Skip to main content
SpringerLink
Log in

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

  • Original Article
  • Published:
Irish Journal of Medical Science (1971 -) Aims and scope Submit manuscript

Abstract

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Similar content being viewed by others

References

  1. Punjabi NM (2008) The epidemiology of adult obstructive sleep apnea. Proc Am Thorac Soc 5(2):136–143. https://doi.org/10.1513/pats.200709-155MG

    Article  PubMed  PubMed Central  Google Scholar 

  2. Léger D, Stepnowsky C (2020) The economic and societal burden of excessive daytime sleepiness in patients with obstructive sleep apnea. Sleep Med Rev 51:101275. https://doi.org/10.1016/j.smrv.2020.101275

    Article  PubMed  Google Scholar 

  3. Golbin JM, Somers VK, Caples SM (2008) Obstructive sleep apnea, cardiovascular disease, and pulmonary hypertension. https://doi.org/10.1513/pats.200708-143MG

  4. Andrade RGS et al (2018) Nasal vs oronasal CPAP for OSA treatment: a meta-analysis. Chest 153(3):665–674. https://doi.org/10.1016/j.chest.2017.10.044

    Article  PubMed  Google Scholar 

  5. Grote L, Hedner J, Grunstein R, Kraiczi H (2000) Therapy with nCPAP: incomplete elimination of sleep related breathing disorder. Eur Respir J 16(5):921–927. https://doi.org/10.1183/09031936.00.16592100

    Article  CAS  PubMed  Google Scholar 

  6. Nakata S et al (2008) Effects of nasal surgery on sleep quality in obstructive sleep apnea syndrome with nasal obstruction. Am J Rhinol 22(1):59–63. https://doi.org/10.2500/ajr.2008.22.3120

    Article  PubMed  Google Scholar 

  7. Inoue A, Chiba S, Matsuura K et al (2019) Nasal function and CPAP compliance. Auris Nasus Larynx 46(4):548–558. https://doi.org/10.1016/j.anl.2018.11.006

    Article  PubMed  Google Scholar 

  8. Smith PL, Wise RA, Gold AR et al (1988) Upper airway pressure-flow relationships in obstructive sleep apnea. J Appl Physiol (Bethesda, Md. : 1985) 64(2):789–795. https://doi.org/10.1152/jappl.1988.64.2.789

  9. Kimmelman CP (1989) The problem of nasal obstruction. Otolaryngol Clin North Am 22(2):253–264. Accessed: May 18, 2021. Available: http://www.ncbi.nlm.nih.gov/pubmed/2664651

  10. Susarla SM, Thomas RJ, Abramson ZR, Kaban LB (2010) Biomechanics of the upper airway: changing concepts in the pathogenesis of obstructive sleep apnea. Int J Oral Maxillofac Surg 39(12):1149–1159. https://doi.org/10.1016/j.ijom.2010.09.007

    Article  CAS  PubMed  Google Scholar 

  11. Ishii L, Roxbury C, Godoy A et al (2015) Does nasal surgery improve OSA in patients with nasal obstruction and OSA? A meta-analysis. Otolaryngol Head Neck Surg Official J Am Acad Otolaryngol Head Neck Surg 153(3):326–333. https://doi.org/10.1177/0194599815594374

  12. Verse T, Maurer JT, Pirsig W (2002) Effect of nasal surgery on sleep-related breathing disorders. Laryngoscope 112(1):64–68. https://doi.org/10.1097/00005537-200201000-00012

    Article  PubMed  Google Scholar 

  13. Friedman M, Tanyeri H, Lim JW et al (2000) Effect of improved nasal breathing on obstructive sleep apnea. Otolaryngol Head Neck Surgery Official J Am Acad Otolaryngol Head Neck Surg 122(1):71–74. https://doi.org/10.1016/S0194-5998(00)70147-1

  14. Iwata N, Nakata S, Inada H et al (2020) Clinical indication of nasal surgery for the CPAP intolerance in obstructive sleep apnea with nasal obstruction. Auris Nasus Larynx 47(6):1018–1022. https://doi.org/10.1016/j.anl.2020.06.005

    Article  PubMed  Google Scholar 

  15. Kribbs NB et al (1993) Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea. Am Rev Respir Dis 147(4):887–895. https://doi.org/10.1164/ajrccm/147.4.887

    Article  CAS  PubMed  Google Scholar 

  16. Stewart MG, Witsell DL, Smith TL et al (2007) Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) scale. Otolaryngol Head Neck Surg Official J Am Acad Otolaryngol Head Neck Surg 130(2):157–163. https://doi.org/10.1016/j.otohns.2003.09.016

  17. Johns MW (1991) A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep 14(6):540–545. https://doi.org/10.1093/sleep/14.6.540

    Article  CAS  PubMed  Google Scholar 

  18. Weaver TE et al (2007) Relationship between hours of CPAP use and achieving normal levels of sleepiness and daily functioning. Sleep 30(6):711–719. https://doi.org/10.1093/sleep/30.6.711

    Article  PubMed  PubMed Central  Google Scholar 

  19. Weaver TE, Grunstein RR (2008) Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Proc Am Thorac Soc 5(2):173–178. https://doi.org/10.1513/pats.200708-119MG

    Article  PubMed  PubMed Central  Google Scholar 

  20. Krieger J (1992) Long-term compliance with nasal continuous positive airway pressure (CPAP) in obstructive sleep apnea patients and nonapneic snorers. Sleep 15(6 Suppl):S42–S46. https://doi.org/10.1093/sleep/15.suppl_6.s42

    Article  CAS  PubMed  Google Scholar 

  21. Bachour A, Maasilta P (2004) Mouth breathing compromises adherence to nasal continuous positive airway pressure therapy. Chest 126(4):1248–1254. https://doi.org/10.1378/chest.126.4.1248

    Article  PubMed  Google Scholar 

  22. Camacho M et al (2015) The effect of nasal surgery on continuous positive airway pressure device use and therapeutic treatment pressures: a systematic review and meta-analysis. Sleep 38(2):279–286. https://doi.org/10.5665/sleep.4414

    Article  PubMed  PubMed Central  Google Scholar 

  23. Richards GN, Cistulli PA, Ungar RG et al (1996) Mouth leak with nasal continuous positive airway pressure increases nasal airway resistance. Am J Respir Crit Care Med 154(1):182–186. https://doi.org/10.1164/ajrccm.154.1.8680678

    Article  CAS  PubMed  Google Scholar 

  24. Lebret M et al (2017) Factors contributing to unintentional leak during CPAP treatment: a systematic review. Chest 151(3):707–719. https://doi.org/10.1016/j.chest.2016.11.049

    Article  PubMed  Google Scholar 

  25. Sopkova Z, Dorkova Z, Tkacova R (2009) Predictors of compliance with continuous positive airway pressure treatment in patients with obstructive sleep apnea and metabolic syndrome. Wien Klin Wochenschr 121(11–12):398–404. https://doi.org/10.1007/s00508-009-1181-z

    Article  PubMed  Google Scholar 

  26. Balcerzak J, Niemczyk K, Arcimowicz M, Gotlib T (2007) The role of functional nasal surgery in the treatment of obstructive sleep apnea syndrome. Otolaryngol Pol Polish Otolaryngol 61(1):80–84. https://doi.org/10.1016/S0030-6657(07)70388-8

  27. Zonato AI, Bittencourt LRA, Martinho FL et al (2006) Upper airway surgery: the effect on nasal continuous positive airway pressure titration on obstructive sleep apnea patients. European Archives of Oto-Rhino-Laryngology: Official Journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS): Affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery 63(5):481–486. https://doi.org/10.1007/s00405-005-1018-y

  28. Poirier J, George C, Rotenberg B (2014) The effect of nasal surgery on nasal continuous positive airway pressure compliance. Laryngoscope 124(1):317–319. https://doi.org/10.1002/lary.24131

    Article  PubMed  Google Scholar 

  29. Sufioğlu M et al (2012) The efficacy of nasal surgery in obstructive sleep apnea syndrome: a prospective clinical study. European Archives of Oto-Rhino-Laryngology: Official Journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS): Affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery 269(2):487–494. https://doi.org/10.1007/s00405-011-1682-z

  30. Nowak C, Bourgin P, Portier F et al (2003) Nasal obstruction and compliance to nasal positive airway pressure. Annales d’oto-laryngologie et de chirurgie cervico faciale : bulletin de la Societe d’oto-laryngologie des hopitaux de Paris 120(3):161–166. Accessed: 15 May 2021.. Available: http://www.ncbi.nlm.nih.gov/pubmed/12843985

  31. Nakata S et al (2005) Nasal resistance for determinant factor of nasal surgery in CPAP failure patients with obstructive sleep apnea syndrome. Rhinology 43(4):296–299. Accessed: 15 May 2021. Available: http://www.ncbi.nlm.nih.gov/pubmed/16405275

  32. Reilly EK et al (2021) Tolerance of continuous positive airway pressure after sinonasal surgery. Laryngoscope 131(3):E1013–E1018. https://doi.org/10.1002/lary.28968

    Article  PubMed  Google Scholar 

  33. Li H-Y et al (2005) Acoustic reflection for nasal airway measurement in patients with obstructive sleep apnea-hypopnea syndrome. Sleep 28(12):1554–1559. https://doi.org/10.1093/sleep/28.12.1554

    Article  PubMed  Google Scholar 

  34. Morris LG, Setlur J, Burschtin OE et al (2006) Acoustic rhinometry predicts tolerance of nasal continuous positive airway pressure: a pilot study. Am J Rhinol 20(2):133–137. https://doi.org/10.1177/194589240602000202

    Article  PubMed  Google Scholar 

  35. Bican A, Kahraman A, Bora I et al (2010) What is the efficacy of nasal surgery in patients with obstructive sleep apnea syndrome? J Craniofac Surg 21(6):1801–1806. https://doi.org/10.1097/SCS.0b013e3181f40551

    Article  PubMed  Google Scholar 

  36. Knappe SW, Sonnesen L (2020) The reliability and influence of body position on acoustic pharyngometry and rhinometry outcomes. J Oral Maxillofac Res 11(4). https://doi.org/10.5037/jomr.2020.11401

  37. Hellgren J, Yee BJ, Dungan G, Grunstein RR (2009) Altered positional regulation of nasal patency in patients with obstructive sleep apnoea syndrome. European Archives of Oto-Rhino-Laryngology: Official Journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS): Affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery 266(1):83–87. https://doi.org/10.1007/s00405-008-0701-1

Download references

Author information

Authors and Affiliations

  1. Department of Otolaryngology, Alexandria Faculty of Medicine, Alexandria, Egypt

    Samy Elwany, Ahmed Yassin Bahgat & Remon Bazak

  2. Department of Chest, Alexandria Faculty of Medicine, Alexandria, Egypt

    Mahmoud Ibrahim

Authors
  1. Samy Elwany
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ahmed Yassin Bahgat
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Mahmoud Ibrahim
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Remon Bazak
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All the authors contributed to the study conception and design. Material preparation and data collection were performed by Mahmoud Ibrahim. Data analysis was performed by Samy Elwany. The initial draft of the manuscript was written by Ahmed Yassin Bahgat and Remon Bazak. It was subsequently modified by Samy Elwany and Remon Bazak. All the authors read and approved the final manuscript.

Corresponding author

Correspondence to Remon Bazak.

Ethics declarations

Ethics approval

The study was performed in accordance with the Helsinki declaration and was approved by the Institutional Review Board.

Consent to participate

Informed consent was obtained from all individual participants included in the study.

Consent for publication

Informed consent to publish the data in the study was obtained from participants.

Competing interests

The authors declare no competing interests.

Additional information

Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Elwany, S., Bahgat, A.Y., Ibrahim, M. et al. Surgical correction of nasal obstruction in obstructive sleep apnea improves CPAP outcomes and compliance. Ir J Med Sci 191, 2723–2728 (2022). https://doi.org/10.1007/s11845-021-02896-6

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11845-021-02896-6

Keywords

Search

Navigation