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 Table of Contents  
ORIGINAL ARTICLE
Year : 2012  |  Volume : 28  |  Issue : 3  |  Page : 196-200

The effect of treatment of nasal and sinus diseases on the success rate of palatal surgery for obstructive sleep apnea


1 Department of E.N.T., Faculty of Medicine, Cairo University, Cairo, Egypt
2 National Institute of Enhanced Laser Sciences, Cairo University, Cairo, Egypt

Date of Submission28-May-2012
Date of Acceptance13-Jun-2012
Date of Web Publication18-Jun-2014

Correspondence Address:
Nassim T. Nassim
MD, 15 Morad Street, 11121 Giza
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.7123/01.EJO.0000418069.27183.21

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  Abstract 

Objective

Many patients with obstructive sleep apnea (OSA) have coexisting nasal and sinus problems. In the absence of major anatomical abnormalities, these problems may be overlooked, hence jeopardizing the success rate of palatal surgery. Our objective was to identify the effect of medical management of nasal and sinus diseases on the success rate of palatal surgery in mild to moderate cases of OSA.

Methodology

This prospective study included 28 patients divided in two groups; group A was treated medically with antibiotics and local steroids before palatal surgeries, whereas group B was not treated medically before palatal surgeries. Assessment was made preoperatively and postoperatively using polysomnography.

Results

Group A showed more improvement in the apnea hypopnea index than group B.

Conclusion

Management of nasal and sinus problems improves the results of palatal surgery in cases of mild to moderate OSA.

Keywords: apnea hypopnea index, Lund–Mackay score, obstructive sleep apnea


How to cite this article:
Nassim NT, Elhoshy HM, Fattah AF, Safwat SF, Atef AM. The effect of treatment of nasal and sinus diseases on the success rate of palatal surgery for obstructive sleep apnea. Egypt J Otolaryngol 2012;28:196-200

How to cite this URL:
Nassim NT, Elhoshy HM, Fattah AF, Safwat SF, Atef AM. The effect of treatment of nasal and sinus diseases on the success rate of palatal surgery for obstructive sleep apnea. Egypt J Otolaryngol [serial online] 2012 [cited 2019 Dec 5];28:196-200. Available from: http://www.ejo.eg.net/text.asp?2012/28/3/196/134635


  Introduction Top


Sleep-disordered breathing is a serious disorder that affects a high percentage of the population. In the past few decades, advances have been made in identifying risk factors, understanding the pathophysiologic processes and adverse health sequelae, and in improving diagnosis and treatment. The condition includes a range of abnormal breathing events that include frequent episodes of apnea, hypopnea, and snores or breaths with high airway resistance 1.

Overweight and central ponderosity, aging, male sex, and severe (but relatively rare) craniofacial abnormalities such as acromegaly have been identified as strong risk factors for sleep-disordered breathing. Hypothesized but untested risk factors include problems originating in the nose, including physical obstruction, allergic rhinitis, and chronic sinusitis. Other risk factors include familial predisposition, smoking, alcohol use, menopause, and ethnicity 2.

A biologic basis for nasal obstruction as a cause of sleep-disordered breathing lies in the effect of nasal breathing on resistance and flow velocity, which affects the pressure differential between the atmosphere and the intrathoracic space. Partial or complete obstruction can occur when the intrathoracic negative pressure generated by the inspiratory muscles pulls on the compliant soft tissue in the upper airway, sucking the airway closed. Moreover, the nose accounts for half of the total respiratory system resistance. In this regard, the nose has been described as a variable resistor with a collapsible segment, such that flow limitation in the nasopharynx results in conditions favorable for downstream pharyngeal collapse 3.

It is unfortunate that opening of an obstructed nose using standard nasal procedures is not regularly effective in improving snoring, although it should improve nasal breathing. There are several reports that show subjective improvement; a review of eight papers found the average rate for cessation of snoring to be 41.9%, and that for reduction of snoring to be 85.3%, after correction of nasal obstruction 4.

Nasal congestion is a prominent and troublesome symptom of inflammatory disorders of the upper respiratory tract. It is a major symptom of allergic rhinitis, along with rhinorrhea, sneezing, and pruritus of the eyes, nose, and throat, particularly in patients with perennial allergic rhinitis 5 The symptoms of rhinosinusitis and nasal polyposis are similar; nasal congestion/obstruction is a key feature, accompanied by nasal discharge or postnasal drip, facial pain/pressure, and reduction or loss of smell. In chronic rhinosinusitis, nasal obstruction/congestion is typically the most common major symptom 6. Typical sleep-related problems observed with these three conditions include sleep-disordered breathing, sleep apnea, and snoring, all of which are associated with nasal congestion/obstruction 7.

Inflammatory disorders of the upper respiratory tract are prevalent in the general population. The sleep impairment associated with these conditions, therefore, is likely to be a common problem. Allergic rhinitis, for example, is thought to affect up to 40% of the population, and its prevalence is increasing 8.

The physiologic tasks of the nose and experimental alteration of nasal resistance support the hypothesis that chronic conditions that increase nasal resistance, including permanent physical obstruction and the congestion and irritation associated with rhinitis and sinusitis, contribute to sleep-disordered breathing. Despite a strong rationale for the hypothesis, few clinical or epidemiologic studies have investigated the association. Such studies are important to determine whether the specific mechanisms identified during basic experimental studies are overcome with habituation and actually translate to measurable health outcomes that persist in daily life 9.

As nasal congestion is a subjective variant, it is more appropriate to use a scoring system [Lund–Mackay score (LMS)] to assess and compare nasal and sinus conditions.

The aim of this study was to assess the effect of management of nasal congestion (measured by LMS) on the success of treatment of snoring [measured using the apnea hypopnea index (AHI)].


  Materials and methods Top


This study is a prospective randomized study that was conducted at the Kasr Elaini Hospital in the period from March 2010 to January 2012; 28 patients with an age range from 22 to 61 years completed the study (18 men and 10 women). After obtaining approval from the scientific committee and informed consent, all patients were subjected to the following:

  1. Detailed history taking and clinical examination, including diagnostic nasal endoscopy
  2. Computed tomography of the nose and paranasal sinuses.
  3. Overnight sleep studies were conducted using standard polysomnography. Results of electroencephalography; electrooculography; submental electromyelography; ECG; and nasal and oral airflow, arterial oxygen saturation (SaO2), heart rate, and respiratory movement measurements were recorded. Apnea episodes were defined by the absence of ventilation for longer than 10 s, as measured by calibrated inductive plethysmography. Hypopnea was defined as a reduction in ventilation and a reduction in tidal volume to below 50%, without a major change in respiratory frequency. The respiratory disturbance index (RDI) was defined as the mean number of hypopneas and apneas per hour of sleep. Mild OSA severity (OSAS) was defined as an RDI equal to or greater than 10, but less than 20; severe OSAS as an RDI greater than 50 with the lowest SaO2 being less than 50%; and moderately severe OSAS as falling between the criteria for mild and severe OSAS.


Exclusion criteria were as follows:

  1. Patients with major nasal anatomical abnormalities, for example severe septal deviation and nasal polyps.
  2. Patients with severe OSAS.
  3. Patients with any kind of previous surgery to the nose or palate.
  4. An LMS of less than 5.


Patients were divided randomly into two groups: the first group was given medical treatment in the form of systemic antibiotics for 10 days (amoxicillin/clavulanate) and nasal steroids (fluticasone propionate) for 1 month before palatal surgery; in the second group, no medical treatment was administered before palatal surgery.

The palatal surgeries conducted were as follows:

In the first group: uvulopalatopharyngoplasty (seven), laser-assisted uvulopalatoplasty (three), tonsillectomy (two), and radiofrequency (two).

In the second group: uvulopalatopharyngoplasty (six), laser-assisted uvulopalatoplasty (four), tonsillectomy (one), and radiofrequency (three).

Follow-up examination was carried out after 3 months to assess AHI and LMS for all patients.

Data were statistically described in terms of mean±SD or frequencies (number of cases) and percentages when appropriate. Numerical variables in the study groups were compared using the Student t-test for independent samples. Within group comparisons of numerical variables were made using the paired t-test. For comparing categorical data, χ2-test was performed. The exact test was used when the expected frequency was less than 5. P-values less than 0.05 were considered statistically significant. All statistical calculations were performed using the SPSS program (version 15; SPSS Inc., Chicago, Illinois, USA) for Microsoft Windows.


  Results Top


Study included two groups (each contains 14 patients), group A had 10 men (71.4%) and four women (28.6%), whereas group B had eight men (57.1%) and six women (42.9%). The age in group A ranged from 22 to 50 years (mean 41.36), whereas the age in group B ranged from 29 to 61 years (mean 49.21). The t-test for data description of the two groups is shown in [Table 1].
Table 1: T-test for data description

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As regards group A, paired sample statistics are shown in [Table 2].
Table 2: Group A, paired sample statistics

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Paired sample correlations are shown in [Table 3].
Table 3: Paired sample correlations in group A

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[Figure 1] shows pre-AHI and post-AHI in group A; [Figure 2] shows pre-LMS and post-LMS in the same group.
Figure 1: Pre-AHI and post-AHI in group A. AHI, apnea hypopnea index.

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Figure 2: Pre-LMS and post-LMS in group A. LMS, Lund–Mackay score.

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As regard group B, paired sample statistics are shown in [Table 4].
Table 4: Group B, paired sample statistics

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Paired sample correlations are shown in [Table 5].
Table 5: Paired sample correlations in group B

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[Figure 3] shows pre-AHI and post-AHI in group B; [Figure 4] shows pre-LMS and post-LMS in the same group.
Figure 3: Pre-AHI and post-AHI in group B. AHI, apnea hypopnea index.

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Figure 4: Pre-LMS and post-LMS in group B. LMS, Lund–Mackay score.

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The mean percentage improvement in the AHI score and LMS in group A and group B is illustrated in [Figure 5] and [Figure 6], respectively:
Figure 5: Percentage improvement in AHI and LMS in group A. AHI, apnea hypopnea index; LMS, Lund–Mackay score.

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Figure 6: Percentage improvement in AHI and LMS in group B. AHI, apnea hypopnea index; LMS, Lund–Mackay score.

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The mean percentage improvement in AHI score in group A and group B patients is illustrated in [Figure 7].
Figure 7: Mean percentage improvement in the apnea hypopnea index score between group A and group B.

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  Discussion Top


Sleep impairment associated with allergic rhinitis, rhinosinusitis, and nasal polyposis has a significant impact on patients’ quality of life. Nasal congestion, one of the most common and bothersome symptoms of these conditions, is thought to be a major cause of sleep impairment and sleep-disordered breathing. Recent research has suggested that poor sleep associated with nasal congestion is an important therapeutic target 10. Nasal resistances in adults do not correlate with the severity of respiratory disturbances during sleep 11, nor do they represent a risk factor for causing or worsening OSA 12 or a diagnostic predictive factor 13; however, they are a risk factor for snoring 14. Although a linear trend between decreased nasal airflow and greater AHI was not observed, habitual snoring was consistently associated with decreased nasal airflow, self-reported stuffiness attributed to allergy, and self-reported night-time nasal congestion or discharge. The lack of a linear relationship between nasal obstruction and severity of sleep-disordered breathing is not consistent with the physiologic hypothesis that increased nasal resistance and decreased flow increase the frequency of airway collapse. In their comprehensive review of research on nasal obstruction and sleep-disordered breathing, Olsen and Kern 14 stated that nasal obstruction is more likely to cause snoring than mild or severe obstructive sleep apnea (with frank apnea and hypopnea), and that the degree of nasal obstruction and severity of sleep-disordered breathing are not directly correlated. The findings from the Oxford epidemiologic study 15 were consistent with this conclusion.

Self-reported chronic symptoms of rhinitis were significantly related to excessive daytime sleepiness and not feeling rested regardless of the amount of sleep. Sleep-disordered breathing, including habitual snoring, is related to hypersomnolence; therefore, associations between rhinitis and sleepiness may be explained by sleep-disordered breathing. However, it is possible that symptoms of rhinitis, independent of their effect on breathing, may cause cortical arousal and fragmented sleep. This association warrants further investigation for the management of rhinitis, because somnolence due to sleep fragmentation may be compounded by sleepiness caused by daytime use of medication 9. Treatment of nasal obstruction has three potential goals. It can reduce nasal obstruction, reduce the severity of sleep-disordered breathing (possibly even eliminating it), or facilitate sleep-disordered breathing treatment by allowing the nose to be used more easily as a conduit for positive airway pressure therapy. Because there are multiple causes of nasal obstruction, the combination of history, physical examination, and accurate diagnosis is critical for the selection of a treatment from the long list of medical and surgical treatments 16. In contrast, the isolated treatment of nasal obstruction does not successfully treat obstructive sleep apnea in most patients. Verse and Pirsig 17 performed a literature review that showed that medical treatment resulted in resolution of obstructive sleep apnea in 9% of patients and surgical treatment in 18%. Nasal corticosteroids can produce small changes in snoring and the AHI, but the degree of improvement varies widely 18. A few studies specifically concerning surgical treatment showed that there was minimal to no change in the AHI, but some patients showed improvements in sleep quality and symptoms of daytime somnolence 19.

In our study, group A, which showed an improvement in nasal and sinus conditions as reflected by LMS, had better control of AHI than did group B; it is also noticed that when all other factors are standardized, the improvement of AHI is better after control of nasal and sinus conditions using antibiotics and nasal steroids.

Using LMS as an indicator of nasal and sinus conditions is more accurate and measurable than only considering nasal obstruction. Finally, there is evidence showing that nasal treatments can facilitate the treatment of sleep-disordered breathing by decreasing the magnitude of the positive airway pressure necessary to treat sleep-disordered breathing. Schonhofer et al. 20 showed a reasonable improvement (range 9.3–6.7 cm of water) on septoplasty, with or without inferior turbinate reduction 21, and a smaller effect (range 8.6–8.0 cm of water) was seen on using an external nasal valve dilator device. Two additional studies have shown that nasal surgery can increase the adherence to CPAP devices 22,23.


  Conclusion Top


Treatment of nasal and sinus problems, even in the absence of major anatomical abnormalities, improves the results of palatal surgeries in controlling AHI in mild to moderate OSA.[23]

 
  References Top

1.Lugaresi E, Cirignotta F, Geraldi R, Montagna PGuilleminault C, Partinin M. Snoring and sleep apnea: natural history of heavy snorers disease. Obstructive sleep apnea syndrome: clinical research and treatment. 1990 New York Raven Press:25–36  Back to cited text no. 1
    
2.Papsidero MJ. The role of nasal obstruction in obstructive sleep apnea syndrome. Ear Nose Throat J. 1993;72:82–84  Back to cited text no. 2
    
3.Shepard JW Jr, Burger CD. Nasal and oral flow-volume loops in normal subjects and patients with obstructive sleep apnea. Am Rev Respir Dis. 1990;142(Pt 1):1288–1293  Back to cited text no. 3
    
4.Hormann K, Verse T Surgery for sleep disordered breathing. 2005 New York Springer  Back to cited text no. 4
    
5.D’Alonzo GE Jr. Scope and impact of allergic rhinitis. J Am Osteopath Assoc. 2002;102(Suppl 2):S2–S6  Back to cited text no. 5
    
6.Bhattacharyya N. The economic burden and symptom manifestations of chronic rhinosinusitis. Am J Rhinol. 2003;17:27–32  Back to cited text no. 6
    
7.Suratt PM, Turner BL, Wilhoit SC. Effect of intranasal obstruction on breathing during sleep. Chest. 1986;90:324–329  Back to cited text no. 7
    
8.Bachert C, van Cauwenberge P, Khaltaev N. Allergic Rhinitis and its Impact on Asthma (ARIA). In collaboration with the World Health Organization. Executive summary of the workshop report; 7–10 December 1999; Geneva, Switzerland. Allergy. 2002;57:841–855  Back to cited text no. 8
    
9.Young T, Finn L, Kim H. Nasal obstruction as a risk factor for sleep-disordered breathing. The University of Wisconsin Sleep and Respiratory Research Group. J Allergy Clin Immunol. 1997;99:S757–S762  Back to cited text no. 9
    
10.Craig TJ, Ferguson BJ, Krouse JH. Sleep impairment in allergic rhinitis, rhinosinusitis, and nasal polyposis. Am J Otolaryngol. 2008;29:209–217  Back to cited text no. 10
    
11.Miljeteig H, Hoffstein V, Cole P. The effect of unilateral and bilateral nasal obstruction on snoring and sleep apnea. Laryngoscope. 1992;102:1150–1152  Back to cited text no. 11
    
12.Atkins M, Taskar V, Clayton N, Stone P, Woodcock A. Nasal resistance in obstructive sleep apnea. Chest. 1994;105:1133–1135  Back to cited text no. 12
    
13.Desfonds P, Planès C, Fuhrman C, Foucher A, Raffestin B. Nasal resistance in snorers with or without sleep apnea: effect of posture and nasal ventilation with continuous positive airway pressure. Sleep. 1998;21:625–632  Back to cited text no. 13
    
14.Olsen KO, Kern EB. Nasal influences on snoring and obstructive sleep apnea. Mayo Clinic Proc. 1990;65:1095–1105  Back to cited text no. 14
    
15.Stradling JR, Crosby JH. Predictors and prevalence of obstructive sleep apnoea and snoring in 1001 middle aged men. Thorax. 1991;46:85–90  Back to cited text no. 15
    
16.Egan KK, Kezirian EJ, Kim DW. Nasal obstruction and sleep-disordered breathing. Op Teh in Otolaryng H & N Surg. 2006;17:268–272  Back to cited text no. 16
    
17.Verse T, Pirsig W. Impact of impaired nasal breathing on sleep-disordered breathing. Sleep Breath. 2003;7:63–76  Back to cited text no. 17
    
18.Kiely JL, Nolan P, McNicholas WT. Intranasal corticosteroid therapy for obstructive sleep apnea in patients with co-existing rhinitis. Thorax. 2004;59:50–55  Back to cited text no. 18
    
19.Friedman M, Tanyeri H, Lim JW, Landsberg R, Vaidyanathan K, Caldarelli D. Effect of improved nasal breathing on obstructive sleep apnea. Otolaryngol Head Neck Surg. 2000;122:71–74  Back to cited text no. 19
    
20.Schönhofer B, Kerl J, Suchi S, Köhler D, Franklin KA. Effect of nasal valve dilation on effective CPAP level in obstructive sleep apnea. Respir Med. 2003;97:1001–1005  Back to cited text no. 20
    
21.Constantian MB. Four common anatomic variants that predispose to unfavorable rhinoplasty results: a study based on 150 consecutive secondary rhinoplasties. Plast Reconstr Surg. 2000;105:316–331  Back to cited text no. 21
    
22.Powell NB, Riley RW, Guilleminault C, Murcia GN. Obstructive sleep apnea, continuous positive airway pressure, and surgery. Otolaryngol Head Neck Surg. 1988;99:362–369  Back to cited text no. 22
    
23.Series F, St Pierre S, Carrier G. Effects of surgical correction of nasal obstruction in the treatment of obstructive sleep apnea. Am Rev Respir Dis. 1992;146:1261–1265  Back to cited text no. 23
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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