Endoscopic Sinus Surgery Improves Sleep Quality in Chronic Rhinosinusitis: A Systematic Review and Meta-analysis

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

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

Patient perspectives on chronic rhinosinusitis in cystic fibrosis: Symptom prioritization in the era of highly effective modulator therapy

BACKGROUND

Chronic rhinosinusitis (CRS) is common in people with cystic fibrosis (PwCF). Rhinologic symptom prioritization and areas that influence CRS treatment choices, including pursuing endoscopic sinus surgery (ESS), remain understudied.

METHODS

Adult PwCF + CRS were enrolled at eight centers into a prospective, observational study (2019-2023). Participants were administered the 22-SinoNasal Outcome Test (SNOT-22) survey and a modified SNOT-22 instrument examining symptom importance. We determined importance rankings for individual symptoms and SNOT-22 symptom importance subdomains in two sets of subgroups-those pursuing ESS versus continuing medical management (CMT), and those on elexacaftor/tezacaftor/ivacaftor (ETI) versus not on ETI.

RESULTS

Among 69 participants, the highest priorities were nasal congestion (n = 48, 69.6% important), post-nasal discharge (32, 46.4%), facial pain (29, 43.3%), waking up tired (27, 39.1%), and fatigue (26, 37.7%). Those electing surgery (n = 23) prioritized sleep and psychological dysfunction symptoms compared to those pursuing CMT (n = 49) (sleep median score = 19.0 [interquartile range: 12.0, 25.0] vs. 4.5 [0.0, 12.8]; p < 0.0001; psychological = 17.0 [7.0, 26.0] vs. 7.0 [0.0, 15.8]; p = 0.002). ETI users had comparable SNOT-22 total symptom importance scores to non-ETI users (p = 0.14). Non-ETI users (n = 34) showed a trend toward prioritizing sleep symptoms compared to ETI users (n = 35) (13.0 [2.8, 22.3] vs. 6.0 [2.0, 17.0]; p = 0.055).

CONCLUSIONS

Nasal congestion and post-nasal discharge were top priorities reported by PwCF + CRS. Those electing surgery prioritized sleep and psychological symptoms, highlighting their importance in pre-operative discussions. Non-ETI users' prioritization of sleep improvement may highlight their unique disease impact and therapeutic needs; however, additional investigation is required.

Omalizumab improves sleep and health status for patients with chronic rhinosinusitis with nasal polyps: An analysis of randomized clinical trials

BACKGROUND

Patients with chronic rhinosinusitis with nasal polyps (CRSwNP) have high incidence of sleep impairment. We evaluated the impact of omalizumab treatment on sleep characteristics and associated health status in patients with CRSwNP.

METHODS

Prespecified exploratory analysis assessed outcomes from patients included in the POLYP 1 and POLYP 2 phase 3 clinical trials and the open-label extension. Sleep was assessed by the sleep domain of the Sino-Nasal Outcome Test-22 (SNOT-22; MCID > 4 in patients with CRS) and the Medical Outcomes Study Sleep Scale (MOS-Sleep). Health status was assessed by Healthy Days Core Module (HDCM) and sinonasal-specific Patient Global Impression of Change (PGIC).

RESULTS

Omalizumab improved sleep as assessed by the SNOT-22 sleep domain. At week 24, adjusted mean (95%CI) SNOT-22 sleep scores had reduced from baseline by -8.5 (-9.9 to -7.1) with omalizumab versus -2.7 (-4.1 to -1.3) with placebo. At week 52 (all patents on OMA), adjusted mean (95%CI) SNOT-22 sleep scores had reduced from baseline by -10.1 (-11.4 to -8.7) with omalizumab. Improvements were observed in all eight items of the SNOT-22 sleep domain: difficulty falling asleep, fatigue, frustration/restlessness/irritability, lack good night's sleep, reduced concentration, reduced productivity, wake up tired, and wake up at night. In addition, omalizumab improved six of eight sleep outcomes on the MOS-Sleep scale. There were concurrent improvements in HDCM and PGIC.

CONCLUSION

Omalizumab improved sleep and self-reported health status in patients with CRSwNP. This contributes to evidence that omalizumab provides value for patients beyond the reduction of sinonasal symptoms.

Treatment of the Nose for Patients with Sleep Apnea

Nasal obstruction is common in patients with obstructive sleep apnea (OSA) and may variably impact symptoms and severity of OSA. It is associated with decreased continuous positive airway pressure (CPAP) compliance, and both medical and surgical management of nasal obstruction have resulted in increased CPAP adherence. Treatment of OSA with comorbid rhinitis via topical nasal steroids demonstrates a beneficial impact on daytime sleepiness. Isolated nasal surgery has been shown to result in decreased daytime sleepiness and snoring, with minimal effect on OSA severity.

Factors that predict pursuing sinus surgery in the era of highly effective modulator therapy

BACKGROUND

Comorbid chronic rhinosinusitis (CRS) remains unresolved for many people with cystic fibrosis (PwCF). While highly effective modulator therapy improves quality-of-life and symptom severity, the impact of this intervention and other factors associated with pursuing endoscopic sinus surgery (ESS) remains understudied.

METHODS

Adult PwCF + CRS were enrolled into a prospective, observational, multi-institutional study. Participants completed validated outcome measures to evaluate respiratory symptom severity, depression, headache, and sleep quality, as well as nasal endoscopy, sinus computed tomography (CT), and olfactory testing. Bivariate comparisons and regression modeling evaluated treatment cofactors, disease characteristics, and outcome measures associated with pursuing ESS.

RESULTS

Sixty PwCF were analyzed, including 24 (40%) who elected ESS. Pursuing ESS was associated with worse SinoNasal Outcome Test (SNOT-22) total, rhinologic, psychological, and sleep dysfunction domain scores; worse Patient Health Questionnaire-9-Revised depression scores; worse Pittsburgh Sleep Quality Index total scores; worse weight, role, emotion, and eating domain scores on the Cystic Fibrosis Questionnaire-Revised; more severe disease on nasal endoscopy; and lack of modulator therapy (all p < 0.050). Multivariable regression identified that worse SNOT-22 total score was associated with electing ESS (odds ratio [OR] 1.09, 95% confidence interval [CI] 1.02-1.16, p = 0.015) and elexacaftor/tezacaftor/ivacaftor (ETI) treatment (OR 0.04, 95% CI 0.004-0.34, p = 0.004) was associated with pursing medical therapy.

CONCLUSIONS

Worse sinonasal symptom burden, lack of ETI treatment, sleep quality, depression, and nasal endoscopy scores were associated with electing ESS, while lung disease severity and sinus CT scores were not. ETI use was associated with lower odds of pursuing ESS independent of sinonasal symptom burden.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Pathogenesis and treatment of chronic rhinosinusitis from the perspective of sinonasal epithelial dysfunction

Background

Chronic rhinosinusitis (CRS) is a clinical syndrome primarily characterized by long-term mucosal inflammation of the nasal cavity and sinuses. The pathogenesis of CRS is still unclear due to its high heterogeneity. A number of studies have recently focused on the sinonasal epithelium. Thus, there has been a quantum leap in awareness of the role of the sinonasal epithelium, which is now understood as an active functional organ rather than simply an inert mechanical barrier. Undoubtedly, epithelial dysfunction plays a vital role in the onset and development of CRS.

Objective

In this article, we discuss the potential contribution of sinonasal epithelium dysfunction to CRS pathogenesis and explore a few current and developing therapeutic options targeting the sinonasal epithelium.

Results

Impaired mucociliary clearance (MCC) and an abnormal sinonasal epithelial barrier are usually considered to be the main causative factors in CRS. Epithelial-derived bioactive substances, such as cytokines, exosomes, and complements, play a vital role in the regulation of innate and adaptive immunity and contribute to the pathophysiological alterations of CRS. The phenomena of epithelial-mesenchymal transition (EMT), mucosal remodeling, and autophagy observed in CRS offer some novel insights into the pathogenesis of this disease. In addition, existing treatment options targeting disorder of sinonasal epithelium can help to relieve the main symptoms associated with CRS to some extent.

Conclusion

The presence of a normal epithelium is fundamental for maintaining homeostasis in the nasal and paranasal sinuses. Here, we describe various aspects of the sinonasal epithelium and highlight the contributions of epithelial dysfunction to CRS pathogenesis. Our review provides sound evidence of the need for in-depth study of the pathophysiological alterations of this disease and for the development of novel epithelium-targeting alternative treatments.

Functional Endoscopic Sinus Surgery and Recurrence of Post-COVID Mucormycosis

Purpose

To evaluate the value and limitation of functional endoscopic sinus surgery alone for the management of post-COVID mucormycosis and need for adjunctive invasive procedure.

Materials and Methods

This is a clinical observational study that included a total of 17 patients who underwent FESS for post-COVID mucormycosis from April 2021 to May 2021. These patients reported to our institute with no improvement in their symptoms post-FESS from June 2021 to July 2021. Aggressive Surgical debridement of the involved sinuses, removal of surrounding necrotic bone and orbital exenteration (wherever necessary) was done in these patients. A regular follow-up till six months was done for every patient. Sixteen out of 17 patients did not report with any fresh complaint or recurrence.

Results

The study included male and female in ratio of 12:5, with a mean age of 62.5 ± 7.7 years (range: 50-75 years). These patients underwent functional endoscopic sinus surgery, one to two months before reporting to our institute. Post-FESS, there was no improvement in the symptoms. All these patients were given systemic antifungal treatment post-operatively. The specimen was sent for histopathological as well as microbiological examination. All the FESS operated patients required a secondary more aggressive surgical intervention.

Conclusion

Post-COVID mucormycosis is an aggressive fungal infection, for which FESS proves inadequate. It requires an aggressive surgical debridement of the necrotic bone along with the debridement of the sinuses.

Changes in Sleep Quality Following Treatment for Chronic Rhinosinusitis: A Systematic Review and Meta-Analysis

BACKGROUND

Chronic rhinosinusitis (CRS) presents with broad and systemic manifestations, including impaired sleep; however, the impact of CRS treatments upon sleep is unknown.

OBJECTIVE

To establish the effect of medical or surgical CRS treatment on subjective and objective sleep metrics for patients not previously diagnosed with sleep apnea.

METHODS

Review of PubMed, Scopus, Web of Science, and the Cochrane Library was performed from the databases' date of inception through August 13, 2020, for studies evaluating the effect of CRS treatment on sleep quality. All studies reporting on subjective and objective sleep parameters for patients with CRS, with completed pre- and posttreatment data were included. Studies composed of patients with diagnosed sleep apnea were excluded.

RESULTS

Sixteen unique studies reporting data on a total of 1770 patients (mean age, 50.6 ± 15.6 (n = 1675) years) following treatment for CRS were included. Patient-reported outcome measures, Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, and Fatigue Severity Scale, demonstrated mean posttreatment differences of -2.8 (95% CI: -4.9 to -0.7), -2.4 (95% CI: -3.7 to -1.2), and -1.2 (95% CI: -1.6 to -0.7), respectively. The SNOT-22 and its sleep domain demonstrated a mean posttreatment difference of -23.5 (95% CI: -31.7 to -15.3) and -5.4 (95% CI: -6.8 to -4.0), respectively. EpSS, FSS and SNOT-22 exceeded their respective reported MCID values. Objective findings did not significantly change with treatment; mean difference: AHI: 0.7 (95% CI: -1.5 to 2.9), oxygen nadir: 0.3 (95% CI: -0.4 to 0.9).

CONCLUSIONS

Treatment of CRS may lead to clinically meaningful reduction in disease burden and improvements in both overall sleep quality and patient-reported fatigue. Despite clinically meaningful quality of life improvements, objective sleep parameters did not demonstrate corresponding posttreatment improvements.

Effect of sinus opacification on the severity of obstructive sleep apnea

PURPOSE

The association between rhinosinusitis and obstructive sleep apnea (OSA) remains unclear. Here, we aimed to elucidate the association between sinus opacification and OSA severity.

METHODS

Patients with snoring problems who visited our clinic from April 2018 to December 2020 were retrospectively enrolled. Among these patients, we included those who underwent a physical examination, overnight polysomnography, and osteomeatal-unit computed tomography. We evaluated the association between apnea-hypopnea index (AHI) and Lund-Mackay score (LMS). LMS ≥ 5 was considered indicative of sinus opacification.

RESULTS

Among the 122 patients included in the study, LMS exhibited an increasing trend based on OSA severity. The LMS in the moderate OSA group was significantly higher than that in the no OSA group (P = 0.002), and the LMS in the severe OSA group was significantly higher than that in the no OSA (P < 0.001) and mild OSA (P = 0.006) groups. A correlation analysis revealed that AHI was significantly associated with body mass index (BMI) (r = 0.367, P < 0.001) and LMS (r = 0.255, P = 0.005). A multivariate analysis revealed that sinus opacification was associated with moderate and severe OSA [Adjusted odds ratio = 11.986 (P = 0.005) and 3.756 (P = 0.044), respectively] after adjusting for age, sex, BMI, smoking, hypertension, atopy, tonsil size, and palatal position. The effect of sinus opacification on OSA severity was comparable to that of overweight.

CONCLUSION

Sinus opacification may increase OSA severity since moderate and severe OSA is independently associated with it.

Sleep Dysfunction is an Independent Predictor of Productivity Losses in Patients with Chronic Rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is known to have a significant impact on economic productivity. Sleep dysfunction is associated with staggering productivity losses and is highly prevalent in patients with CRS. The effect of sleep dysfunction on productivity in CRS has not been elucidated. The objective of this study was to determine the relationship between sleep dysfunction and lost productivity in patients with CRS.

METHODS

Eighty-two adult patients with CRS were prospectively enrolled into a cross-sectional cohort study. Patients with obstructive sleep apnea were excluded. Sleep quality was measured using the Pittsburgh Sleep Quality Index (PSQI). Presenteeism (reduced work efficiency), absenteeism (missed work days), and lost work, household, and overall productivity were analyzed. The primary aim was assessing the correlation between PSQI and productivity. Regression analyses were performed to account for disease severity, pain, and depression.

RESULTS

Sleep dysfunction is significantly correlated with overall lost productivity (R² = 0.397, P < .05). Presenteeism is the most strongly affected by sleep dysfunction (R² = -0.441, P < .001). Higher PSQI scores were significantly associated with productivity losses, whereas lower scores were not. Sleep remained an independent predictor of productivity when regression analysis accounted for disease severity, depression, and pain.

CONCLUSION

Sleep dysfunction has a significant association with lost productivity in patients with CRS, particularly with worsening PSQI scores. More clearly defining those components of CRS that most impact a patient's daily function will allow clinicians to more optimally manage and counsel patients with CRS.

Multiple genetic variations of chronic rhinosinusitis with nasal polyps are associated with respiratory parameters in men with obstructive sleep apnea

Purpose

Patients with chronic rhinosinusitis with nasal polyps (CRSwNP) have a higher risk of obstructive sleep apnea (OSA). However, the relationship between CRSwNP and OSA remains unclear. The aim of this research study was to evaluate the association of multiple single nucleotide polymorphism (SNP) variations in CRSwNP with sleep- and breath-related parameters in men with OSA.

Methods

We included eight CRSwNP SNPs in 2320 participants after strict screening. For each participant, the genetic risk score (GRS) was calculated based on the cumulative effect of multiple genetic variants of CRSwNP. A bivariate correlation analysis was used to assess the relationship between CRSwNP genetic polymorphisms and polysomnography parameters in men with OSA. Logistic regression analyses were used to assess the relationship between the risk of OSA and CRSwNP genetic polymorphisms.

Results

In moderate OSA, rs28383314 was related to the oxygen desaturation index, and rs4807532 was positively associated with the microarousal index (r = 0.09, P = 0.03 and r = 0.11, P = 0.01, respectively). The CRSwNP GRS was positively correlated with the oxygen desaturation index and cumulative time percentage with SpO₂ < 90% in moderate OSA (r = 0.13, P < 0.001 and r = 0.1, P = 0.01, respectively). There was no association between the CRSwNP GRS and the risk of OSA (OR = 1.007; 95% CI, 0.973–1.042; P = 0.702).

Conclusion

In men with moderate OSA, single CRSwNP genetic variations correlated with sleep-related parameters, and the cumulative effects of CRSwNP genetic variations were associated with the hypoxic index. CRSwNP may be a predisposing condition for sleep disorders in men with moderate OSA.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11325-021-02356-6.

Manifesto on united airways diseases (UAD): an Interasma (global asthma association - GAA) document

OBJECTIVE

The large amount of evidence and the renewed interest in upper and lower airways involvement in infectious and inflammatory diseases has led Interasma (Global Asthma Association) to take a position on United Airways Diseases (UAD).

METHODS

Starting from an extensive literature review, Interasma executive committee discussed and approved this Manifesto developed by Interasma scientific network (INES) members.

RESULTS

The manifesto describes the evidence gathered to date and defines, states, advocates, and proposes issues on UAD (rhinitis, rhinosinusitis and nasal polyposis), and concomitant/comorbid lower airways disorders (asthma, chronic obstructive pulmonary disease, bronchiectasis, cystic fibrosis, obstructive sleep apnoea) with the aim of challenging assumptions, fostering commitment, and bringing about change. UAD refers to clinical pictures characterized by the coexistence of upper and lower airways involvement, driven by a common pathophysiological mechanism, leading to a greater burden on patient's health status and requiring an integrated diagnostic and therapeutic plan. The high prevalence of UAD must be taken into account. Upper and lower airways diseases influence disease control and patient's quality of life.

CONCLUSIONS

Patients with UAD need to have a timely and adequate diagnosis, treatment, and, when recommended, referral for management in a specialized center. Diagnostic testing including skin prick or serum specific IgE, lung function, fractional exhaled nitric oxide (FeNO), polysomnography, allergen-specific immunotherapies, biological therapies and home based continuous positive airway pressure (CPAP) whenever these are recommended, should be part of the management plan for UAD. Education of medical students, physicians, health professionals, patients and caregivers on the UAD is needed.

The value of endoscopic sinus surgery in chronic rhinosinusitis

OBJECTIVES

Chronic rhinosinusitis (CRS) is a disease with significant impacts at both a societal and personal level. There has been an increase in emphasis on patient-centered care and patient outcomes, with value becoming a commonplace concept in health care systems. This review seeks to better define the value that endoscopic sinus surgery (ESS) provides in the treatment of CRS.

DATA SOURCES

PubMed literature review.

REVIEW METHODS

A review of published literature related to ESS and its effects on CRS patients from multiple perspectives (quality outcomes, patient satisfaction, cost-effectiveness) was integrated and analyzed through the viewpoint of a value equation.

RESULTS

ESS provides long-term quality outcomes in both patient-reported outcome measures (PROMs) as well as in objective metrics for patients refractory to medical therapy. The vast majority undergoing ESS are satisfied both in the short and long-term with their decision to pursue surgery. Treatment of CRS with ESS is generally more cost-effective than continued medical therapy (CMT), especially in refractory patients. Taken together, the combination of improved outcomes as well as patient satisfaction after ESS in relation to the costs of surgery provides significant quantifiable value to CRS patients.

CONCLUSION

ESS clearly provides value in the treatment of CRS. Understanding both quality and outcome metrics along with patient expectations and priorities will assist providers in generating a more personalized and value-based approach to patients with CRS.

LEVEL OF EVIDENCE

5.

Rhinologic disease and its impact on sleep: a systematic review

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Objective sleep measures after endoscopic sinus surgery in patients with chronic rhinosinusitis

BACKGROUND

Poor sleep quality is common in chronic rhinosinusitis (CRS). Prior studies have demonstrated improvements in patient-reported measures of sleep quality following endoscopic sinus surgery (ESS). The purpose of this study was to evaluate the effect of ESS on objective sleep parameters and identify any associations between specific objective measures and patient characteristics, comorbidities, and patient-reported outcome measures (PROMs).

METHODS

Adults with CRS undergoing ESS were prospectively enrolled from 4 centers across North America. Any subject previously diagnosed with a known primary sleep disorder was excluded. Objective sleep indices were recorded using a portable sleep diagnostic device preoperatively and postoperatively. Patient-reported outcome instruments were completed including the Pittsburgh Sleep Quality Index (PSQI) and the 22-item Sino-Nasal Outcome Test (SNOT-22).

RESULTS

Thirty-six patients (mean age 47 years, 56% male) completed baseline and postoperative sleep studies with mean ± standard deviation (SD) follow-up 9.6 ± 7.7 months. Mean PSQI and SNOT-22 before and after ESS was 10.2 ± 3.9 vs 7.8 ± 4.4 (p = 0.001); and 54.6 ± 14.6 vs 28.5 ± 15.3 (p < 0.001), respectively. Total sleep time, sleep latency, and awakenings after sleep onset did not change following ESS (all p > 0.5) despite improvements in PSQI and SNOT-22. Changes in PSQI did not correlate with comorbidities or objective sleep indices (all p > 0.1).

CONCLUSION

In this multicenter prospective cohort, objective sleep indices were not improved following ESS for CRS despite significant improvements in patient-reported sleep quality and CRS-specific QOL.

The impact of nasal surgery on sleep quality

OBJECTIVE

Nasal obstruction is considered to be one of the risk factors for obstructive sleep apnea, together with a high arched narrow palate, elongated uvula, malocclusion, and tongue and tonsil size. The impact of nasal obstruction on sleep apnea is controversial, however, and its relation to sleep quality is rarely discussed. The purpose of this study was to investigate the independent effect of nasal obstruction on sleep quality.

METHODS

Sixty-nine patients with nasal obstructive symptoms and without sleep apnea episodes were enrolled from September 2018 to August 2019, and compared before and after surgery with thirty-four patients who had benign diseases of the thyroid or parathyroid as a control group, to investigate effects of surgery. Sleep quality was evaluated using the Japanese version of the Pittsburgh Sleep Quality Index (PSQI-J). All cases were reassessed at three months after surgery.

RESULTS

The postoperative PSQI scores in the nasal surgery group were significantly lower than the preoperative scores (p < 0.001). In contrast, there was no statistically significance difference between the pre- and postoperative PSQI scores in the neck surgery group. Difference of PSQI scores before and after surgery in the nasal surgery group was significantly higher than the neck surgery group.

CONCLUSIONS

This double-arm study suggests that reduction of nasal disfunction with nasal surgery contributes significantly to sleep quality, in patients who may not have noticed their impaired quality of sleep previously because of their long-term nasal symptoms.

Patient-reported sleep outcomes lack association with mucosal eosinophilia or neutrophilia in patients with chronic rhinosinusitis undergoing functional endoscopic sinus surgery

BACKGROUND

Chronic rhinosinusitis (CRS) is associated with sleep dysfunction, but the underlying pathophysiology is poorly understood. The purpose of this study was to determine if mucosal eosinophilia or neutrophilia were associated with sleep dysfunction severity or altered the improvement in sleep dysfunction following functional endoscopic sinus surgery (FESS).

METHODS

A total of 104 patients with medically refractory CRS with nasal polyposis (CRSwNP) and CRS without nasal polyposis (CRSsNP), completed the Pittsburgh Sleep Quality Index (PSQI) before and after FESS. Anterior ethmoid mucosa was collected during FESS and densest infiltrates of eosinophilia and neutrophilia per high-power field (HPF) were determined by microscopy. Eosinophilic (>10 eosinophils/HPF) and neutrophilic (>4 neutrophils/HPF) CRS were then compared to preoperative and postoperative PSQI measures.

RESULTS

Of 104 study participants, 88 (85%) reported preoperative PSQI scores consistent with "poor sleep," (PSQI total > 5). The cohort overall demonstrated significant improvement in poor sleep (65%; χ² = 12.03; p < 0.001) 16.8 ± 5.0 months after FESS. Regardless of nasal polyposis, neither eosinophilic nor neutrophilic CRS was associated with differences in mean postoperative PSQI improvement. However, in patients with neutrophilic CRSsNP, there was a significant relationship between severity of neutrophilia and improvement in sleep latency (R = -0.798, p = 0.003) and sleep efficacy (R = -0.777, p = 0.005).

CONCLUSION

Chronic inflammation has been hypothesized to play a pathophysiologic role in sleep dysfunction associated with CRS. This study suggests that in patients with medically refractory CRS, evidence of mucosal eosinophilia and neutrophilia lack strong associations with patient-reported sleep dysfunction or improvements in sleep quality after FESS, overall. However, neutrophilia may impact sleep latency and efficacy in patients with CRSsNP.

Effect of endoscopic endonasal skull base surgery on snoring

BACKGROUND

As the number of endoscopic skull base surgeries has increased, postoperative changes in quality of life require attention, including evaluation of whether snoring symptoms change.

OBJECTIVE

To investigate the effect of endoscopic endonasal skull base surgery on snoring and nasal symptom scores.

METHODS

Between February 2009 and September 2018, 510 patients underwent skull base tumor resection via an endoscopic endonasal approach and were included in this study. Nasal symptoms were scored using the Nasal Obstruction Symptoms Evaluation (NOSE) scale and snoring symptoms were subjectively scored from 0 to 10 by partners using a visual analog scale (VAS). Computational fluid dynamics (CFD) was employed for pilot patient analysis.

RESULTS

A pituitary adenoma was the most common surgical pathology encountered over the past 10 years (81.6% of all tumors). The NOSE scores increased significantly after surgery (pre-surgery, 3.28 ± 3.18; post-surgery, 4.09 ± 3.61; P < .001). The snoring VAS score decreased significantly postoperatively (pre-surgery, 2.91 ± 2.74; post-surgery, 2.43 ± 2.45; P < .001). A positive correlation was apparent between the NOSE and snoring score changes (r = 0.374; P < .001).

CONCLUSIONS

Snoring improved after endoscopic endonasal skull base surgery, associated with changes in nasal symptoms.

LEVEL OF EVIDENCE

4.

Methodological Quality of Systematic Reviews and Meta-analyses Published in High-Impact Otolaryngology Journals

OBJECTIVE

To assess the methodological quality of intervention-focused systematic reviews (SRs) and meta-analyses (MAs) published in high-impact otolaryngology journals.

DATA SOURCES

Ovid Medline, Embase, and Cochrane Library.

REVIEW METHODS

A comprehensive search was performed for SR and MA citations from 2012 to 2017 in the 10 highest impact factor otolaryngology journals. Abstracts were screened to identify published manuscripts in which the authors indicated clearly that they were performing an SR or MA. Applying a modified typology of reviews, 4 reviewers characterized the review type as SR, MA, or another review type. A simplified version of the AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews 2) tool was used to assess the reporting and methodological quality of the SRs and MAs that were focused on interventions.

RESULTS

Search and abstract screening generated 499 manuscripts that identified themselves as performing an SR or MA. A substantial number (85/499, 17%) were review types other than SRs or MAs, including 34 (7%) that were literature reviews. In total, 236 SRs and MAs focused on interventions. Over 50% of these SRs and MAs had weaknesses in at least 3 of the 16 items in the AMSTAR 2, and over 40% had weaknesses in at least 2 of the 7 critical domains. Ninety-nine percent of SRs and MAs provided critically low confidence in the results of the reviews.

CONCLUSION

Intervention-focused SRs and MAs published in high-impact otolaryngology journals have important methodological limitations that diminish confidence in the results of these reviews.

The Influence of Functional Endoscopic Sinus Surgery on Sleep Related Outcomes in Patients with Chronic Rhinosinusitis

Purpose

Chronic rhinosinusitis (CRS) patients often complain of nasal obstruction, which may cause sleep impairment for them. The goal of this study was to investigate the influence of functional endoscopic sinus surgery (FESS) on sleep related outcomes in CRS patients.

Materials and Methods

CRS patients who received FESS were included in this study. Prior to FESS and 3 months after surgery the patients were asked about the severity of nasal obstruction and completed the 20-item Sinonasal Outcome Test (SNOT-20), along with the Epworth Sleepiness Scale (ESS) questionnaire. Endoscopic examination, acoustic rhinometry, and polysomnography were performed in all patients. They were divided into four groups according to their preoperative apnea hypopnea index (AHI) scores: nonobstructive sleep apnea syndrome (non-OSAS), mild OSAS, moderate OSAS, and severe OSAS.

Results

A total of 96 subjects completed the study. The scores of the sleep domain of the SNOT-20 and ESS decreased in all of the AHI groups, with the exception of the severe OSAS group, after FESS. A reduction in the AHI of less than 5 was achieved in 9 patients (13.2%) after FESS.

Conclusions

Our results showed that FESS improved sleep quality in CRS patients, except those with severe OSAS, and a preoperative lower AHI was the only significant predictor of post-FESS OSAS outcome.