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

Considerations for Functional Nasal Surgery in the Obstructive Sleep Apnea Population

Obstructive sleep apnea (OSA) and nasal obstruction are common in the general population and frequently treated by otolaryngologists and facial plastic surgeons. Understanding the appropriate pre-, peri-, and postoperative management of OSA patients undergoing functional nasal surgery is important. OSA patients should be appropriately counseled in the preoperative period on their increased anesthetic risk. In OSA patients who are continuous positive airway pressure (CPAP) intolerant, the role of drug-induced sleep endoscopy should be discussed with the patient, and depending on the surgeon's practice may prompt referral to a sleep specialist. Should multilevel airway surgery be indicated, it can safely be performed in most OSA patients. Surgeons should communicate with the anesthesiologist regarding an airway plan given this patient population's higher propensity for having a difficult airway. Given their increased risk of postoperative respiratory depression, extended recovery time should be given to these patients and the use of opioids as well as sedatives should be minimized. During surgery, one can consider using local nerve blocks to reduce postoperative pain and analgesic use. After surgery, clinicians can consider opioid alternatives such as nonsteroidal anti-inflammatory agents. Neuropathic agents, such as gabapentin, require further research in their indications for managing postoperative pain. CPAP is typically held for a period of time after functional rhinoplasty. The decision on when to restart CPAP should be individualized to the patient based on their comorbidities, OSA severity, and surgical maneuvers performed. More research would provide further guidance in this patient population to shape more specific recommendations regarding their perioperative and intraoperative course.

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.

Role of Nasal Ventilation Function in Obstructive Sleep Apnea Syndrome in Children

Background: The association between increased nasal resistance (NR) and obstructive sleep apnea syndrome (OSAS) is controversial. The purpose of this study was to examine nasal ventilation function (NVF) in children with OSAS, with a focus on its pathogenetic role. Methods: Children were recruited and divided into the OSAS group (n = 109) and control group (n = 116). The participants underwent polysomnography (PSG), measurement of NR, and acoustic rhinometry (AR). A combination of intranasal corticosteroids (ICS) and oral montelukast (OM) was administered to 90 children with mild to moderate OSAS for 12 weeks. After excluding participants who dropped out or were lost to follow-up, there were 58 children who responded to the treatment, who were divided into 2 groups-A and B. We compared the size of the tonsil adenoids, the PSG, NR, and AR before and after treatment in the 2 groups. Results: Children aged 6 to 12 years with OSAS had significantly higher NR than the control group (P < .05). The OSAS group had a smaller nasal minimal cross-sectional area (NMCA), nasal cavity volume (NCV) from 0 to 5 cm, and nasopharyngeal volume (NPV) from 6 to 8 cm than the control group, and the difference was statistically significant (P < .05 or P < .01). A total of 58 (84.1%) children responded to the 12-week ICS+OM treatment and 11 (15.9%) children did not respond to the treatment. Effective treatment was achieved in 32 children, as evidenced by a significant reduction in tonsil adenoid size and variations in NR and AR values. There were significant improvements in NR, NMCA, and NCV in the remaining 26 children who were successfully treated, but there was no change in tonsil adenoids and NPV value. Conclusion: NVF may play an important pathogenetic role in children with OSAS.

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.

Evidence-Based Medicine: The Role of Nasal Surgery in Treatment of Obstructive Sleep Apnea

Nasal surgery performed for the management of obstructive sleep apnea includes septoplasty with and without inferior turbinate reduction and functional rhinoplasty. There is controversy over the effectiveness of these techniques in terms of their ability to decrease apnea-hypopnea index. However, it is fairly accepted that nasal surgery can improve sleep-related quality of life measures. This review focuses on the recently published evidence surrounding the role of nasal surgery in obstructive sleep apnea. Findings suggest that functional rhinoplasty may improve apnea-hypopnea index (AHI) in patients with mild OSA. The effect of septoplasty on AHI is less consistent. Further studies are needed to better clarify the role for both septoplasty and functional rhinoplasty in the OSA treatment algorithm.

The Role of Isolated Nasal Surgery in Obstructive Sleep Apnea Therapy-A Systematic Review

Nasal obstruction is believed to play a significant role in the pathophysiology and management of obstructive sleep apnea (OSA). However, controversy remains about the ability of isolated nasal surgery to improve OSA. The objective of this systematic review is to give an updated overview of the literature on whether isolated nasal surgery can improve OSA subjectively (Epworth Sleepiness Scale (ESS)) and/or objectively (polysomnography (PSG)). Methods: A systematic review was performed searching the electronic databases PubMed, Embase.com (accessed on 20 June 2022) Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials (CENTRAL) up to 20 June 2022. Eligible studies were reviewed for methodological quality using the NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Results: Twenty-one studies met the inclusion criteria. The majority of the included studies reported no significant reduction in the apnea-hypopnea index (AHI) after isolated nasal surgery in patients with OSA. The meta-analysis suggests that the AHI slightly decreases after nasal surgery. The ESS was significantly lower after nasal surgery in eighteen studies. Conclusion: Based on the present analysis of objective outcomes, isolated nasal surgery did not improve the AHI significantly in the majority of the studies. The meta-analysis suggests a slight decrease in AHI after nasal surgery, but this reduction is not clinically relevant in terms of treatment success. Isolated nasal surgery should therefore not be recommended as a first-line treatment for OSA. Because of high study heterogeneity, these results should be interpreted with caution. Isolated nasal surgery can possibly improve OSA subjectively. Perhaps only OSA patients with complaints of nasal obstruction or OSA patients experiencing difficulty with continuous positive airway pressure (CPAP) compliance would benefit from isolated nasal surgery.

Holistic care for obstructive sleep apnea (OSA) with an emphasis on restoring nasal breathing: A review and perspective

Obstructive sleep apnea (OSA) is characterized by partial or complete airway blockage during sleep. Nocturnal nasal obstruction usually leads to mouth breathing while sleeping, which worsens sleep apnea by aggravating tongue base and lateral pharyngeal wall collapse. The pathogenesis of OSA is multifactorial, and the precipitating factors vary significantly among individuals. Although continuous positive airway pressure (CPAP) is considered the first-line therapy for OSA, its adherence rate remains a challenge. Oral appliances are more suitable for simple snorers or patients with mild OSA. Maxillomandibular advancement (MMA) is highly effective for treating those with mandibular retrognathia and moderate-to-severe OSA. Intrapharyngeal surgeries yield favorable outcomes in patients with large tonsils and low tongue resting position (Friedman Stage I); however, their efficacy declines with time. Each therapy has its own strength and weakness; thus, the principle of multimodality treatment should be adopted. Nasal surgery plays an indispensable role in the holistic care for OSA. In addition to alleviating nasal congestion, nasal surgery significantly reduces snoring intensity and daytime sleepiness, which improves the quality of life of patients with OSA. Although it significantly reduces the respiratory disturbance index, its effect on the apnea-hypopnea index remains controversial. A combination of nasal surgery and multilevel pharyngeal surgery may result in better prognosis. Nasal surgery can significantly reduce the therapeutic pressure and improve the CPAP compliance of patients undergoing CPAP therapy. In conclusion, multimodality treatment and holistic care for OSA should involve nasal surgery for optimizing treatment outcomes.

Surgical correction of nasal obstruction in obstructive sleep apnea improves CPAP outcomes and compliance

BACKGROUND

Although continuous positive airway pressure (CPAP) therapy curtails most of the negative impacts of obstructive sleep apnea (OSA), its efficacy is limited by its low long-term adherence. Nasal obstruction contributes to OSA pathophysiology and necessitates high CPAP titration pressures which reduce CPAP compliance.

AIM

This study aims at elucidating the outcomes of surgical correction of nasal obstruction in patients intolerant to CPAP therapy.

METHODS

Forty-nine patients with severe OSA intolerant to CPAP secondary to surgically correctable nasal obstruction were operated upon. Patients were evaluated preoperatively and at least 3 months after the surgical intervention. Subjective assessment entailed the Nasal Obstruction Symptom Evaluation score (NOSE) and the Epworth Sleepiness Scale (ESS). Objectively the patients were assessed by acoustic rhinometry and standard polysomnography.

RESULTS

Nasal surgical intervention resulted in an a statistically significant decrease in the mean NOSE score, ESS and optimal CPAP titration pressure. In addition, the minimal cross-sectional area (MCA1&2) increased significantly postoperatively. There was a positive correlation between the improvement in NOSE score as well as the MCA1& 2 and the postoperative decrease in CPAP titration pressure. Surgical correction of nasal obstruction improved CPAP outcomes and compliance in all patients.

CONCLUSIONS

Nasal surgery in OSA objectively assessed by acoustic rhinometry improved nasal obstruction with a resultant decrease in the CPAP pressure requirements. Given that lower CPAP pressures improve adherence to CPAP therapy, surgical alleviation of nasal obstruction should be considered a crucial intervention in the management armamentarium of 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.

Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment

INTRODUCTION

This systematic review provides supporting evidence for the accompanying clinical practice guideline on the referral of adults with obstructive sleep apnea (OSA) for surgical consultation.

METHODS

The American Academy of Sleep Medicine commissioned a task force of experts in sleep medicine. A systematic review was conducted to identify studies that compared the use of upper airway sleep apnea surgery or bariatric surgery to no treatment as well as studies that reported on patient-important and physiologic outcomes pre- and postoperatively. Statistical analyses were performed to determine the clinical significance of using surgery to treat obstructive sleep apnea in adults. Finally, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) process was used to assess the evidence for making recommendations.

RESULTS

The literature search resulted in 274 studies that provided data suitable for statistical analyses. The analyses demonstrated that surgery as a rescue therapy results in a clinically significant reduction in excessive sleepiness, snoring, blood pressure (BP), apnea-hypopnea index (AHI), respiratory disturbance index (RDI), and oxygen desaturation index (ODI); an increase in lowest oxygen saturation (LSAT) and sleep quality; and an improvement in quality of life in adults with OSA who are intolerant or unaccepting of positive airway pressure (PAP) therapy. The analyses demonstrated that surgery as an adjunctive therapy results in a clinically significant reduction in optimal PAP pressure and improvement in PAP adherence in adults with OSA who are intolerant or unaccepting of PAP due to side effects associated with high pressure requirements. The analyses also demonstrated that surgery as an initial treatment results in a clinically significant reduction in AHI/RDI, sleepiness, snoring, BP, and ODI and an increase in LSAT in adults with OSA and major anatomical obstruction. Analysis of bariatric surgery data showed a clinically significant reduction in BP, AHI/RDI, sleepiness, snoring, optimal PAP level, BMI, and ODI and an increase in LSAT in adults with OSA and obesity. Analyses of very limited evidence suggested that upper airway surgery does not result in a clinically significant increase in risk of serious persistent adverse events and suggested that bariatric surgery may result in a clinically significant risk of iron malabsorption that may be managed with iron supplements. The task force provided a detailed summary of the evidence along with the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations.

CITATION

Kent D, Stanley J, Aurora RN, et al. Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med. 2021;17(12):2507-2531.

Nasal function and CPAP use in patients with obstructive sleep apnoea: a systematic review

PURPOSE

This systematic review was conducted to answer the following 3 questions: 'Does nasal pathology affect CPAP use?', 'What is the effect of CPAP on the nose?' and 'Does treatment of nasal pathology affect CPAP use?'.

METHODS

Pubmed and Scopus databases were searched for articles relevant to the study questions up to October 2020.

RESULTS

Sixty-three articles were selected, of which a majority were observational studies. Most studies identified a correlation between larger nasal cross-sectional area or lower nasal resistance and higher CPAP compliance or lower CPAP pressures; however, nasal symptoms at baseline did not appear to affect CPAP use. The effect of CPAP on the nose remains uncertain: while most studies suggested increased mucosal inflammation with CPAP, those investigating symptoms presented contradictory results, with some reporting an increase and others an improvement in nasal symptoms. Evidence is clearer for nasal surgery leading to an increase in CPAP compliance and a decrease in CPAP pressures, whereas there is little evidence available for the use of topical nasal steroids.

CONCLUSION

There appears to be a link between nasal volumes or nasal resistance and CPAP compliance, an increase in nasal inflammation caused by CPAP and a beneficial effect of nasal surgery on CPAP usage, but no significant effect of CPAP on nasal patency or effect of topical steroids on CPAP compliance. Results are more mitigated with regard to the effect of nasal symptoms on CPAP use and vice versa, and further research in this area would help identify patients who may benefit from additional support or treatment alongside CPAP.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Future Direction in Rhinoplasty: Functional Improvements for a Better Outcome

The nose plays both an aesthetic and functional role in the human body. Physiologically, the nose is an important part of the upper airway. Aesthetically, it is the central focal point of the face. Thus, rhinoplasty has evolved to be both an aesthetic and functional surgery, as the manipulation of the aesthetic subunits of the nose inadvertently leads to the functional alterations of the nose. While the aesthetic goals of rhinoplasty are well described in the literature, functional outcomes from rhinoplasty have been more challenging to delineate. Rhinoplasty can have an impact on the sense of smell, sleep apnea, oxygenation, cognitive function, cardiovascular function, and voice. We have systematically reviewed the current literature in regard to functional rhinoplasty and septoplasty to summarize current surgical maneuvers and their impact on nasal function, along with physiological and perceived functional changes from rhinoplasty.

Nasal Surgery May Improve Upper Airway Collapse in Patients With Obstructive Sleep Apnea: A Drug-Induced Sleep Endoscopy Study

OBJECTIVE

The aim of this study is to evaluate the effects of nasal surgery in the upper airway (UA) collapse using drug induced sleep endoscopy (DISE) in a group of patients with obstructive sleep apnea hypopnea syndrome (OSAHS).

METHODS

Prospective cohort of patients treated with nasal surgery between 2015 and 2016. All patients were diagnosed with mild to severe OSAHS. The inclusion criteria were age between 18 and 70 years, apnea-hypopnea index (AHI) higher than 15, and septal deviation. All patients had a DISE performed before surgery and 3 months after. The DISE findings were evaluated through the NOHL scale.

RESULTS

Thirty-four patients were included. Surgical success with subjective and objective improvement in nasal obstructions was achieved in all cases. The pattern of UA obstruction did change significantly following nasal surgery (P < 0.05). Before nasal surgery, 74% of the patients demonstrated multilevel obstruction. After nasal surgery, only 50% patients showed multilevel collapse (P < 0.05). Among patients with single-level collapse, the oropharynx was the most common location of obstruction. It became more frequent after nasal surgery was done (41% vs 21%, P < 0.05). Significant improvement was shown in hypopharyngeal collapse. Postoperative AHI decreased from a mean of 26.7 to 19 events/h, but this change was not significant.

CONCLUSION

Nasal surgery may improve hypopharyngeal collapses observed during DISE in patients with OSAHS. Thus, an improvement in nasal obstruction may also modify the surgical plan based on UA functional findings in OSAHS patients.

Nasal pathologies in patients with obstructive sleep apnoea

Nasal obstruction is a frequent condition in patients with obstructive sleep apnoea (OSA). Nasal obstruction leads to mouth breathing, which is thought to destabilise the upper airway and aggravate the condition. Three conditions could be considered as the cause of the nasal breathing obstruction: anatomical conditions of the nose (septum deviation, hypertrophy of the inferior turbinates), chronic rhinosinusitis (CRS) and chronic nasal inflammation caused by allergic rhinitis or non-allergic cellular rhinitis. In this prospective study, we present an evaluation of all these possible rhino-sinusal aspects in OSA patients to correlate different nasal pathologies with nasal obstruction. Fifty patients with a diagnosis of OSA were enrolled in the study. In 70% of OSA patients, nasal obstruction was confirmed by clinical evaluation and rhinomanometry testing. Normal rhino-sinus aspects were present in only 20% of OSA patients, whereas one or more pathological rhino-sinus conditions were present in the remaining 80%. The percentage of OSA patients with a diagnosis of allergic rhinitis and non-allergic rhinitis was 18% and 26% respectively. Non-allergic rhinitis with neutrophils (NARNE) was the most frequent type of cellular rhinitis diagnosed in OSA patients (20% of cases). The results of the present study support and extend the observation that rhinitis is present in OSA patients. Mucosal inflammation caused by these conditions could be the cause of upper airway patency impairment inducing nasal mucosa swelling.

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.

Gravitational forces, negative pressure and facial structure in the genesis of airway dysfunction during sleep: a review of the paradigm

The recent and distant literature has extensive discussion of how sleep apnea, adeno-tonsillar growth, and facial structural deformity are related. Conventionally, the order of cause and effect is as follows: (1) Inflammatory/infectious process→tonsillar/adenoid tissue growth→(2) airway obstruction and mouth breathing/Obstructive Sleep Apnea (OSA)→(3) altered facial structure (adenoid facies). Using this same reasoning, adenotonsillectomy is the first line of treatment in the prevention of structural abnormalities. However, through a lifetime of clinical research Christian Guilleminault and his colleagues have challenged this paradigm. Through multiple articles and studies, Guilleminault et al., teach that even slight (subclinical) facial structure/muscle tone variations may be the inciting event triggering mouth-breathing and the eventual adenotonsillar growth in most patients. Essentially, this is the reverse of the conventional paradigms. Initial treatments therefore shift from simplified removal of inflammatory tissue to limiting mouth-breathing via musculo-skeletal modification. The purpose of this paper is to synthesize and analyze the recent (and distant) relevant literature to provide support for, and provide a potential anatomic mechanism for Guilleminault et al.'s paradigm-questioning clinical observations.

[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.

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.

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.

A comparative study on oxidative stress role in nasal breathing impairment and obstructive sleep apnoea syndrome

Obstructive sleep apnoea syndrome (OSAS) is a sleep disorder that leads to metabolic abnormalities and increased cardiovascular risk. This study aimed to define the expression and clinical significance of biomarkers involved in oxidative stress in patients with OSAS. A prospective study was designed to compare outcomes of oxidative stress laboratory tests in three groups of subjects. The study involved the recruitment of three groups of subjects, 10 patients with obstructive sleep apnoea syndrome with AHI > 30; 10 patients suffering from snoring at night with AHI < 15; 10 patients with nasal respiratory impairment with AHI < 5. Patients were subjected to skin prick tests for common aero-allergens, nasal endoscopy, active anterior rhinomanometry, fibrolaryngoscopy and polysomnography; and extra-routine diagnostic tests and procedures; analysis of oxidative and antioxidant (plasma thiol groups) biomarkers in blood and urine samples. No statistical differences in age, sex distribution or body mass index were present between the three groups (p > 0.05). There were significant differences in AHI among the three groups of patients (p < 0.05). No statistical significance was found in the Analysis of Variance (ANOVA) test (p > 0.05) between the levels of biomarkers of oxidative stress in the three populations studied. The results of our study show that the nose can play a role in the pathogenesis of OSAS through the production of biomarkers of oxidative stress.

Surgical Management of Obstructive Sleep Apnea

Surgical management of snoring and obstructive sleep apnea is indicated when a surgically correctable abnormality is believed to be the source of the problem. Many patients opt for surgical treatment after noninvasive forms of treatment have been proven ineffective or difficult to tolerate. With increasing frequency, functional rhinoplasty, septoplasty, turbinoplasty, palatal surgery, and orthognathic surgery are being used in the management of snoring and obstructive sleep apnea. Plastic surgeons' experience with aesthetic nasal surgery, nasal reconstruction, palatal surgery, and craniofacial surgery puts them at the forefront of performing surgery for snoring and sleep apnea. The role of functional septorhinoplasty, turbinoplasty, palatal surgery, genioglossal advancement, and orthognathic surgery is indispensable in the surgical management of obstructive sleep apnea. Multidisciplinary management of these patients is critical, and plastic surgeons are encouraged to work collaboratively with sleep medicine clinicians and centers.

Surgical Approaches to Obstructive Sleep Apnea

Surgery in adult obstructive sleep apnea (OSA) has undergone significant advancement in recent years and continues to evolve. It is a modality of treatment used in the context of failed device use, specifically, failed continuous positive airway pressure or mandibular advancement splint. In this context, the role of surgery is either as salvage therapy or to facilitate better tolerance of device use. Other treatments such as weight loss, adjuvant nasal therapy (medical ± prephase nasal surgery) and positional devices may be combined with airway surgery. In general, patients with OSA are managed with in-hospital monitoring perioperatively.

Systematic review: the influence of nasal obstruction on sleep apnea

Introduction

Obstructive sleep apnea syndrome (OSAS) is a common disorder that can lead to cardiovascular morbidity and mortality, as well as to metabolic, neurological, and behavioral consequences. It is currently believed that nasal obstruction compromises the quality of sleep when it results in breathing disorders and fragmentation of sleep. However, recent studies have failed to objectively associate sleep quality and nasal obstruction.

Objective

The aim of this systematic review is to evaluate the influence of nasal obstruction on OSAS and polysomnographic indices associated with respiratory events.

Methods

Eleven original articles published from 2003 to 2013 were selected, which addressed surgical and non-surgical treatment for nasal obstruction, performing polysomnography type 1 before and after the intervention.

Results/conclusions

In most trials, nasal obstruction was not related to the apnea–hypopnea index (AHI), indicating no improvement in OSAS with reduction in nasal resistance. However, few researchers evaluated other polysomnography indices, such as the arousal index and rapid eye movement (REM) sleep percentage. These could change with nasal obstruction, since it is possible that the nasal obstruction does not completely block the upper airways, but can increase negative intrathoracic pressure, leading to sleep fragmentation.

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.

The effect of nasal surgery on continuous positive airway pressure device use and therapeutic treatment pressures: a systematic review and meta-analysis

BACKGROUND

The relationship between nasal surgery and its effect on continuous positive airway pressure (CPAP) device therapeutic treatment pressures and CPAP device use has not been previously systematically examined.

STUDY OBJECTIVES

To conduct a systematic review and meta-analysis evaluating the effect of isolated nasal surgery on therapeutic CPAP device pressures and use in adults with obstructive sleep apnea (OSA).

METHODS

MEDLINE, Scopus, Web of Science, and The Cochrane Library were searched through July 15, 2014. The MOOSE consensus statement and PRISMA statement were followed.

RESULTS

Eighteen studies (279 patients) reported CPAP data after isolated nasal surgery. Seven studies (82 patients) reported preoperative and postoperative mean therapeutic CPAP device pressures and standard deviations (SD), which reduced from 11.6 ± 2.2 to 9.5 ± 2.0 centimeters of water pressure (cwp) after nasal surgery. Pooled random effects analysis demonstrated a statistically significant pressure reduction, with a mean difference (MD) of -2.66 cwp (95% confidence interval (CI), -3.65 to -1.67); P < 0.00001. Eleven studies (153 patients) reported subjective, self-reported data for CPAP use; and a subgroup analysis demonstrated that 89.1% (57 of 64 patients) who were not using CPAP prior to nasal surgery subsequently accepted, adhered to, or tolerated it after nasal surgery. Objective, device meter-based hours of use increased in 33 patients from 3.0 ± 3.1 to 5.5 ± 2.0 h in the short term (<6 mo of follow-up).

CONCLUSION

Isolated nasal surgery in patients with OSA and nasal obstruction reduces therapeutic CPAP device pressures and the currently published literature's objective and subjective data consistently suggest that it also increases CPAP use in select patients.

The role of lateral pharyngoplasty in obstructive sleep apnea syndrome

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