgery has been discussed in several studies and shows a promising growing interest. In this study, we intended to evaluate the effects of nasal surgery on the upper airway dimensions in patients with OSA using three-dimensional (3D) reconstruction of cone-beam computed tomography (CT).

Methods:

Twelve patients with moderate to severe OSA who underwent nasal surgery were included in this study. All patients were diagnosed with OSA using polysomnography (PSG) in multi sleep health centers associated with Massachusetts General Hospital, Massachusetts Eye and Ear Infirmary and the Partners Health Care from May 31, 2011 to December 14, 2013. The effect of nasal surgery was evaluated by the examination of PSG, subjective complains, and 3D reconstructed CT scan. Cross-sectional area was measured in eleven coronal levels, and nasal cavity volume was evaluated from anterior nasal spine to posterior nasal spine. The thickness of soft tissue in oral pharynx region was also measured.

Results:

Five out of the 12 patients were successfully treated by nasal surgery, with more than 50% drop of apnea–hypopnea index. All the 12 patients showed significant increase of cross-sectional area and volume postoperatively. The thickness of soft tissue in oral pharynx region revealed significant decrease postoperatively, which decreased from 19.14 ± 2.40 cm² and 6.11 ± 1.76 cm² to 17.13 ± 1.91 cm² and 5.22 ± 1.20 cm².

Conclusions:

Nasal surgery improved OSA severity as measured by PSG, subjective complaints, and 3D reconstructed CT scan. 3D assessment of upper airway can play an important role in the evaluation of treatment outcome.

Evaluation of the subjective efficacy of nasal surgery

OBJECTIVES

This study aimed to evaluate subjective symptom changes in obstructive sleep apnoea hypopnea syndrome patients following nasal surgery, and to explore treatment efficacy in improving patient quality of life.

METHODS

Patients with nasal blockage accompanied by habitual snoring were stratified into four groups. Their subjective symptoms were evaluated before and after nasal surgery.

RESULTS

There was a significant decrease in the nasal blockage symptom visual analogue scale, Epworth Sleepiness Scale, Snore Outcomes Survey, Spouse/Bed Partners Survey and Sino-Nasal Outcome Test 20 scores for all patients at six months after surgery. The visual analogue scale score for subjective olfactory function was significantly improved in the severe obstructive sleep apnoea hypopnea syndrome patient group.

CONCLUSION

Nasal surgery can effectively improve the subjective symptoms of patients with simple snoring accompanied by nasal blockage and of patients with obstructive sleep apnoea hypopnea syndrome, thus improving their quality of life.

Role of the Allergist-Immunologist and Upper Airway Allergy in Sleep-Disordered Breathing

BACKGROUND

Sleep-disordered breathing in general and obstructive sleep apnea in particular are commonly encountered conditions in allergy practice. Physiologically, nasal (or nasopharyngeal) obstruction from rhinitis, nasal polyposis, or adenotonsillar hypertrophy are credible contributors to snoring and nocturnal respiratory obstructive events. Nevertheless, existing practice parameters largely relegate the role of the allergist to adjunctive treatment in cases of continuous positive airway pressure intolerance.

OBJECTIVES

To survey active American Academy of Allergy, Asthma & Immunology members regarding their perceptions and practices concerning sleep-disordered breathing in adult and pediatric patients with rhinitis, and to review the medical literature concerning this connection to identify therapeutic implications and research gaps.

METHODS

Members of the Work Group on Rhinitis and Sleep-disordered Breathing composed and distributed a Web-based clinically oriented survey to active American Academy of Allergy, Asthma & Immunology members in mid-2015. The group, in addition, conducted an English-language literature review using PubMed and other sources.

RESULTS

Survey results were returned by 339 of 4881 active members (7%). More than two-third of respondents routinely asked about sleep problems, believed that sleep-disordered breathing was a problem for at least a "substantial minority" (10%-30%) of their adult patients, and believed that medical therapy for upper airway inflammatory conditions could potentially help ameliorate sleep-related complaints. Literature review supported the connection between high-grade nasal congestion/adenotonsillar hypertrophy and obstructive sleep apnea, and at least in the case of pediatric patients, supported the use of anti-inflammatory medication in the initial management of obstructive sleep apnea of mild-to-moderate severity.

CONCLUSIONS

Clinical allergy practice and the medical literature support a proactive role for allergists in the diagnosis and management of sleep-disordered breathing.

The effect of compound nasal surgery on obstructive sleep apnea syndrome

BACKGROUND

Nasal surgery often fails to ameliorate the symptoms of obstructive sleep apnea syndrome (OSAS). We developed a compound nasal surgery (CNS) method that consists of septoplasty combined with submucosal inferior turbinectomy and posterior nasal neurectomy to ensure low nasal resistance during sleep.

OBJECTIVE

To clarify the effect of CNS on OSAS, pre- and postoperative changes in sleep-related events were studied by using polysomnography, the Epworth sleepiness scale (ESS), the visual analog scale for snoring, and health-related quality of life (QOL).

METHODS

Forty-five consecutive patients with OSAS and with nasal problems underwent CNS. Three months later, the postoperative effect on OSAS was assessed by using polysomnography findings, daytime sleepiness by the ESS, nasal allergy symptoms, and health-related QOL. Snoring was assessed by the family by using a visual analog scale.

RESULTS

The indices of apnea, apnea-hypopnea, oxygen desaturation, and arousal; the ESS; allergic symptom score; health-related QOL; and snoring on a visual analog scale were all significantly improved.

CONCLUSIONS

CNS improves OSAS events without any pharyngeal surgical procedure in selected patients. If high nasal resistance associated with OSAS is present, then CNS should thus be considered.

The Effect of Nasal Septal Perforation and its Treatment on Objective Sleep and Breathing Parameters

Background

Nasal septal perforation (NSP) may alter nasal airflow patterns and physiology. To the best of our knowledge, no studies in the English literature have investigated the effect of NSP and its treatment on polysomnographic parameters. In this study, we aimed to investigate polysomnographic parameters in patients with NSP as well as changes in those parameters after treatment of NSP.

Material/Methods

Nineteen patients diagnosed with NSP were included in the study. All patients had baseline and post-procedure polysomnographies (PSG) after insertion of silicone septal button for closure of NSP.

Results

Both median AHI [5.30 (14.40) vs. 2.40 (14.50)] and median supine AHI [10.00 (42.10) vs. 6.60 (37.00)] decreased after correction of the perforation. There was a large reduction in median supine AHI in patients with a perforation size >66 mm² [10.10 (34.15) vs. 1.60 (28.30)].

Conclusions

We conclude that NSP did not cause any deterioration in objective sleep parameters as determined by PSG, other than a decrease in REM sleep duration and an increase in supine AHI. Correction of NSP did not affect REM duration and supine AHI decreased after treatment.

The role of nasal treatments in snoring and obstructive sleep apnoea

PURPOSE OF REVIEW

This review highlights recent advances and views on the role of the nose in snoring and obstructive sleep apnoea.

RECENT FINDINGS

Recent reviews and past randomized controlled trials generally agree that nasal surgery may improve quality of life in snoring and obstructive sleep apnoea. There have been no published randomized controlled trials regarding nasal treatments in snoring or obstructive sleep apnoea in the past year.

SUMMARY

Snoring and obstructive sleep apnoea are upper airway disorders in which the role of the nose has been well researched. Studies support that nasal surgery improves quality of life in snoring, but it may not lead to resolution of snoring. Likewise, nasal treatments for obstructive sleep apnoea increase the quality of life and treatment compliance in some patients. Further stratification of patients who may benefit from nasal intervention may clarify the role of nasal surgery.

Does Nasal Surgery Improve OSA in Patients with Nasal Obstruction and OSA? A Meta-analysis

Objective

To perform a systematic review and meta-analysis to determine if isolated nasal surgery in patients with obstructive sleep apnea and nasal airway obstruction improves obstructive sleep apnea.

Data Sources

Computerized searches were performed in PubMed, EMBASE, and the Cochrane Library through October 2014. Manual searches and subject matter expert input was also solicited.

Review Methods

A search protocol was defined a priori, and 2 independent investigators performed the data extraction, focusing on relevant data, including quality data polysomnography data, and taking note of methodological quality and risk for bias.

Results

The 10 studies meeting criteria included a total of 320 patients. There were 2 randomized controlled trials, 7 prospective studies, and 1 retrospective study. There was a significant improvement in the pooled results of both Epworth Sleepiness Scale (ESS; difference 3.53, 95% confidence interval [CI] [0.64, 6.23]) and Respiratory Disturbance Index (RDI; 11.06, 95% CI [5.92, 16.19]) scores with isolated nasal surgery. There was no significant improvement in the Apnea Hypopnea Index (AHI) in the random effects model (4.83, 95% CI [–1.6, 11.62]).

Conclusions

The pooled results showed that isolated nasal surgery for patients with nasal obstruction and obstructive sleep apnea improved some sleep parameters, as shown by significant improvements in ESS and RDI, but had no significant improvements on AHI. Future controlled studies with larger groups are needed to confirm the benefits of isolated nasal surgery in this patient population.

An observational cohort study of the effects of septoplasty with or without inferior turbinate reduction in patients with obstructive sleep apnea

BACKGROUND

The objective of this observational study was to evaluate the outcomes of intranasal surgery in patients with obstructive sleep apnea (OSA) in a single institution in Norway.

METHODS

Fifty-nine patients with OSA and clinically significant nasal obstruction underwent either septoplasty alone or septoplasty with concomitant volume reduction of the turbinates from August 2008 until the end of December 2010. Subjects were scheduled for sleep polygraphy before and 3 months after treatment. In this observational single-centre cohort study we evaluated and compared the effect of these two specific surgical procedures on sleep related parameters.

RESULTS

There was a significant reduction in the apnea-hypopnea index (AHI) only in the group that had septoplasty with turbinate reduction (17.4, (SD 14.4) - 11.7, (SD 8.2), p <0.01), and this effect was significantly better than in the group treated with septoplasty alone. Other objective parameters remained unchanged. Subjective assessments obtained with a postoperative questionnaire showed an equally positive effect on diurnal sleepiness and nasal obstruction in both groups, and a better effect on sleep quality in the combined treatment group.

CONCLUSION

The effect of nasal surgery on obstructive sleep apnea seemed to be greater when there were indications for combined surgery of the inferior turbinates and the nasal septum, compared to when there were indications for septoplasty alone.

Clinical effect of surgical correction for nasal pathology on the treatment of obstructive sleep apnea syndrome

Objectives

This study aimed to evaluate the hypothesis that relief of nasal obstruction in subjects with obstructive sleep apnea (OSA) would lead to reduce OSA severity and to discuss the available evidence on the clinical efficacy of nasal surgery as a treatment modality for OSA.

Study Design

Twenty-five subjects who had reduced patency of nasal cavity and narrowing of retroglossal or retropalatal airways were diagnosed with OSA and underwent nasal surgery, such as septoplasty or turbinoplasty to correct nasal pathologies. The effect of the surgery on nasal patency was quantified by measuring minimal cross-sectional area (MCA) using acoustic rhinometry. The watch-PAT-derived respiratory disturbance index (RDI), apnea and hypopnea index (AHI), lowest oxygen saturation, and valid sleep time were measured before and after nasal surgery.

Results

The present study shows that the AHI and RDI decreased significantly and the lowest oxygen saturation and valid sleep time rose after nasal surgery in 25 OSA subjects. In addition, a reduction in subjective symptoms was observed in subjects and mean MCA increased after nasal surgery. Fourteen subjects were classified as responders and 11 subjects as non-responders. Responders showed considerable improvement of their subjective symptoms and the AHI and RDI were significantly lower after surgery. We found that the changes between pre- and post-operative AHI and RDI values were minimal in 11 non-responders. However, daytime somnolence and REM sleep time improved after nasal surgery in non-responders.

Conclusions

Our study provides evidence that the surgical treatment of nasal pathology improves nasal airway patency and reduces OSA severity in 56% subjects. Furthermore, correction of nasal pathology appears to result in improved sleep quality in both responder and non-responders OSA subjects.

A rational approach to the management of obstructive sleep apnea syndrome

Snoring & obstructive sleep apnea syndrome (OSAS) is a globally prevalent problem which is on the rise in recent times. The treatment modalities include medical appliances and surgery. It is mandatory to have a rational approach in the management of OSAS, by meticulously analyzing both anatomical and physiological parameters causing the disorder. To define a rational approach for the management of OSAS, by devising a comprehensive protocol with assessment of anatomical level of obstruction by dynamic MRI and physiological factors by Epworth sleepiness scale (ESS) and Polysomnography. A prospective study in 110 patients was conducted over a period of 2 years, at our institute. All patients in the study group were evaluated with dynamic MRI and ESS and Polysomnography. As per the management protocols defined in the study, surgery was advocated in 46 patients (Group 1) with severe compromise in airway, while another group of 64 patients (Group 2) were provided continuous positive airway pressure support (CPAP). Successful outcomes among these 110 patients were analyzed at the end of the study period. A few patients required multimodal therapy which included surgery and CPAP support. Among 46 patients, surgical treatment proved successful in 41 patients in whom AHI reduced from 46.96 to 12.88 (improved by 62%) and ESS improved by almost ten points. Among 64 patients in CPAP group, AHI reduced from 54.2 to 11.3 (improved by 79%) and ESS improved by 11 points in all the patients, but six of them had poor compliance. Five patients among the surgical group had persistence of symptoms. Inferences derived from the above results proved the success of formulating a rational approach in the management of OSAS. Critical analysis of the anatomical and physiological factors inducing obstructive episodes and an appropriate treatment plan is vital, to produce successful outcomes in patients with OSAS. Failure of surgical procedures, are often due to improper case selection. A small group of patients may require multimodal therapy with surgery and CPAP.

The role of the nose in sleep-disordered breathing

BACKGROUND

Sleep-disordered breathing (SDB) is a spectrum of airway collapse, ranging from primary snoring to profound obstructive sleep apnea (OSA). Studies have shown an association between impaired nasal breathing and SDB; consequently, treatments of nasal obstruction are often used in an attempt to improve disease severity. The authors performed a review of the literature to determine the impact of nasal obstruction and the effectiveness of nonsurgical and surgical interventions on SDB.

METHODS

Relevant literature up to 2012 on the association between nasal obstruction and SDB and effectiveness of nonsurgical and surgical treatment of the nose in SDB were reviewed.

RESULTS

The literature is mostly limited to uncontrolled case series in which patient groups, interventions, disease definitions, and outcome measures are not standardized. Nasal medications, including intranasal steroids and nasal decongestants, have not been shown to improve either snoring or OSA. Nasal dilators have no impact on OSA but may improve snoring. Surgery for nasal obstruction does not improve objective indicators of SDB but can improve subjective elements of disease, such as snoring, sleepiness, and quality of life. Nasal surgery can facilitate continuous positive airway pressure use in cases where nasal obstruction is the factor limiting compliance.

CONCLUSION

Nasal obstruction plays a modulating, but not causative, role in SDB. Nasal interventions may improve subjective aspects of snoring and OSA but do not improve objective indicators of disease. Standardization of methods and higher evidence level studies will further clarify the benefit of nasal interventions in the treatment of SDB.

Correlation between nasal anatomy and objective obstructive sleep apnea severity

OBJECTIVES

To determine if a correlation exists between nasal anatomical obstruction and obstructive sleep apnea severity as measured by overnight polysomnogram (PSG).

STUDY DESIGN

Cross-sectional study.

SETTING

Tertiary medical center.

SUBJECTS AND METHODS

Subjects were recruited immediately prior to an overnight, in-lab PSG. All subjects who agreed to participate underwent a standardized nasal examination performed by the senior author and then completed the Nasal Obstruction Symptom Evaluation (NOSE) questionnaire, the Snore Outcomes Survey (SOS), and the Epworth Sleepiness Scale (ESS) prior to their sleep study. In addition, tonsil size, Mallampati score, Friedman tongue position, neck circumference, uvula length, and occlusion were assessed and documented. Nasal anatomy assessments were then compared with PSG, NOSE, SOS, and ESS results. Bonferroni correction was used to account for multiple comparisons.

RESULTS

One hundred subjects were included in the study. Fifty-nine subjects (59%) were found to have obstructive sleep apnea syndrome (OSAS) (mean apnea-hypopnea index, 13.1; range, 0-64). Severity of OSAS was associated with age (Spearman's ρ = 0.386, P = .0001). No single nasal anatomy measurement or combined nasal anatomy index was found to correlate with objective sleep-disordered breathing severity measured by PSG. The sample size should have provided 90% power to detect a significant correlation if one existed. After accounting for multiple comparisons, turbinate hypertrophy was found to correlate with the NOSE score (0.3577, P = .0305 corrected), and external and internal nasal valve collapse correlated with each other (0.4986, P < .0001 corrected).

CONCLUSIONS

Objectively assessed abnormal nasal anatomy was not found to be significantly correlated with PSG-measured OSAS severity. Specific objective measurements of obstructive nasal anatomy were correlated to subjective measures of nasal obstruction.

Polysomnographic effect of nasal surgery on positional and non-positional obstructive sleep apnea/hypopnea patients

CONCLUSION

The polysomnographic (PSG) effects of nasal surgery on positional obstructive sleep apnea/hypopnea syndrome (OSAHS) patients (PPs) and non-positional OSAHS patients (NPPs) were different.

OBJECTIVE

We aimed to determine the PSG data changes after nasal surgery and evaluate the PSG effect of nasal surgery on PPs and NPPs, respectively.

METHODS

A total of 79 OSAHS patients with nasal obstruction were recruited. Preoperative rhinomanometry and overnight polysomnography were recorded. Patients were distributed into three groups based on the severity level of the apnea and hypopnea indexes (AHI) (mild, moderate, and severe OSAHS). Three groups were each subdivided into two subgroups (PPs and NPPs). Postoperative data were obtained at least 6 months later.

RESULTS

After surgery, although nasal resistance decreased significantly in all patients, the total rate of success and response in treating OSAHS was only 22.7%. Grouped on the basis of the severity level of AHI, the lowest SpO2 increased and AHI, supine AHI, and arousal indexes decreased significantly only in mild OSAHS (p < 0.05). Subdivided according to the presence or absence of positional dependency, the lowest SpO2 increased and supine AHI decreased significantly in both PPs and NPPs with mild OSAHS and in PPs with moderate OSAHS (p < 0.05). AHI significantly increased in PPs with severe OSAHS (p < 0.05). Supine sleep time was relatively prolonged significantly in PPs with moderate and severe OSAHS (p < 0.05).

Nasal cavity ventilation expansion techniques

Nasal cavity ventilation expansion surgery has been progressively developed alongside an advanced understanding of the pathophysiological mechanisms of sleep-disordered breathing and the maturation of endoscopic surgery techniques. Nasal cavity ventilation expansion surgery could increase the ventilation volume of the nasal cavity effectively and decrease the nasal resistance, relieve the upper airway obstruction, and finally remove the original obstructive factor in the upper airway obstruction. The major significance of these procedures is to decrease the pre-ventilation resistance of the upper airway, to relieve pharyngeal collapse, to recover normal ventilatory function, to promote physical recovery, to re-establish normal metabolic functions, and to restore sleep structure. Nasal cavity ventilation expansion surgery includes a series of procedures and to open nasal sinuses symmetrically could decrease the nasal resistance, relieve the upper airway obstruction, and finally remove the original obstructive factor in the upper airway obstruction. The application of endoscopic surgery to obstructive sleep apnea (OSA) enhances the ventilation volume and symmetry of nasal cavity ventilation and has expanded the range of indications for which functional endoscopic sinus surgery (FESS) is effective. Combined with H-uvulopalatopharyngoplasty (H-UPPP), the outcome of surgical treatment on ventilation disorders of the upper airway obstruction and the symptoms of OSA will both be improved.

Effectiveness of Nasal Surgery Alone on Sleep Quality, Architecture, Position, and Sleep-Disordered Breathing in Obstructive Sleep Apnea Syndrome with Nasal Obstruction

Background

The goal of this study was to evaluate the effect of nasal surgery alone on sleep quality, architecture, position, and sleep-disordered breathing (SDB) (including obstructive apnea and snoring) in adult patients with obstructive sleep apnea syndrome (OSAS) and nasal obstruction.

Methods

A total of 22 consecutive male patients (mean age, 41.3 ± 10.9 years) with OSAS and nasal obstruction, who underwent nasal surgery alone, were enrolled in the study. We compared polysomnographic data related with sleep quality (sleep efficiency [SE] and arousal index [ArI]), sleep architecture (stages N [nonrapid eye movement], 1, 2, and 3, and R [rapid eye movement]), the distribution of sleep positions, and SDB (apnea–hypopnea index [AHI], apnea index [AI], minimum arterial oxygen saturation [SaO 2 ], and snoring) before and after nasal surgery.

Results

SE (from 86.6 ± 6.3% to 89.7 ± 7.1%; p = 0.039), stage R (from 15.3 ± 4.8% to 18.6 ± 5.4%; p = 0.016) and snoring (from 32.2 ± 16.4% to 25.8 ± 18.6%; p = 0.045) significantly changed after nasal surgery. However, there were no significant changes in ArI, other sleep stages, the proportion of sleep time spent in the supine position, AHI, AI, and minimum SaO 2 after nasal surgery.

Conclusion

Nasal surgery alone was partially effective in improving sleep quality, architecture, and snoring, but it had no effect on the change of the distribution of sleep positions and obstructive apnea in patients with OSAS and nasal obstruction.

The efficacy of nasal surgery in obstructive sleep apnea syndrome: a prospective clinical study

The aim of this study was to investigate the effects of surgical intervention for nasal pathologies on obstructive sleep apnea syndrome (OSAS) and continuous positive airway pressure (CPAP) titrations in patients with OSAS. The study was designed as a prospective case control study. Between December 2007 and June 2010, 31 patients (26 men and 5 women) who were diagnosed with OSAS with polysomnography and confirmed to have obstructive nasal pathology were enrolled in the study. The average age of the patients was 53 ± 9.6 (range 33-68 years) and the body mass index ranged from 22 to 40.6 kg/m(2) with an average of 30.3 ± 4.1. The patients were evaluated with Epworth Sleepiness Scale, OSAS Complaints Questionnaire, visual analog scale, and CPAP titration before and 3 months after nasal surgery. As three patients did not attend the control polysomnography, data analysis was performed on 28 patients. Although there was a significant improvement in the nasal passage and subjective complaints, namely, snoring frequency, apnea and daytime sleepiness, the difference between preoperative and postoperative AHI values was not statistically significant. Postoperative CPAP titration results indicated a decrease both in pressures and in AHI in comparison to preoperative values. These reductions were not statistically significant, although the decrease in CPAP pressures was close to significance (p = 0.062). Nasal pathologies should be treated in all patients with OSAS, particularly those undergoing CPAP treatment. However, patients should be counseled that favorable results might not be achieved after nasal surgery.

Efficacy of Single-Staged Modified Uvulopalatopharyngoplasty with Nasal Surgery in Adults with Obstructive Sleep Apnea Syndrome

Objective. The aim of this study was to investigate the clinical efficacy of single-staged modified uvulopalatopharyngoplasty (UPPP) with nasal surgery and the relationship between its surgical outcomes and an anatomy-based staging system in patients with obstructive sleep apnea syndrome (OSAS) with nasal obstruction.

Study Design and Setting. Before–after analysis at a university hospital.

Subjects and Methods. A total of 41 consecutive OSAS patients (mean age 40.1 ± 7.3 years) who underwent single-staged modified (uvula-preserving) UPPP with nasal surgery were included. The investigators compared subjective symptoms and polysomnographic data before and after surgery and investigated objective surgical outcomes according to the anatomy-based (Friedman) staging system and postoperative complications. Surgical success was defined as a reduction of at least 50% in preoperative apnea–hypopnea index (AHI) and a postoperative AHI of less than 20 per hour.

Results. After simultaneous nasal–oropharyngeal surgery, the AHI significantly decreased (from 45.9 ± 23.4 to 20.9 ± 22.1 events per hour; P < .001) and the overall success rate was 56.1% (23/41). Surgical success rates in stages I, II, and III were 70.6% (12/17), 60.0% (9/15), and 22.2% (2/9), respectively. There were no major complications during or after surgery, and most minor complications were transient and resolved without morbidity.

Conclusions. Single-staged modified UPPP with nasal surgery is an available and relatively safe surgical approach in OSAS patients with nasal obstruction. To achieve the best possible surgical outcomes, it is important to select appropriate patients using the anatomy-based staging system.

The role of the nose in snoring and obstructive sleep apnoea: an update

Multilevel anatomic obstruction is often present in snoring and obstructive sleep apnoea (OSA). As the nose is the first anatomical boundary of the upper airway, nasal obstruction may contribute to sleep-disordered breathing (SDB). A number of pathophysiological mechanisms can potentially explain the role of nasal pathology in SDB. These include the Starling resistor model, the unstable oral airway, the nasal ventilatory reflex and the role of nitric oxide (NO). Clinically, a number of case–control studies have shown that nasal obstruction is associated with snoring and mild SDB. However, there is not a linear correlation between the degree of nasal obstruction and the severity of SDB, while nasal obstruction is not the main contributing factor in the majority of patients with moderate to severe OSA. Randomised controlled studies have shown that in patients with allergic rhinitis or non-allergic rhinitis and sleep disturbance, nasal steroids could improve the subjective quality of sleep, and may be useful for patients with mild OSA, however, they are not by themselves an adequate treatment for most OSA patients. Similarly, nasal surgery may improve quality of life and snoring in a subgroup of patients with mild SDB and septal deviation, but it is not an effective treatment for OSA as such. On the other hand, in patients who do not tolerate continuous positive airway pressure (CPAP) well, if upper airway evaluation demonstrates an obstructive nasal passage, nasal airway surgery can improve CPAP compliance and adherence.

Critical Appraisal and Meta-Analysis of Nasal Surgery for Obstructive Sleep Apnea

Background

Nasal surgery is commonly involved in surgical treatment for obstructive sleep apnea (OSA). The aim of this study was to investigate the outcomes of nasal surgery for OSA using evidence-based methodology.

Methods

The MedLine database (1999∼2009) was searched for original articles published in peer-reviewed journals concerning nasal surgery for snoring/sleep apnea. Data extracted from these articles were reviewed and analyzed using meta-analysis technology.

Results

Thirteen articles were critically appraised. Two studies provided control groups and 11 articles (84.6%) consisted of prospective noncontrolled clinical trials (level II in evidence strength). The weighted mean apnea/hypopnea index measured by polysomnography in nine studies decreased from 35.2 ± 22.6 to 33.5 ± 23.8 event/hour after nasal surgery (overall, p = 0.69). The pooled success rate of nasal surgery in treating OSA was 16.7%. Epworth Sleepiness Scale scores in eight studies decreased from 10.6 ± 3.9 to 7.1 ± 3.7 (overall, p <0.001). Nasal surgery for snoring assessed by individual questionnaires and visual analog scale reported significant improvement (p < 0.05).

Conclusion

The critical literature appraisal and meta-analyses show that nasal surgery can effectively reduce daytime sleepiness and snoring. However, the efficacy of nasal surgery in treating OSA is limited.

[Guideline: Treatment of obstructive sleep apnea in adults]

The current guideline discusses conservative and surgical therapy of obstructive sleep apnea (OSA) in adults from the perspective of the ear, nose and throat specialist. The revised guideline was commissioned by the German Society of Ear-Nose-Throat, Head-Neck Surgery (DG HNO KHC) and compiled by the DG HNO KHC's Working Group on Sleep Medicine. The guideline was based on a formal consensus procedure according to the guidelines set out by the German Association of Scientific Medical Societies (AWMF) in the form of a"S2e guideline". Research of the literature available on the subject up to and including December 2008 forms the basis for the recommendations. Evaluation of the publications found was made according to the recommendations of the Oxford Centre for Evidence-Based Medicine (OCEBM). This yielded a recommendation grade, whereby grade A represents highly evidence-based studies and grade D those with a low evidence base.