Smoking and Improvement after Nasal Surgery in Snoring Men

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.

Smoking and sleep apnea duration mediated the sex difference in daytime sleepiness in OSA patients

PURPOSE

Daytime sleepiness is a common symptom of obstructive sleep apnea (OSA) and is more common in men, but the underlying mechanism remains unclear. The aim of this study was to assess whether or not sex differences in daytime sleepiness persisted after controlling for age and OSA severity and to explore the factors contributing to daytime sleepiness in patients with OSA.

METHODS

A total of 104 pairs of patients with OSA, matched by age and apnea-hypopnea index (AHI), were enrolled in this retrospective study. Demographic data were collected; daytime sleepiness was measured by the Epworth Sleepiness Scale (ESS); and polysomnography (PSG) was performed on each participant. These measurements were compared between sexes, and the factors affecting daytime sleepiness were explored with correlation and multivariate linear regression analyses.

RESULTS

Men had significantly higher ESS scores (p = 0.021) than women. Regarding demographics, BMI, neck/height ratio, and proportion of habitual smoking and alcohol intake were significantly higher in men. Regarding PSG findings, men had more rapid eye movement sleep, a longer mean apnea-hypopnea duration, and a longer mean apnea duration (MAD). Regression analysis showed that two sex-associated variables, habitual smoking (β = 0.189, p = 0.006) and MAD (β = 0.154, p = 0.024), had the strongest association with ESS scores. Further analysis revealed that MAD was significantly influenced by apnea index (β = 0.306, p < 0.001) and sex (β = - 0.193, p = 0.003).

CONCLUSION

The sex difference in daytime sleepiness persists in patients with OSA, even after matching AHI and age. The difference is mediated by sex-specific smoking habits and sex differences in apnea duration.

Comparison of Auto- and Fixed-Continuous Positive Airway Pressure on Air Leak in Patients with Obstructive Sleep Apnea: Data from a Randomized Controlled Trial

Auto-CPAP may cause sleep fragmentation due to variations in pressure and unintentional leaks. The aim of this study was to compare air leak between fixed-CPAP and auto-CPAP after 4 months of CPAP treatment. This study is an ancillary analysis of a randomized, double-blind, parallel, controlled trial over 4 months, comparing fixed- and auto-CPAP in newly diagnosed patients with OSA. The following data were extracted from the CPAP devices: mean and 90th percentile pressure, residual apnea-hypopnea index, mean CPAP use, and amount of leak. Within each arm, patients were also randomly allocated to use of one of the three different brands of devices. Since the leak was reported differently for each device, median leak value was determined for each brand and leaks were classified as “above the median” or “below the median”. Data from 269 patients were analyzed. The univariate analysis showed that tobacco consumption, CPAP level, and oronasal masks were associated with leaks above the median value but not the type of CPAP. The multivariate analysis showed that only CPAP level and oronasal masks were associated with leaks below the median. There were no differences in the types of mask used between fixed- and auto-CPAP. There was no impact of the type of CPAP on leaks or the type of interface used. We used a method based on the median leak value to standardize comparisons across devices which report leaks with different definitions.

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

BACKGROUND

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

AIMS/OBJECTIVES

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Establishing a Patent Nasal Passage in Obstructive Sleep Apnea

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

The sawtooth sign is predictive of obstructive sleep apnea

BACKGROUND

The sawtooth sign in spirometry is associated with redundant upper airway tissue and snoring, but its predictive value for identifying obstructive sleep apnea (OSA) is disputed. We retrospectively assessed the predictive value of the spirometric sawtooth sign in terms of the odds ratio (OR) of association with a diagnosis of OSA compared to those without the sign.

METHODS

Consecutive spirometry reports showing a sawtooth sign were identified from our laboratory. We identified 50 subjects with sawtooth sign and 100 control subjects without sawtooth sign, matched for age, BMI, and gender. The electronic medical record of each patient was queried for a diagnosis of OSA based on physician-reported diagnoses.

RESULTS

Of the 50 subjects with sawtooth sign, 22 were found to have a current diagnosis of OSA (44%). Twenty-seven of the 100 controls (27%) also had OSA. From logistic regression analysis, sawtooth sign was associated with an increased likelihood of OSA (OR = 2.12, 95% C.I. 1.04 to 4.35). Similar results were obtained after adjustment for age, gender, pack years, and BMI (OR = 2.61, 95% C.I. 1.13 to 6.21).

CONCLUSIONS

Patients with the sawtooth sign have greater odds of having a diagnosis of OSA compared with those without the sign. If prospectively evaluated, as a result of improved identification, we hypothesize that the sawtooth sign may show an even stronger association with OSA. This relatively common finding, which adds no cost to routine spirometry, may serve as an indicator for OSA workup for some individuals not already identified as having OSA.

Evaluation of the Nasal Surgical Questionnaire for Monitoring Results of Septoplasty

Monitoring the results of surgery is important. The otorhinolaryngology department of our hospital currently uses preoperative and postoperative versions of the Nasal Surgical Questionnaire (NSQ) for continuous evaluation of nasal septoplasty. In this study, 55 patients undergoing septoplasty answered the preoperative version twice to assess the NSQ's test-retest precision, and 75 patients answered the preoperative questionnaire before and the postoperative one 6 months after surgery to evaluate the NSQ's ability to detect change in symptoms following surgery. Both the pre- and postoperative versions of the NSQ use separate visual analogue scales (VAS) to assess nasal obstruction during the day, at night, and during exercise. Other nasal symptoms are graded as secondary outcomes using 4-point Likert scales. The mean VAS scores for the two preoperative obstruction ratings were not significantly different. The scores were significantly higher than in a normal population. There were also significant differences between preoperative and postoperative ratings. The mean pre- and postoperative scores at night for those who reported complete improvement were 66.1 and 8.4, substantial improvement 74.5 and 24.2, and no improvement 83.3 and 76.4. The NSQ reliably assesses nasal symptoms in patients and may be useful for both short and long term prospective studies of septoplasty.

Where there is smoke…there is sleep apnea: exploring the relationship between smoking and sleep apnea

Smoking and OSA are widely prevalent and are associated with significant morbidity and mortality. It has been hypothesized that each of these conditions adversely affects the other, leading to increased comorbidity while altering the efficacy of existing therapies. However, while the association between smoking and OSA is plausible, the evidence is less than conclusive. Cigarette smoking may increase the severity of OSA through alterations in sleep architecture, upper airway neuromuscular function, arousal mechanisms, and upper airway inflammation. Conversely, some evidence links untreated OSA with smoking addiction. Smoking cessation should improve OSA, but the evidence to support this is also limited. This article reviews the current evidence linking both conditions and the efficacy of various treatments. Limitations of the current evidence and areas in need of future investigation are also addressed.

The role of the nose in sleep-disordered breathing

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Acoustic rhinometry, spirometry and nitric oxide in relation to airway allergy and smoking habits in an adolescent cohort

OBJECTIVE

This study aimed to analyze upper and lower airway function and the impact of smoking habits in a cohort of allergic and healthy adolescents. The influence of smoking habits on the outcomes of rhinitis and asthma is well documented, but only few reports are available showing smoke related upper airway impairment by rhinometric measurements, and none with focus on early changes in adolescents.

METHODS

A cohort followed from infancy was re-examined at the age of 18 years concerning allergy development. Acoustic rhinometry (VOL2), spirometry (FEV(1)) and measurements of nitric oxide levels from the upper (nNO) and lower airways (eNO) were performed before and after physical exercise, and smoking habits were registered.

RESULTS

Active smoking habits were reported by 4/21 subjects suffering from allergic rhinitis, by 1/4 from probable allergic rhinitis, by 0/3 subjects with atopic dermatitis and by 2/10 healthy controls. Smoking habits were reported as daily by 2 and occasional by 5 of the 7 active smokers. VOL2 did not increase in smokers after exercise as in non-smokers, resulting in a post-exercise group difference (7.3±1.1cm(3) vs. 8.8±1.5cm(3); p=0.02), and FEV(1) values were lower in smokers compared to non-smokers (89±7% vs. 98±8%; p=0.02). The nNO and eNO levels were, however, only slightly reduced in smokers. Airway allergy was discerned only in subjects with current allergen exposure by increased eNO levels compared to healthy controls (41±44ppb vs. 13±5ppb). The levels of VOL2, nNO and FEV(1) did not differentiate allergic subjects from healthy controls.

CONCLUSIONS

Low levels of tobacco smoke exposure resulted in reduced airway functions in this adolescent cohort. Acoustic rhinometry and spirometry were found to be more sensitive methods compared to nitric oxide measurements in early detection of airway impairment related to smoke exposure. A possible difference in airway vulnerability between allergic and healthy subjects due to smoke exposure remains to be evaluated in larger study groups.

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.

Smoker's nose: structural and functional characteristics

OBJECTIVES/HYPOTHESIS

The effects of smoking on endonasal geometry and airflow remain largely unknown. Our study examined the relationship between smoking status and objective measures of nasal cavity dimensions, nasal congestion, and nasal airflow, using acoustic rhinometry (AR) and peak nasal inspiratory flow (PNIF).

STUDY DESIGN

Cross-sectional study.

METHODS

Included in the study were 2,523 consecutive patients referred for evaluation of chronic nasal or sleep-related complaints. Smoking history was recorded, and AR and PNIF were measured at baseline and after decongestion of the nasal mucosa. Minimal cross-sectional areas (MCA), nasal cavity volumes (NCV), and PNIF, as well as quantified reversible mucosal congestion based on nasal congestion indexes (NCI) were analyzed to reveal possible associations with smoking status. Linear and logistic regressions were applied adjusting for possible confounders.

RESULTS

Smokers exhibited lower values of MCA, NCV, and PNIF than nonsmokers, both at baseline and after decongestion. Further, smokers had a lower decongestive capacity of the nasal mucosa, reflected by lower NCI for AR measures. Cigarette consumption, expressed as either pack-years or cigarettes smoked per day, showed a similar inverse relationship with the rhinometric measures even though a linear dose-response relationship could not be established.

CONCLUSIONS

We have clearly demonstrated that smokers exhibit lower MCA and NCV, achieve lower PNIF values, and have a less-compliant nasal mucosa than nonsmokers. Our results are unique, and provide evidence that smoking has adverse effects on the nasal airway, possibly due to mucosal inflammation. This might have further implications because altered nasal function could compromise the lower airways.

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.

[Smoking and sleep disorders]

Snoring and sleep apnea-hypopnea syndrome (SAHS) are two disorders of considerable relevance due to their high prevalence in the general population and their notable morbidity and mortality, particularly in association with their harmful effects on the cardiovascular system. As well as sex, age, weight, craniofacial malformations, alcohol consumption, and use of hypnotic drugs, it has been suggested that smoking may be a risk factor for developing sleep-disordered breathing. While there is solid evidence for the independent association between snoring and smoking in both children and adults, it is still unclear whether smoking constitutes an independent risk factor for developing SAHS, despite the many studies carried out to assess this link. This is probably because the association, if it exists, is very weak.