Impact of impaired nasal breathing on sleep-disordered breathing

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 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.

The Impact on Nasal Septal Anatomy and Physiology Following Le Fort I Osteotomy for Orthognathic Surgery

ABSTRACT

Orthognathic surgery utilizing a Le Fort I osteotomy is performed by oral and maxillofacial surgeons to correct midface and dental occlusal abnormalities. However, the potential sequelae on sinonasal function have had minimal discussion in the literature. The objective of this study was to assess the impact on nasal septum anatomy and physiology following Le Fort I osteotomy for maxillary repositioning surgery. Thirty patients who previously underwent elective orthognathic surgery with Le Fort I osteotomy were enrolled retrospectively to assess the change in their nasal septal anatomy and nasal breathing. Pre- and postoperative computed tomography (CT) scans were used to determine axial displacement of the septum, in both degrees and millimeters, at 4 different standardized anatomic sites following the surgery. These objective anatomic measurements were then compared to the patient's perception of nasal congestion and difficulty breathing via the validated Chronic Sinusitis Survey-Duration Based (CSS-D). Comparison of the CTs before and after surgery demonstrated a new deviation of the nasal septum in all 30 patients, with maximal axial displacements up to 7.22 mm and a mean of 2.64 mm. Postoperative angular displacement changes ranged from minimal to 24°. The CTs showed persistence of a new septal perforation in 20% (6 of 30 patients) following surgery. The CSS-D results demonstrated a mean worsening of nasal breathing and congestion scores from 1.4 before surgery to 3.0 at least 8 weeks after surgery (P < 0.001). Orthognathic surgery utilizing Le Fort I osteotomy may result in persistent nasal septal perforations, new displacement of the nasal septum, and increased perception of nasal dyspnea not previously reported. Further understanding of anatomic changes and nasal airway obstruction that may be caused following such operations warrants further study in order to improve surgical technique and postoperative outcomes.

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.

The Impact of Nasal Obstruction and Functional Septorhinoplasty on Sleep Quality

Importance: Functional septorhinoplasty (FSRP) has been shown to improve both global and disease-specific quality of life (QOL). However, the mechanism by which FSRP improves QOL has not been fully defined. We reasoned that NAO may impact sleep quality and, therefore, studied the relationship using validated patient-reported outcome measures. Objective: To investigate the correlation between NAO and sleep quality using Nasal Obstruction Symptom Evaluation (NOSE) and Functional Outcomes of Sleep Quality (FOSQ-10) questionnaires, and to evaluate the effect of FSRP on NAO and sleep quality. Design, Setting, and Participants: This is a prospective longitudinal study of 125 patients undergoing FSRP for the repair of NAO between November 2017 and April 2019 in a university-based tertiary care medical center. The individuals (mean age = 38 ± 15.6 years, 65 females; 52%) were invited to complete the FOSQ-10 survey preoperatively and at 2, 4, 6, and 12 months postoperatively, and 122 of these patients also completed the NOSE questionnaire. Sixty individuals who reported a history of snoring also completed the Snoring Outcomes Survey (SOS). Twelve of 125 patients had obstructive sleep apnea. Patient demographics, nasal surgery, and medical histories and outcomes were analyzed. Intervention: Functional septorhinoplasty. Main Outcomes and Measures: Comparison of pre- and postoperative sleep and NAO scores to determine the correlation between the severity of NAO and sleep quality and the impact of correction of NAO on sleep quality. Results: A total of 125 patients completed FOSQ-10 questionnaire with a median score of 18.00 (IQR = 15.33-19.66) at baseline. Among these individuals, 122 patients completed the NOSE questionnaire with a median score of 65 (IQR = 45-75). A negative correlation between NOSE and FOSQ-10 scores was found at baseline (r = -0.380, p < 0.001). There was a significant difference in baseline FOSQ-10 scores between individuals with (n = 12, mean FOSQ-10 score = 13.28 ± 3.19) (p < 0.001) and without sleep apnea (n = 100, mean FOSQ-10 score = 17.24 ± 3.21). After FSRP, the NOSE and FOSQ-10 scores improved at each postoperative follow-up time point. The change in FOSQ-10 scores was statistically significant at months 2, 4, and 6 (p < 0.001) but not at month 12 (p = 0.161). The NOSE scores were statistically different from baseline level for each postoperative follow-up visits (p < 0.001-months 2, 4, and 6 and p = 0.031-month 12). The distribution of NOSE scores was not different statistically (p = 0.984). The negative correlation between NOSE and FOSQ-10 mean scores that was demonstrated at baseline increases postoperatively (r = 0.508, p < 0.001). Conclusions and Relevance: FSRP can improve both symptoms of NAO and sleep quality. The increased correlation between NAO and sleep quality after surgery is consistent with the hypothesis that improvement in NAO improves sleep quality and QOL.

Effects of Septoplasty on Tp-e Interval and Tp-e/QT Ratio in Patients With Nasal Septal Deviation

OBJECTIVES

There are multiple nasal airway pathologies leading to upper airway obstruction, and one of the most common ones is nasal septum deviation (NSD). Our study aimed to evaluate the effect of nasal septal surgery in patients with NSD on ventricular arrhythmogenesis using the novel electrocardiographic parameters, Tp-e interval, and Tp-e/QT ratio.

METHODS

This retrospective cross-sectional study included 102 consecutive patients diagnosed with NSD. All participants completed a validated outcomes instrument (the NOSE scale), echocardiographic and electrocardiographic evaluation before and 3 months after septoplasty. The degree of nasal septal deviation was evaluated with the Dreher classification.

RESULTS

All of the electrocardiography parameters (except heart rate and QTmin) were significantly decreased with the septoplasty operation. Electrocardiographic parameters have significantly decreased especially in marked NSD patients. (Δ = difference between the preoperative and postoperative values) ΔNOSE was positively correlated both ΔcTp-e (r = 0.348, P < .001) and ΔcTp-e/QT values (r = 0.536, P < .001).

CONCLUSION

Consequently, marked NSD was associated with increased risk of arrhythmogenesis, which were too much improved after septoplasty. So, treatment of especially marked NSD not only reduces otolaryngological complaints, but also leads to improvement of ventricular repolarization parameters.

A randomised controlled trial of nasal decongestant to treat obstructive sleep apnoea in people with cervical spinal cord injury

STUDY DESIGN

Prospective, double-blind, randomised, placebo-controlled, cross-over trial of nasal decongestion in tetraplegia.

OBJECTIVES

Tetraplegia is complicated by severe, predominantly obstructive, sleep apnoea. First-line therapy for obstructive sleep apnoea is nasal continuous positive airway pressure, but this is poorly tolerated. High nasal resistance associated with unopposed parasympathetic activation of the upper airway contributes to poor adherence. This preliminary study tested whether reducing nasal decongestion improved sleep.

SETTING

Participants' homes in Melbourne and Sydney, Australia.

METHODS

Two sleep studies were performed in participants' homes separated by 1 week. Participants were given a nasal spray (0.5 mL of 5% phenylephrine or placebo) in random order and posterior nasal resistance measured immediately. Outcomes included sleep apnoea severity, perceived nasal congestion, sleep quality and oxygenation during sleep.

RESULTS

Twelve middle-aged (average (SD) 52 (12) years) overweight (body mass index 25.3 (6.7) kg/m²) men (C4-6, AIS A and B) participated. Nasal resistance was reduced following administration of phenylephrine (p = 0.02; mean between treatment group difference -5.20: 95% confidence interval -9.09, -1.32 cmH₂O/L/s). No differences were observed in the apnoea hypopnoea index (p = 0.15; -6.37: -33.3, 20.6 events/h), total sleep time (p = 0.49; -1.33: -51.8, 49.1 min), REM sleep% (p = 0.50; 2.37: -5.6, 10.3), arousal index (p = 0.76; 1.15: -17.45, 19.75), 4% oxygen desaturation index (p = 0.88; 0.63: -23.5, 24.7 events/h), or the percentage of mouth breathing events (p = 0.4; -8.07: -29.2, 13.0) between treatments. The apnoea hypopnoea index did differ between groups, however, all except one participant had proportionally more hypopnoeas than apnoeas during sleep after decongestion.

CONCLUSIONS

These preliminary data found that phenylephrine acutely reduced nasal resistance but did not significantly change sleep-disordered breathing severity.

Could Nasal Surgery Affect Multilevel Surgery Results for Obstructive Sleep Apnea?

OBJECTIVE

To study the role of nasal surgery as a part of multilevel surgery for management of obstructive sleep apnea (OSA).

METHODS

All patients underwent multilevel surgery for relieving OSA symptoms and they were classified according to type of surgical intervention into: group A (20 patients), who underwent hyoid suspension (Hyoidthyroidpexy), tonsillectomy, suspension (El-Ahl and El-Anwar) sutures and nasal surgery (inferior turbinate surgery). Group B (20 patients), who underwent hyoid suspension (Hyoidthyroidpexy), tonsillectomy and suspension sutures. Pre and postoperative sleep study, Epworth sleepiness scale, snoring score were reported and compared.

RESULTS

Apnea hypoapnea index (AHI) dropped significantly in both groups. The mean preoperative AHI was significantly less in patients who had no nasal obstruction (P = 0.0367), while the difference in postoperative values was nonsignificant (P = 0.7358).The mean Epworth sleepiness scale improved significantly in both groups, but the difference between pre and postoperative values in both groups was nonsignificant. The lowest oxygen saturation elevated significantly in both groups, but the difference between pre and postoperative values in both groups was nonsignificant. As regards snoring scores, they dropped significantly in both groups. The preoperative snoring score was reported to be significantly more in patients who had associated nasal obstruction (group A) (P = 0.0113). But after surgery the difference in postoperative values was nonsignificant (P = 0.1296).

CONCLUSION

Treatment of nasal obstruction should be considered a crucial component in the comprehensive management plan for OSA patients as it has significant impact on the patients' AHI and snoring.

Integrating the Divided Nasal Cannula Into Routine Polysomnography to Assess Nasal Cycle: Feasibility and Effect on Outcomes

STUDY OBJECTIVES

Patients suspected to have sleep-disordered breathing underwent an overnight polysomnography using a divided nasal cannula to gain additional information about the nasal cycle during sleep.

METHODS

This was a prospective, observational cohort study replacing the undivided nasal cannula with a divided nasal cannula during routine polysomnography (n = 28).

RESULTS

Integration of the divided nasal cannula pressure transducer system into routine polysomnography was easy and affordable. Most patients (89%) demonstrated nasal cycle changes during the test. Nasal cycle changes tended to occur during body position changes (62%) and transitions from non-rapid eye movement sleep to rapid eye movement sleep (41%). The mean nasal cycle duration was 2.5 ± 2.1 hours. Other sleep study metrics did not reveal statistically significant findings in relation to the nasal cycle.

CONCLUSIONS

Replacing an undivided nasal cannula with a divided nasal cannula is easy to implement, adding another physiologic measure to polysomnography. Although the divided nasal cannula did not significantly affect traditional polysomnographic metrics such as the apnea-hypopnea index or periodic limb movement index based on this small pilot study, we were able to replicate past nasal cycle findings that may be of interest to sleep clinicians and researchers. Given the ease with which the divided nasal cannula can be integrated, we encourage other sleep researchers to investigate the utility of using a divided nasal cannula during polysomnography.

Does nasal congestion have a role in decreased resistance to regular CPAP usage?

Nasal obstruction is known to cause resistance to continuous positive airway pressure (CPAP) therapy in obstructive sleep apnea syndrome (OSAS). In this paper, short- and long-term nasal congestion in OSAS patients receiving CPAP treatment were evaluated with acoustic rhinometry (AR). A total of 36 patients with moderate-to-severe OSAS, diagnosed with polysomnography were included in the study. Ten healthy subjects without OSAS constituted the control group. Pre-treatment nasal patency were measured with AR in all participants. 26 patients used the recommended CPAP treatment. Ten patients did not accept CPAP treatment. The AR test was repeated for all the subjects after 1 and 3 months except the 3rd month's measurements of the control group. There was no statistically significant difference between the initial minimum cross-sectional area (MCA) measurements of OSAS patients, using or not using CPAP, and the control group (P > 0.05). However, the first month MCA measurements of patients receiving CPAP were found to be significantly decreased compared with the initial values (P < 0.001). There was no significant change in the first and third months MCA values in the control group and patients who did not use CPAP (P > 0.05). No significant difference revealed in the 3rd month MCA measurements of the patients using CPAP compared with the initial values (P > 0.05). In this study, the increased nasal congestion, which is thought to be the cause of CPAP resistance, was objectively demonstrated in OSAS patients using CPAP. In addition, the nasal congestion developing at the first month was shown to disappear over time, supporting the opinion that patient compliance in CPAP treatment is expected to increase after regular device usage.

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.

The effectiveness of nasal surgery on psychological symptoms in patients with obstructive sleep apnea and nasal obstruction

Conclusion Nasal obstruction can aggravate the psychological status of OSA patients, and nasal surgery should reduce this aggravation. Nasal surgery significantly improved sleep latency and ameliorated several polysomnographic characteristics. Background The aim of this study was to investigate the psychological status of patients with obstructive sleep apnea (OSA) and nasal obstruction and to evaluate the effects of nasal surgery on the psychological symptoms and polysomnographic (PSG) parameters of these patients. Methods The study was designed as a prospective comparative study. This study compared 30 patients (all male) with nasal obstruction and 30 matched patients without nasal obstruction using the Pittsburgh Sleep Quality Index (PSQI) and the Symptom Check List 90 (SCL-90). All of the patients had been previously diagnosed with OSA (apnea hypopnea index [AHI] ≥ 5 events/h) via a whole-night polysomnographic examination. Nasal obstruction was assessed using a visual analogue scale (VAS). The patients with nasal obstruction underwent nasal surgery, and their weight, VAS, nocturnal PSG characteristics, and psychological symptoms at baseline and 3 months after surgery were compared. Results The OSA patients with nasal obstruction suffered from significantly longer sleep latency on the PSQI and higher somatization and anxiety scores on the SCL-90 than the subjects without nasal obstruction (p < 0.05). The nasal obstruction symptoms significantly improved after surgery (VAS decreased from 6.18 ± 1.85 to 1.87 ± 1.76, p < 0.01). The assessments also showed a significant reduction in weight (from 84.60 ± 11.30 kg to 82.27 ± 9.87 kg, p < 0.05) between the pre-operative and post-operative values. Although there was significant reduction in the AHI (from 49.67 ± 19.49/h to 43.07 ± 21.86/h, p < 0.01) and a significant improvement in lowest oxygen saturation (LSpO2, from 73.83 ± 8.49% to 75.97 ± 9.86%, p < 0.05), only 23.3% of patients achieved a response of nasal surgery that met Sher's criteria. Remarkable reductions were observed in the sleep latency scores, daytime dysfunction scores on the PSQI, anxiety and hostility scores, and the number of positive symptoms on the SCL-90 (p < 0.05). There was a strong positive correlation between PSQI total score and some psychosomatic symptoms on the SCL-90, including inter-personal sensitivity, depression, hostility, paranoid ideation, psychoticism, global symptom index, and the number of positive symptoms (r > 0.3, p < 0.05).

Multilevel Surgery for Obstructive Sleep Apnea: Short-Term Results

OBJECTIVE: To determine the efficacy of a new multilevel surgical protocol for obstructive sleep apnea (OSA).

STUDY DESIGN AND SETTING: Sixty patients with moderate to severe OSA because of multilevel pharyngeal obstruction were enrolled into this prospective, controlled clinical trial after clinical examination, endoscopy, and polysomnography. Surgery included uvulaflap, tonsillectomy, hyoid suspension, and radiofrequency treatment of the tongue base (group A). A second group did not receive hyoid suspension (group B). In both groups, nasal surgery was performed if necessary. Polysomnography and Epworth Sleepines Scale (ESS) were recorded at baseline and 2 to 15 months after surgery.

RESULTS: In group A, the mean apnea-hypopnea index (AHI) decreased significantly after surgery (38.9 ± 20.0 vs 20.7 ± 20.6, P < 0.0001), whereas in group B the AHI did not. All secondary variables (minimal oxygen saturation, mean oxygen saturation, arousal index), and the ESS significantly improved in group A with only changes in arousal index and ESS reaching levels of significance in group B.

CONCLUSION: The presented protocol including the hyoid suspension proved to be effective in the treatment of OSA, whereas surgery without hyoid suspension was less successful.

Effects of Nasal Septum Deviation and Septoplasty on Cardiac Arrhythmia Risk

OBJECTIVE

Upper airway obstruction (UAO) can result in cardiac complications, including arrhythmias and sudden cardiac death. Nasal septum deviation (NSD) is a common cause of UAO. The aim of this study was to assess the risk of cardiac arrhythmias in patients with NSD. To assess this risk, we measured noninvasive indicators of atrial arrhythmia (P-wave dispersion [Pd]) and ventricular arrhythmia (corrected QT dispersion [QTcd]) and compared these values between NSD patients and healthy subjects.

STUDY DESIGN

Prospective study.

SETTINGS

Tertiary referral center.

SUBJECTS AND METHODS

This study included 53 consecutive patients who had underwent septoplasty due to marked NSD. Electrocardiographic records were used to determine Pd and QTcd values preoperatively and 6 months postoperatively. Fifty-three consecutive age- and sex-matched subjects without any UAO were also examined as a control group.

RESULTS

Preoperative Pd and QTcd values were significantly higher in NSD patients than in the control group (Pd: 57.40 ± 14.21 vs 34.11 ± 7.12 milliseconds, P < .001; QTcd: 81.77 ± 16.39 vs 50.25 ± 11.51 milliseconds, P < .001, respectively). In addition, Pd and QTcd values were significantly greater in preoperative NSD patients when compared with the same patients postoperatively (Pd: 57.40 ± 14.21 vs 36.32 ± 8.9 milliseconds, P = .013; QTcd: 81.77 ± 16.39 vs 55.76 ± 11.4 milliseconds, P = .012, respectively).

CONCLUSION

In conclusion, NSD patients are at risk for both atrial and ventricular cardiac arrhythmias; however, septoplasty in these patients can relieve UAO and reduce the risk of arrhythmias.

Pang-Rotenberg sign--snoring surgery prognosticator: A prospective clinical trial of 153 patients

OBJECTIVES/HYPOTHESIS

To illustrate the reliability of the Pang-Rotenberg (PR) sign as a prognosticator of snoring surgery. Our hypothesis was that patients who are PR-positive have better snoring reduction scores and outcomes than PR-negative patients after nose and palate surgery.

STUDY DESIGN

A multicenter prospective series of 153 patients with snoring.

METHODS

All patients graded the snoring intensity on a visual analog scale (VAS). All 137 patients enrolled had both the nose surgery and palate surgery. The control group consisted of 16 patients who underwent nasal surgery alone.

RESULTS

There were 122 men and 15 women, the mean age was 44.6 years old, and mean body mass index was 26.1. There were 15 simple snorers and 122 obstructive sleep apnea patients. Patients who were PR-positive showed significantly better postoperative snoring VAS reduction (from 9.04 to 1.02) compared to those patients who were PR-negative (from 8.91 to 3.14) (P < .001). The mean follow-up time was 7.4 months. The control group had poor snoring VAS reduction from 9.21 to 6.72. After adjusting for covariates that influence the snoring VAS change due to surgery, we found that PR-negative patients achieved an average of 5.78 improvement in snoring VAS, whereas PR-positive patients achieved an average of 8.02 improvement in snoring VAS (P < .001).

CONCLUSIONS

The PR sign is a reliable prognosticator of snoring reduction, after combined nose and palate surgery, for patients with troublesome snoring.

Nasal involvement in obstructive sleep apnea syndrome

Numerous studies have reported an association between nasal obstruction and obstructive sleep apnea syndrome (OSAS), but the precise nature of this relationship remains to be clarified. This paper aimed to summarize data and theories on the role of the nose in the pathophysiology of sleep apnea as well as to discuss the benefits of surgical and medical nasal treatments. A number of pathophysiological mechanisms can potentially explain the role of nasal pathology in OSAS. These include the Starling resistor model, the unstable oral airway, the nasal ventilatory reflex, and the role of nitric oxide (NO). Pharmacological treatment presents some beneficial effects on the frequency of respiratory events and sleep architecture. Nonetheless, objective data assessing snoring and daytime sleepiness are still necessary. Nasal surgery can improve the quality of life and snoring in a select group of patients with mild OSAS and septal deviation but is not an effective treatment for OSA as such. Despite the conflicting results in the literature, it is important that patients who are not perfectly adapted to CPAP are evaluated in detail, in order to identify whether there are obstructive factors that could be surgically corrected.

Nasal symptoms in patients with obstructive sleep apnea and their impact on therapeutic compliance with continuous positive airway pressure

Continuous positive airway pressure (CPAP) is the first line treatment for moderate to severe obstructive sleep apnea syndrome. Despite the high effectiveness of this treatment, its use is often limited by suboptimal compliance and/or intolerance. Nasal side effects are considered a major cause of low therapeutic compliance. At present, there are no data to predict which patients will develop CPAP intolerance caused by nasal symptoms and only few studies looked at the effect of treatment of nasal symptoms on CPAP compliance. The first section of this review focuses on the impact of nasal symptoms (pre-existing or as a side effect of CPAP) on CPAP compliance/intolerance. The second section deals with the effect of nasal symptom treatment on CPAP compliance.

Surgical reconstruction of the upper airway for obstructive sleep apnea

Positive airway pressure can be effective for OSA treatment but is not effectively used by many patients. Surgical reconstruction of the airway is appropriate for patients who are not otherwise effectively treated or as first-line treatment for patients with focal airway lesions. For surgical planning, examination schemes of the awake patient, as well as sleep endoscopy may be used. Nasal surgery may facilitate treatment using positive airway pressure or oral appliances or to improve quality of life. Pharyngoplasty and tongue base techniques for therapeutic upper airway reconstruction may be performed staged or simultaneously. Current and future approaches are described.

Subjective, anatomical, and functional nasal evaluation of patients with obstructive sleep apnea syndrome

BACKGROUND

Studies have shown a high occurrence of nasal alterations in patients with obstructive sleep apnea syndrome (OSAS), but no studies have used different methods to evaluate the nose of patients with OSAS. The objective of this study was to evaluate the nose of patients with OSAS, compare them to controls, and correlate the different methods used to evaluate the nose.

METHODS

Forty-seven patients with moderate/severe OSAS and 20 controls who were matched for gender, age, and body mass index were included. Questionnaires regarding sleep and nasal symptoms, physical examination, rhinoscopy, nasofibroscopy, nasal inspiratory peak flow (NIPF), and acoustic rhinometry (AR) measurements were performed.

RESULTS

In the OSAS group, 33 (70.2%) were male, with a mean age of 53.2 ± 9.1 years. In the control group, 13 (65%) were male, with a mean age of 53.7 ± 9.7 years. The OSAS group had a higher score on the nasal symptoms scale (p < 0.01) and a higher frequency of nasal alterations [presence of septal deviation, clinical complaints (p = 0.01) and hypertrophy of the inferior nasal turbinate (p < 0.01)]. The NIPF and AR parameters could not differentiate between the OSAS and control groups. There were no significant correlations among the different methods used to evaluate the nose. Lower NIPF values were capable of predicting higher apnea-hypopnea index scores (p = 0.007).

CONCLUSION

Clinical complaints and nasal alterations as measured by rhinoscopy and nasofibroscopy were associated with the presence of OSAS, which was not the case for the NIPF and AR parameters. The results of different evaluation methods were not correlated with each other.

Changes in Peak Flow value during immunotherapy administration

Nasal allergies are prevalent affecting a large percentage of the population. Not only the upper respiratory tract but the whole body is involved. Allergies produce morbidity (and even occasional mortality) as they can lead to asthma development, and increased number of accidents. Immunotherapy results can be evaluated by following symptom scores, medication use, and objective measurements. Using a Peak Flow Meter (PFM) to evaluate immunotherapy results, it became evident that patients with and without asthma exhibited an improvement in the Peak Flow (PF) value, suggesting that lower airway involvement in allergic patients could be more prevalent than assumed. A consecutive chart review was performed including patients of any age with nasal allergies (with or without asthma) treated with immunotherapy for at least 6 months that had at least 2 complete evaluations. When immunotherapy was successful, most patients exhibited an increase in the PF value regardless of asthma status. A very significant finding was that most allergy sufferers may have lower airway inflammation. The use of the PF value to assess immunotherapy results and the potential failure to diagnose asthma in allergy sufferers are discussed. A better diagnosis of lower airway inflammation could be substantial in the management of these patients.

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.

What is the efficacy of nasal surgery in patients with obstructive sleep apnea syndrome?

PURPOSE

Obstructive sleep apnea syndrome (OSAS) is characterized by repetitive episodes of partial or complete obstruction of the upper airway during sleep and is associated with increasing respiratory efforts, with a consequent oxyhemoglobin desaturation, sleep fragmentation, and daytime symptoms, most commonly excessive sleepiness. The effectiveness of continuous positive airway pressure (CPAP) is undoubtedly high in treating those patients who use it regularly, but for those who refuse it, the success rate is 0. It is for this subset of patients that surgical therapy can be useful. The purpose of this study was to evaluate the effects of nasal surgery on nasal resistance, sleep apnea, sleep quality, and nasal volumetric measurement in adult male patients with OSAS.

METHODS

Twenty male patients with complaints of hypersomnia and snoring were included in the study. Polysomnography of patients with the prediagnosis of OSAS was planned. All patients underwent CPAP treatment before and after surgery. Patients, who had anatomic structural defects causing nasal valve shrinkage, were operated on at the Plastic Reconstructive and Aesthetic Department. Volumetric measurements of the nose were obtained before and after the operation.

RESULTS

In our study, it was observed that respiratory tract space of patients increased subsequent to the surgery, and thereby OSAS level decreased, and tolerating CPAP device was easier. Measurements of internal nasal valve vertex and fields and external nasal valve fields before and after operation were significant.

CONCLUSIONS

Surgical relief of this nasal obstruction may improve quality of life in patients with OSAS.

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.

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.

Can Nasal Surgery Improve Obstructive Sleep Apnea: Subjective or Objective?

Background

This study assessed changes in sleep-related symptoms and polysomnographic parameters after nasal surgery for nasal obstruction in obstructive sleep apnea (OSA) adults in Taiwan.

Methods

A total of 66 patients with OSA and chronic nasal obstruction were recruited (surgical, n = 44; control, n = 22). Nasal surgery alone was the treatment in surgical patients. Outcomes were measured in a Snore Outcome Survey (SOS), Epworth Sleepiness Scale (ESS), rhinomanometry, and polysomnographic parameters at baseline and again after 3 months.

Results

Significantly improved nasal resistance as measured by the SOS and ESS were found only in the surgical group (all, p < 0.001). Both groups revealed insignificant changes in polysomnographic parameters. The patients with lower body weight index, less daytime sleepiness, and lower tongue position had a better success rate than the others (50% versus 3%; p < 0.001).

Conclusion

Although nasal surgery relieved snoring and daytime sleepiness, it had variable effects on polysomnographic parameters.

Pharyngeal morphology: a determinant of successful nasal surgery for sleep apnea

OBJECTIVES/HYPOTHESIS

To estimate the effectiveness of nasal surgery on the occurrence of sleep apnea, and to analyze the pharyngeal morphology of apnea patients whose sleep-disordered breathing was ameliorated postoperatively.

STUDY DESIGN

Prospective study.

METHODS

Thirty-five consecutive patients with apnea and nasal obstruction underwent polysomnography and a morphological examination of the upper airway before and after nasal surgery, which included septoplasty, inferior turbinectomy, and/or functional endoscopic sinus surgery.

RESULTS

Sleep apnea was significantly ameliorated in only eight patients. The postoperative reduction in the apnea-hypopnea index tended to be lower in those with a low-positioned soft palate, reflected in an elevated modified Mallampati score, and a narrow retroglossal space. Neither swollen tonsils nor narrow fauces affected the surgical outcome. Regression analysis showed that the modified Mallampati score (P < .05) and the retroglossal space (P < .05) were significant predictors of postoperative improvement in the apnea-hypopnea index.

CONCLUSIONS

Among sleep apnea patients suffering from nasal obstruction, nasal surgery is effective in those with a high-positioned soft palate and/or a wide retroglossal space.

Effect of weight reduction on rhinometric measurements in overweight patients with obstructive sleep apnea

BACKGROUND

Elevated nasal resistance and obesity predispose to obstructive sleep apnea (OSA). Weight loss has been shown to result in an alleviation of OSA, but its effect on nasal airflow has not been studied.

METHODS

This study was a prospective, randomized, controlled study with two parallel groups. A total of 52 adult overweight patients (body mass index [BMI], 28-40 kg/m2) with mild obstructive sleep apnea (apnea-hypopnea index (AHI), 5-15) were randomized into two study groups. The intervention group (n = 26) followed a very low calorie diet with a supervised lifestyle intervention while the control group (n = 26) received routine lifestyle counseling. The changes in BMI, total nasal resistance, total nasal volume, and quality of life scores (Mini Rhinoconjunctivitis Quality of Life Questionnaire, MiniRQLQ) were assessed at baseline and after the intervention at 3 months.

RESULTS

The reduction in BMI in the intervention group was significantly greater than that achieved by patients in the control group (5.4 kg/m2 versus 0.5 kg/m2). Accordingly, AHI was reduced by 3.2 events/hour in the intervention group and by 1.3 in the control group. However, there were no significant changes in rhinometric measurements despite significant weight loss. There was no correlation between the reduction of BMI and the change in nasal resistance or MiniRQLQ scores.

CONCLUSION

Weight reduction does not seem to have any effect on nasal resistance or volume in overweight patients with mild OSA. Patients with OSA and impaired nasal breathing need specific medical or surgical treatment to restore nasal airflow.

Effects of Nasal Surgery on Sleep Quality in Obstructive Sleep Apnea Syndrome with Nasal Obstruction

Background

The purpose of this study was to evaluate the effects of nasal surgery on nasal resistance, sleep apnea, and sleep quality in adult male patients with obstructive sleep apnea syndrome (OSAS). A prospective study was performed in OSAS patients who underwent isolated nasal surgery in a tertiary referral center.

Methods

During the 3-year study period, 49 OSAS patients suffering from symptomatic nasal obstruction/impaired nasal breathing underwent the standard polysomnography before and after surgery. Polysomnography along with measures of nasal resistance and daytime sleepiness (the Epworth sleepiness scale [ESS] scores) were reviewed also.

Results

Surgery decreased the nasal resistance (0.55 ± 0.37 Pa/cm3 per second versus 0.17 ± 0.19 Pa/cm3 per second; p < 0.001) and ESS scores (11.7 ± 4.1 versus 3.3 ± 1.3; p < 0.001), without changes in the apnea-hypopnea index (AHI; 44.6 ± 22.5 versus 42.5 ± 22.0). Surgery increased nadir oxygen saturation (76.2 ± 10.9% versus 78.8 ± 8.1%; p < 0.01), shortened apnea–hypopnea duration (averaged/maximum; 33.5 ± 7.3/61.1 ± 46.0 versus 28.8 ± 7.4/47.3 ± 36.1 second; p < 0.05/p < 0.01), and improved sleep quality.

Conclusion

The results suggest that nasal surgery is useful for lowering nasal resistance, ameliorating sleep-disordered breathing, and improving sleep quality and daytime sleepiness in OSAS.

[Sleep-related breathing disorders. Sleep anamnesis questionnaire and determination of clinical results within the framework of staged diagnostics]

Sleep-related breathing disorders (SBAS) affect approximately 8% of the population of middle aged adults. At the age of 20 years, approximately 10% of the population snore, while at the age of 60 about 50% of men snore. Some 9% of middle aged women and 24% of middle aged men have an apnea hypopnea index (AHI) of >5 (number of nocturnal apnea and hypopnea per hour of sleep). Sleep apnea hypopnea syndrome is found in 2% of the women and 4% of the men, i.e. they have an AHI>5 associated with daytime sleepiness. Forms, check lists, summaries and patient-readable questionnaires have proved helpful in the evaluation of SBAS.

Rhinitis and sleep apnea

The nose and pharynx begin the upper airway system and represent a continuum. This is the biologic basis for the mutual influences of rhinitis and obstructive sleep apnea (OSA). Sleep-disordered breathing has a large differential diagnosis that includes snoring, upper airway resistance syndrome, and severe OSA. Nasal obstruction is an independent risk factor for OSA, but there is no correlation of daytime nasal resistance with the severity of OSA. However, nasal resistance was an independent predictor of apnea-hypopnea index in a recent study of nonobese OSA patients. Rhinitis alone is associated with mild OSA, but commonly causes microarousals and sleep fragmentation. Reduction of nasal inflammation with topical treatment improves sleep quality and subsequent daytime sleepiness and fatigue. Patient compliance with the nasal continuous positive airway pressure (nCPAP) device is relatively low, in part due to adverse nasal effects.