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DOI: 10.1055/a-2111-9255
Considerations for Functional Nasal Surgery in the Obstructive Sleep Apnea Population
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Abstract
Obstructive sleep apnea (OSA) and nasal obstruction are common in the general population and frequently treated by otolaryngologists and facial plastic surgeons. Understanding the appropriate pre-, peri-, and postoperative management of OSA patients undergoing functional nasal surgery is important. OSA patients should be appropriately counseled in the preoperative period on their increased anesthetic risk. In OSA patients who are continuous positive airway pressure (CPAP) intolerant, the role of drug-induced sleep endoscopy should be discussed with the patient, and depending on the surgeon's practice may prompt referral to a sleep specialist. Should multilevel airway surgery be indicated, it can safely be performed in most OSA patients. Surgeons should communicate with the anesthesiologist regarding an airway plan given this patient population's higher propensity for having a difficult airway. Given their increased risk of postoperative respiratory depression, extended recovery time should be given to these patients and the use of opioids as well as sedatives should be minimized. During surgery, one can consider using local nerve blocks to reduce postoperative pain and analgesic use. After surgery, clinicians can consider opioid alternatives such as nonsteroidal anti-inflammatory agents. Neuropathic agents, such as gabapentin, require further research in their indications for managing postoperative pain. CPAP is typically held for a period of time after functional rhinoplasty. The decision on when to restart CPAP should be individualized to the patient based on their comorbidities, OSA severity, and surgical maneuvers performed. More research would provide further guidance in this patient population to shape more specific recommendations regarding their perioperative and intraoperative course.
Publication History
Accepted Manuscript online:
16 June 2023
Article published online:
27 July 2023
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References
- 1 Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, Hla KM. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol 2013; 177 (09) 1006-1014
- 2 Rhee JS, Book DT, Burzynski M, Smith TL. Quality of life assessment in nasal airway obstruction. Laryngoscope 2003; 113 (07) 1118-1122
- 3 Ishii LE, Tollefson TT, Basura GJ. et al. Clinical practice guideline: improving nasal form and function after rhinoplasty executive summary. Otolaryngol Head Neck Surg 2017; 156 (02) 205-219
- 4 Gross J, Apfelbaum J, Caplan R. et al; American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology 2014; 120 (02) 268-286
- 5 Gross JB, Bachenberg KL, Benumof JL. et al; American Society of Anesthesiologists Task Force on Perioperative Management. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology 2006; 104 (05) 1081-1093 , quiz 1117–1118
- 6 Neligan PJ, Malhotra G, Fraser M. et al. Continuous positive airway pressure via the Boussignac system immediately after extubation improves lung function in morbidly obese patients with obstructive sleep apnea undergoing laparoscopic bariatric surgery. Anesthesiology 2009; 110 (04) 878-884
- 7 Jordan AS, McSharry DG, Malhotra A. Adult obstructive sleep apnoea. Lancet 2014; 383 (9918) 736-747
- 8 Pivetta B, Chen L, Nagappa M. et al. Use and performance of the STOP-Bang questionnaire for obstructive sleep apnea screening across geographic regions: a systematic review and meta-analysis. JAMA Netw Open 2021; 4 (03) e211009
- 9 Jonas DE, Amick HR, Feltner C. et al. Screening for obstructive sleep apnea in adults evidence report and systematic review for the US preventive services task force. JAMA 2017; 317 (04) 415-433
- 10 Deenadayal DS, Bommakanti V. History, clinical examination, and diagnosis of snoring and obstructive sleep apnea-hypopnea syndrome. In: A Practical Guide Management of Snoring and Obstructive Sleep Apnea. Singapore: Springer; 2022: 31-33
- 11 Caplan RA, Benumof JL, Berry FA. et al. Practice guidelines for management of the difficult airway. A report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology 1993; 78 (03) 597-602
- 12 Mickelson SA. Anesthetic and postoperative management of the obstructive sleep apnea patient. Oral Maxillofac Surg Clin North Am 2009; 21 (04) 425-434
- 13 Bolden N, Posner KL, Domino KB. et al. Postoperative critical events associated with obstructive sleep apnea: results from the Society of Anesthesia and Sleep Medicine Obstructive Sleep Apnea Registry. Anesth Analg 2020; 131 (04) 1032-1041
- 14 Ekici NY, Alagöz S. The effectiveness of endoscopic sphenopalatine ganglion block in management of postoperative pain after septal surgery. Int Forum Allergy Rhinol 2019; 9 (12) 1521-1525
- 15 Kaçar CK, Uzundere O, Salık F, Akgündüz M, Bıçak EA, Yektaş A. Effects of adding a combined infraorbital and infratrochlear nerve block to general anaesthesia in septorhinoplasty. J Pain Res 2020; 13: 2599-2607
- 16 Pang KP, Siow JK, Tseng P. Safety of multilevel surgery in obstructive sleep apnea: a review of 487 cases. Arch Otolaryngol Head Neck Surg 2012; 138 (04) 353-357
- 17 Baker AB, Xiao CC, O'Connell BP, Cline JM, Gillespie MB. Uvulopalatopharyngoplasty: does multilevel surgery increase risk?. Otolaryngol Head Neck Surg 2016; 155 (06) 1053-1058
- 18 Brietzke SE, Ishman SL, Cohen S, Cyr DD, Shin JJ, Kezirian EJ. National database analysis of single-level versus multilevel sleep surgery. Otolaryngol Head Neck Surg 2017; 156 (05) 955-961
- 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 (01) 71-74
- 20 Stapleton AL, Chang YF, Soose RJ, Gillman GS. The impact of nasal surgery on sleep quality: a prospective outcomes study. Otolaryngol Head Neck Surg 2014; 151 (05) 868-873
- 21 Bican A, Kahraman A, Bora I, Kahveci R, Hakyemez B. What is the efficacy of nasal surgery in patients with obstructive sleep apnea syndrome?. J Craniofac Surg 2010; 21 (06) 1801-1806
- 22 Li HY, Wang PC, Chen YP, Lee LA, Fang TJ, Lin HC. Critical appraisal and meta-analysis of nasal surgery for obstructive sleep apnea. Am J Rhinol Allergy 2011; 25 (01) 45-49
- 23 Pang KP, Montevecchi F, Vicini C. et al. Does nasal surgery improve multilevel surgical outcome in obstructive sleep apnea: a multicenter study on 735 patients. Laryngoscope Investig Otolaryngol 2020; 5 (06) 1233-1239
- 24 Haavisto L, Suonpää J. Complications of uvulopalatopharyngoplasty. Clin Otolaryngol Allied Sci 1994; 19 (03) 243-247
- 25 Esclamado RM, Glenn MG, McCulloch TM, Cummings CW. Perioperative complications and risk factors in the surgical treatment of obstructive sleep apnea syndrome. Laryngoscope 1989; 99 (11) 1125-1129
- 26 Mickelson SA, Hakim I. Is postoperative intensive care monitoring necessary after uvulopalatopharyngoplasty?. Otolaryngol Head Neck Surg 1998; 119 (04) 352-356
- 27 Hathaway B, Johnson JT. Safety of uvulopalatopharyngoplasty as outpatient surgery. Otolaryngol Head Neck Surg 2006; 134 (04) 542-544
- 28 Kezirian EJ, Weaver EM, Yueh B. et al. Incidence of serious complications after uvulopalatopharyngoplasty. Laryngoscope 2004; 114 (03) 450-453
- 29 Vuyk J, Sitsen E, Reekers M. Intravenous anesthetics. In: Gropper M. ed. Miller's Anesthesia. Vol. 23. 9th ed. Philadelphia, PA: Elsevier; 2020: 638-679
- 30 Gupta K, Nagappa M, Prasad A. et al. Risk factors for opioid-induced respiratory depression in surgical patients: a systematic review and meta-analyses. BMJ Open 2018; 8 (12) e024086
- 31 Qian ZJ, Alyono JC, Jin MC, Cooperman SP, Cheng AG, Balakrishnan K. Opioid prescribing patterns following pediatric tonsillectomy in the United States, 2009-2017. Laryngoscope 2021; 131 (05) E1722-E1729
- 32 Kendale SM, Wang J, Blitz JD. et al. A retrospective study of opioid prescribing patterns at hospital discharge in surgical patients with obstructive sleep apnea. Can J Anaesth 2018; 65 (08) 914-922
- 33 Pattinson KTS. Opioids and the control of respiration. Br J Anaesth 2008; 100 (06) 747-758
- 34 Akcam T, Arslan HH, Deniz S. et al. Comparison of early postoperative pain among surgical techniques for obstructive sleep apnea. Eur Arch Otorhinolaryngol 2012; 269 (11) 2433-2440
- 35 Despeghel AS, Mus L, Dick C. et al. Long-term results of a modified expansion sphincter pharyngoplasty for sleep-disordered breathing. Eur Arch Otorhinolaryngol 2017; 274 (03) 1665-1670
- 36 Frants A, Garber D, Lafer MP. et al. Prospective randomized trial comparing opioids versus nonsteroidal antiinflammatory drugs for postoperative analgesia in outpatient rhinoplasty. Plast Reconstr Surg 2021; 147 (01) 56-62
- 37 Newberry CI, McCrary HC, Cerrati EW. The efficacy of oral celecoxib following surgical rhinoplasty. Facial Plast Surg Aesthet Med 2020; 22 (02) 100-104
- 38 Cramer JD, Barnett ML, Anne S. et al. Nonopioid, multimodal analgesia as first-line therapy after otolaryngology operations: primer on nonsteroidal anti-inflammatory drugs (NSAIDs). Otolaryngol Head Neck Surg 2021; 164 (04) 712-719
- 39 Jandali D, Barrera JE. Equivocal pain scores one week after rhinoplasty: synthetic opioid versus neuropathic analgesic. Facial Plast Surg Aesthet Med 2022; 24 (01) 69-70
- 40 Hah J, Mackey SC, Schmidt P. et al. Effect of perioperative gabapentin on postoperative pain resolution and opioid cessation in a mixed surgical cohort a randomized clinical trial. JAMA Surg 2018; 153 (04) 303-311
- 41 Verret M, Lauzier F, Zarychanski R. et al; Canadian Perioperative Anesthesia Clinical Trials (PACT) Group. Perioperative use of gabapentinoids for the management of postoperative acute pain: a systematic review and meta-analysis. Anesthesiology 2020; 133 (02) 265-279
- 42 Cohen JC, Larrabee YC, Weinstein AL, Stewart MG. Use of continuous positive airway pressure after rhinoplasty, septoplasty, and sinus surgery: a survey of current practice patterns. Laryngoscope 2015; 125 (11) 2612-2616
- 43 Reilly EK, Boon MS, Vimawala S. et al. Tolerance of continuous positive airway pressure after sinonasal surgery. Laryngoscope 2021; 131 (03) E1013-E1018