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DOI: 10.1055/s-0044-1782527
Role of Nasal Surgery in Adult Obstructive Sleep Apnea: A Systematic Review
Abstract
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.
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Keywords
sleep apnea - obstructive - nasal obstruction - sleep apnea syndromes - nasal surgical procedures - systematic reviewIntroduction
Obstructive sleep apnea (OSA) is a prevalent disease that affects between 4% and 30% of the population,[1] and whose importance is related to the consequences on the quality of life and cardiovascular,[2] [3] metabolic,[4] [5] and neurologic comorbidities.[6]
There are many therapeutic approaches[7] [8] to treat OSA; the most relevant is continuous positive airway pressure (CPAP), and the other options include mandibular advancement devices (MADs),[9] [10] positional therapy,[11] myofunctional therapy[12] [13] [14] and upper airway (UA) surgery.[15] [16] [17] [18]
Even though CPAP therapy is the gold-standard treatment, objectively improving OSA parameters and quality of sleep,[19] [20] [21] its adherence shows a significant reduction in long-term follow-up, being estimated at around 50% until the end of the first year, according to several studies.[22] [23] [24] [25]
The first factor involved in this low adherence rate is related to the mask,[20] [21] which is firmly attached to impaired nasal function. Of the problems with the mask, nasal symptoms, such as obstruction or trauma to the nostrils or dorsum skin, are reported by ∼ 30% to 50% of the patients.[26]
As well as the nose represents around 50% of UA resistance,[27] nasal obstruction has a prevalence close to the 30% in Europe, with its leading causes being Allergic Rhinitis and Chronic Rhinosinusitis,[28] [29] which is why different authors have informed about the strong correlation between nasal pathology and a poor quality of sleep.
Given the consequences of nasal insufficiency on sleep and the correlation with low adherence to the CPAP therapy, nasal function acquires a strong relevance for the OSA patient. One may ask if nasal surgery has consequences on OSA, as much on the disease indeed, or secondarily as an adjuvant treatment to improve and strengthen the results and efficacy of other therapies.
The present systematic review aims to identify whether isolated nasal surgery has any impact on subjective or objective parameters in adult OSA patients.
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Materials and Methods
We designed a systematic review protocol following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement[34] and registered it in the International Prospective Register of Systematic Reviews (PROSPERO; CRD42022385205). The search was conducted from December 2022 to February 2023 on the PubMed (MEDLINE), Scopus, Web of Science, and Cochrane databases. With the objective of including most studies available, the search was designed using the Medical Subject Headings (MeSH) described in [Table 1], and studies written in both English and Spanish were considered.
The search strategy and results are provided as complementary material. After the first search, the results were deduplicated using the SR-Accelerator[35] (Institute for Evidence-Based Healthcare, Bond University, Robina, QLD, Australia), and the selection of studies was performed using the Rayyan (Rayyan Systems Inc., Cambridge, MA, United States) web and mobile app.[36]
The inclusion criteria were: patients over 18 years old, with a diagnosis of anatomical nasal pathology (such as septal deviation, turbinate hypertrophy, nasal polyps, and nasal valve collapse), an objective diagnosis of OSA, who were submitted to an isolated nasal surgical procedure.
We excluded publications with: patients under 18 years of age, subjective OSA diagnosis, nasal surgical procedure not specified, lack of postoperative sleep study, craniofacial malformations, neurological impairment, non-surgical nasal pathologies, and other concomitant UA surgical procedures.
The risk of bias quality assessment was made following the Risk of Bias in Non-randomized Studies – of Interventions (ROBINS-I) tool from Cochrane.[37]
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Results
After deduplication, 3,405 studies were obtained. Titles and abstract were screened, and studies not related to the research topic were discarded. Of the 63 studies selected for full reading, 38 were discarded for not fulfilling the established criteria (19 on pediatric population, 7 with concomitant pharyngeal surgical procedures, and 12 only with subjective measures), resulting in 25 studies for inclusion in the present review, with diverse methodological approaches, including 13 prospective studies, 2 retrospective studies, 1 randomized controlled trial, 6 systematic reviews, and 3 bibliographic reviews ( [Fig. 1] ).
The following data was extracted from the articles: type of study, parameters assessed, intervention, and conclusion, as presented in [Table 2]; the specific outcomes of each study are presented in [Table 3] .
Author |
Year |
Type of study |
Parameters |
Intervention |
Conclusion |
|
---|---|---|---|---|---|---|
Friedman et al.[78] |
2000 |
Prospective (n = 50) |
PSG, use of CPAP |
SP with or without TP |
98% improved nasal breathing; 34% improved snoring; no changes in AHI; reduces CPAP titration pressures |
|
Verse et al.[54] |
2002 |
Prospective (n = 26) |
Epworth, rhinomanometry, PSG |
SP with/without TP, RSP, nasal valve surgery |
Improved Epworth and nasal resistance; no significant changes in AHI |
|
Kim et al.[58] |
2004 |
Retrospective (n = 21) |
PSG |
SP with or without TX |
19% improved PSG parameters |
|
Virkkula et al.[65] |
2006 |
Prospective (n = 40) |
Rhinomanometry, PSG |
SP with or without TX, RSP |
Improved nasal resistance; no significant changes in snoring |
|
Nakata et al.[59] |
2008 |
Prospective (n = 49) |
Epworth, rhinomanometry, PSG |
SP with or without TX, ESS |
Improved Epworth and nasal resistance; no significant changes in AHI |
|
Li et al.[55] |
2008 |
Prospective (n = 51) |
Epworth, SF-36, SOS |
SP + Nasal valve surgery |
Improved quality of sleep, quality of life and snoring |
|
Koutsourelakis et al.[57] |
2008 |
Randomized controlled trial (n = 49) |
Epworth, rhinomanometry, PSG |
SP with or without TP |
Improved Epworth and nasal resistance; No changes in AHI |
|
Tosun et al.[60] |
2009 |
Prospective (n = 27) |
VAS-QS, Epworth, rhinomanometry, PSG |
ESS |
Improved quality of sleep, Epworth and nasal resistance; No significant changes in AHI |
|
Li et al.[62] |
2009 |
Prospective (n = 66) |
Epworth, PSG |
SP + TX |
Improved Epworth and snoring; No significant changes in AHI |
|
Bican et al.[63] |
2010 |
Prospective (n = 20) |
Epworth, PSG |
RSP, nasal valve surgery |
Improved Epworth (higher in CPAP users) and sleep architecture; no significant changes in AHI |
|
Choi et al.[64] |
2011 |
Prospective (n = 22) |
Epworth, PSG |
SP with or without TP, ESS |
Improved Epworth and sleep architecture; no significant changes in AHI |
|
Sufioğlu et al.[79] |
2012 |
Prospective (n = 28) |
Epworth, VAS-QS, PSG, CPAP titration |
SP with or without TP, RSP, TP, ESS |
Improved Epworth, quality of sleep and CPAP titration pressures; no changes in AHI |
|
Poirier et al.[82] |
2014 |
Prospective (n = 18) |
NOSE, use of CPAP |
SP + TP |
Improved nasal obstruction and CPAP adherence |
|
Park et al.[61] |
2014 |
Prospective (n = 25) |
VAS-NO, Epworth, Acoustic Rhinometry, WatchPAT device |
SP with or without TP |
Improved Epworth, nasal obstruction, and resistance; improved AHI in 56% |
|
Ishii et al.[72] |
2015 |
Sytematic review and meta-analysis (10 studies) |
Epworth, PSG |
Isolated nasal surgery |
Improved Epworth (3.3 points) and Respiratory Disturbance Index (11.06); no significant changes in AHI |
|
Mickelson[76] |
2016 |
Bibliographic review |
Epworth, PSG, and use of CPAP |
Nasal surgery (not specified) |
Improved CPAP adherence |
|
Wu et al.[70] |
2017 |
Sytematic review and meta-analysis (18 studies) |
Epworth, PSG |
Isolated nasal surgery |
Improved Epworth; no significant changes in AHI |
|
Sukato et al.[69] |
2018 |
Systematic review (7 studies) |
Epworth, PSQI, SNOT-22, PSG |
ESS |
Improved Epworth, PSQI, and SNOT-22; no changes in AHI |
|
Sharma et al.[73] |
2019 |
Systematic review (16 studies) |
Epworth, PSG |
Isolated nasal surgery or combined multilevel |
Improved Epworth (3.9 points), AHI (10.6 points) and Respiratoy Disturbance Index[4] [6] |
|
Wang et al.[71] |
2019 |
Sytematic review and meta-analysis (19 studies) |
Epworth, PSG |
Isolated nasal surgery |
OSA subgroup improved Epworth; non-OSA subgroup without changes; no changes in AHI in either group |
|
Iwata et al.[80] |
2020 |
Retrospective (n = 86) with control group |
Epworth, rhinomanometry, PSG |
SP + TX |
Improved sleepiness and nasal resistance; no changes in AHI; improved CPAP adherence |
|
Cai et al.[77] |
2020 |
Bibliographic review |
QoL, CPAP tolerance |
SP, TP, RSP, ESS |
Improved sleepiness, snoring, quality of sleep and CPAP adherence |
|
Kim et al.[103] |
2021 |
Prospective (n = 25) |
VAS-NO, Epworth, PSG |
SP + TP |
Improved Epworth and nasal obstruction (more in allergic rhinitis group); no significant changes in AHI |
|
Schoustra et al.[67] |
2022 |
Systematic review (21 studies) |
Epworth, PSG |
Isolated nasal surgery |
Improved Epworth; no significant changes in AHI |
|
Newsome[68] |
2023 |
Review |
AHI |
SP with or without TP, RSP |
RSP may improve AHI in mild OSA; SP inconsistent |
Abbreviations: AHI, apnea-hypopnea index; CPAP, continuous positive airway pressure; ESS, Endoscopic sinus surgery; NOSE, Nasal Obstruction Symptom Evaluation; PSG, polysomnography; PSQI, Pittsburg Sleep Quality Index; QoL, quality of life; RSP, rhinoseptoplasty; SF-36, 36-item Short-Form Health Survey; SNOT-22, 22-item Sinonasal Outcome Test; SOS, Snore Outcome Survey; SP, septoplasty; TP, turbinoplasty; TX, turbinectomy; VAS-NO, Visual Analog Scale on Nasal Obstruction; VAS-QS, Visual Analog Scale on Quality of Sleep.
Outcomes |
|||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|
Author |
Subjective |
Objective |
|||||||||
Nasal obstruction |
Sleepiness (Epworth Sleepiness Scale) |
Quality of sleep |
Quality of life |
Nasal resistance |
Snoring |
AHI |
Sleep architecture |
CPAP use |
CPAP titration pressure |
||
Friedman et al.[78] |
Yes |
No |
No |
No |
No |
Yes |
Yes |
No |
No |
Yes |
|
Verse et al.[54] |
No |
Yes |
No |
No |
Yes |
No |
Yes |
No |
No |
No |
|
Kim et al.[58] |
No |
No |
No |
No |
No |
No |
Yes |
No |
No |
No |
|
Virkkula et al.[65] |
No |
No |
No |
No |
Yes |
Yes |
No |
No |
No |
No |
|
Nakata et al.[59] |
No |
Yes |
No |
No |
Yes |
No |
Yes |
No |
No |
No |
|
Li et al.[55] |
No |
No |
Yes |
Yes |
No |
Yes |
No |
No |
No |
No |
|
Koutsourelakis et al.[57] |
No |
Yes |
No |
No |
Yes |
No |
Yes |
No |
No |
No |
|
Tosun et al.[60] |
No |
Yes |
Yes |
No |
Yes |
No |
Yes |
No |
No |
No |
|
Li et al.[62] |
No |
Yes |
No |
No |
No |
Yes |
Yes |
No |
No |
No |
|
Bican et al.[63] |
No |
Yes |
No |
No |
No |
No |
Yes |
Yes |
No |
No |
|
Choi et al.[64] |
No |
Yes |
No |
No |
No |
No |
Yes |
Yes |
No |
No |
|
Sufioğlu et al.[79] |
No |
Yes |
Yes |
No |
No |
No |
Yes |
No |
No |
Yes |
|
Poirier et al.[82] |
Yes |
No |
No |
No |
No |
No |
No |
No |
Yes |
No |
|
Park et al.[61] |
Yes |
Yes |
No |
No |
Yes |
No |
Yes |
No |
No |
No |
|
Ishii et al.[72] |
No |
Yes |
No |
No |
No |
No |
Yes |
No |
No |
No |
|
Mickelson[76] |
No |
No |
No |
No |
No |
No |
Yes |
No |
Yes |
No |
|
Wu et al.[70] |
No |
Yes |
No |
No |
No |
No |
Yes |
No |
No |
No |
|
Sukato et al.[69] |
No |
Yes |
Yes |
Yes |
No |
No |
Yes |
No |
No |
No |
|
Sharma et al.[73] |
No |
Yes |
No |
No |
No |
No |
Yes |
No |
No |
No |
|
Wang et al.[71] |
No |
Yes |
No |
No |
No |
No |
Yes |
No |
No |
No |
|
Iwata et al.[80] |
No |
Yes |
No |
No |
Yes |
No |
Yes |
No |
Yes |
No |
|
Cai et al.[77] |
No |
Yes |
Yes |
No |
No |
Yes |
No |
No |
Yes |
No |
|
Kim et al.[103] |
Yes |
Yes |
No |
No |
No |
No |
Yes |
No |
No |
No |
|
Schoustra et al.[67] |
No |
Yes |
No |
No |
No |
No |
Yes |
No |
No |
No |
|
Newsome[68] |
No |
No |
No |
No |
No |
No |
Yes |
No |
No |
No |
Abbreviations: AHI, apnea-hypopnea index; CPAP, continuous positive airway pressure.
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Discussion
The current scientific literature obtained through our systematic review shows that nasal surgery positively impacts OSA, mainly improving the subjective parameters, but with a non-significant consequence on the apnea-hypopnea index (AHI). The diversity of the parameters informed in the studies does not enables to perform a meta-analysis in the present systematic review.
Nasal Obstruction and Pathophysiology of OSA
During the evaluation of an OSA patient with nasal obstruction, it is important to understand how the affected nose impacts on the lower airway. According to the Starling model theory,[38] during inspiration, an increased resistance at the level of the nose, due to the Bernoulli effect,[39] will favor the collapsibility of the pharyngeal soft tissues. In the normal airway, there will be no collapse, but in OSA patients, after overcoming the critical closing pressure (Pcrit), a partial or total airway collapse will happen.[40] [41] This concept enables us to understand the relevance of nasal permeability, which makes us search systematically for pathologies at this level in OSA patients. At the same time, oral breathing due to nasal insufficiency modifies UA dynamics, displacing the mandible, tongue, and soft palate posteriorly, reducing the caliber of the UA.[21] [42] As was shown by Fitzpatrick et al.[43] in a randomized study conducted in a healthy population, oral breathing entails an increase in the AHI measured by polysomnography (PSG), compared with nasal breathing during sleep. When these changes present at an early age, maxillomandibular development is affected in the long term, which has been correlated to the onset of OSA in adulthood by other authors[109].
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Consequences of Nasal Obstruction on Sleep
Nasal pathology carries an evident implication on the quality of sleep and cognitive functions;[44] it negatively influences the objective parameters in sleep studies[45] [46] [47] and constitutes a relevant factor for CPAP intolerance.[48] Already in 1986, Suratt et al.[49] found that exposing a healthy population to nasal obstruction by packing the nose with a gauze soaked in petrolatum led to an increased AHI. Following the same line of thought, in 1997, Young et al.[50] proposed chronic nasal congestion as a risk factor for OSA, after identifying through questionnaires a correlation between the frequency of nocturnal nasal congestion and snoring in 4,927 patients. Therefore, a correlation between nasal resistance and adherence to CPAP therapy has been shown,[51] as in the publication by Sugiura et al.,[52] in which 77 OSA patients were prescribed CPAP therapy with a nasal mask. The authors[52] found that high nasal resistance, assessed objectively through rhinomanometry, was statistically correlated as a predictor of low adherence to CPAP.
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Nasal Surgery and OSA
The most performed nasal surgical procedures, as described in the included studies, are septoplasty, with or without concomitant turbinoplasty or turbinectomy, rhinoseptoplasty, and endoscopic sinus surgery (ESS). The role of nasal surgery on OSA has been questioned for many years, such as in early publications by Fairbanks[53] (1985), who found an improvement in snoring of 77% among OSA patients who underwent septoplasty with turbinoplasty.
Several authors[54] [55] have addressed the consequences of nasal surgery for obstructive anatomical diseases (septal deviation, turbinate hypertrophy, nasal polyps), measuring subjective and objective parameters, such as sleepiness through the Epworth Sleepiness Scale,[56] sleep quality through the Visual Analog Scale on Quality of Sleep (VAS-QS), nasal resistance by rhinomanometry, and the AHI through PSG, each of them collected before the surgical procedure and after two to six months of follow-up, depending on the study. All of the authors homogeneously reported a significant improvement in the subjective measures after nasal surgery, but no statistically significant differences in the AHI.
A relevant randomized controlled trial was published by Koutsourelakis et al.[57] in 2008. In this study, 49 OSA patients with nasal obstruction due to septal deviation were randomly assigned to the surgical group or the control group, which was blinded for the patients and nursing staff, including the postoperative care. The authors[57] reported improved sleepiness and nasal resistance in the surgery group, with no changes among the controls. On the other hand, the AHI showed no differences in either group, and the authors concluded that nasal surgery by itself is ineffective to treat OSA; however, it can benefit the patients and must be considered in the therapeutic plan. In 2004, Kim et al.[58] reached the same conclusion, that this therapeutic approach benefits some patients, but a pharyngoplasty must be considered for a second surgical stage. This concept is supported by the findings of other studies.[59] [60] [61] [62] Other authors[63] [64] have informed not only an improvement in sleepiness but also in sleep quality and its architecture, measured by PSG. Nevertheless, the AHI remained with the same values as in the preoperative measure.
On the other hand, Virkulla et al.[65] and Kalam[66] informed no changes in the snoring parameters after nasal surgery. Despite this, there are few publications showing no impact of nasal surgery on the assessed parameters.
Several reviews showed an improvement of the subjective parameters after nasal surgery, with no relevant changes regarding the AHI, such as the ones published by Schoustra et al.[67] and Newsome.[68] Sukato et al.[69] reported a substantial improvement in nasal symptoms and sleep quality after surgery for chronic rhinosinusitis, although there was a slight decrease in the AHI. Similar results were reported by Wu et al.[70] and Wang et al.,[71] who highlighted that isolated nasal surgery improved sleepiness and the AHI, but the latter with scarce significance.
Ishii et al.[72] focused on the role of isolated nasal surgery in their meta-analysis published in 2015, which included ten studies. They identified an improvement in the Epworth Sleepiness Scale and Respiratory Disturbance Index (RDI) after surgery, but without significant changes in the AHI.
In a systematic review, Sharma et al.[73] compared isolated or combined nasal surgery and no surgical therapies or non-rhinological surgical procedures as a treatment for OSA. They concluded that isolated nasal surgery could benefit OSA patients despite not being a primary treatment for this disease, but an adjuvant to improve CPAP adherence and lower the associated symptoms.
The literature found shows a substantial improvement in subjective parameters in OSA patients after nasal surgery, with no significant changes in the objective PSG parameters.
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Nasal Surgery and CPAP Therapy
Even with the technological advances in OSA diagnosis and treatment,[21] such as the development of smaller and more portable equipment, a reduction in the high rate of CPAP dropout has not been achieved yet,[74] and problems with the mask, such as the nasal symptoms reported by 30% to 50% of the patients,[26] are the first cause of lack of adherence.
Considering that CPAP therapy is the gold-standard treatment for OSA, in 2015, Camacho et al.[75] published a systematic review in which they evaluated the effects of nasal surgery, as an isolated treatment, on CPAP use and adherence, as well as the consequences on the required titration pressures. Their analysis[75] showed that 89.1% of patients who did not tolerate CPAP or refused to use it, adapted and became adherent after the surgery. In addition, they informed an increase in the daily use of CPAP (from 3.0 to 5.5 hours/day on average) in the 6-month follow-up. This can be explained by another relevant finding in this revision: CPAP titration pressure was statistically reduced by an average of 2.66 cm H2O.
At the same time, Mickelson[76] reported that the initial CPAP adherence rate among their OSA patients was of around 40%, but nasal surgery reduced the required titration pressures and improved adherence. Similar findings were described in the bibliographic review by Cai et al.[77] in 2020, who concluded that nasal surgery improves sleepiness, snoring, and sleep quality in OSA patients, as well as CPAP adherence.
In 2000, Friedman et al.[78] found that 50 OSA patients required lower pressure in the postoperative CPAP titration after nasal surgery, without distinction regarding the severity of OSA. This improvement was also more significant in the subgroup with severe OSA, even while not showing a statistically significant reduction in the AHI. In 2012, Sufioğlu et al.[79] also reported that CPAP titration pressure was significantly lowered after nasal surgery, which supports the concept of considering nasal surgery an option to improve CPAP adherence.
Iwata et al.[80] compared a group of 43 OSA patients who were intolerant to CPAP, treated with septoplasty and turbinoplasty, and a control group with similar anthropometric characteristics who underwent no intervention. Nasal resistance and sleepiness were reduced in the surgical group, with no relevant changes in the AHI. The most remarkable finding of this study[80] is that 40 of the 43 surgical patients could adapt to the CPAP therapy after the procedure, and that the remaining 3 patients fulfilled OSA cure criteria. This study[80] concluded that despite the fact that nasal surgery could not alter objective PSG parameters, its consideration is relevant for OSA patients to adapt to CPAP therapy.
In 2022, Brimioulle and Chaidas[81] concluded that low nasal resistance correlates with higher CPAP adherence rates, and they identified a beneficial effect of nasal surgery on the use of CPAP. At the same time, they found that CPAP can produce a local inflammatory reaction, thus increasing nasal symptoms, but this does not significantly affect nasal resistance. Similar findings were reported by Poirier et al.,[82] who found a subjective improvement on the Nasal Obstruction Symptom Evaluation (NOSE) scale,[83] [84] as well as an increase in the hours of use of CPAP.
Isolated nasal surgery may not be considered a primary treatment for OSA, but should be offered to those CPAP intolerant patients, aiming to improve adherence.
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Phenotyping OSA Patients
Different phenotypes are recognized in OSA, revealing the heterogeneity of its pathophysiology, such as low arousal threshold, high loop gain, low muscle effectiveness,[85] and anatomical anomalies.[86] [87] [88] This encourages the identification of the factors presented by each patient, with the main objective of providing a personalized approach.
The assessment of an OSA patient during surgical planning requires drug-induced sleep endoscopy (DISE),[89] through which the collapse pattern is identified and recognized, to offer an adequate and tailored surgical procedure.[90] [91] [92] [93] Even though surgery in the nose decreases its resistance and improves its function, the effects on the collapse pattern at other levels (pharynx or larynx) show contradictory results. Victores and Takashima[94] compared the DISE findings before and after nasal surgery on 24 patients, reporting that the procedure did not modify the collapse pattern in OSA. On the other hand, Bosco et al.[95] reported significant changes after nasal surgery in the pharyngeal collapse pattern during DISE, concluding that a new assessment is required before a second pharyngeal surgical stage.
Allergic rhinitis is an influential factor both in terms of nasal symptoms and CPAP therapy failure, and it can be found in ∼ 30% of the general population,[96] [97] with the rates in some series rising to 60%.[98] The scientific literature exposes in different studies the impact of allergic disease on the quality of sleep[99] [100] and, in objective sleep studies parameters, with impaired self-reported sleep questionnaires and increased AHI.
Considering that topical nasal steroid therapy is the first line of treatment for AR, Charakorn et al.[101] reported that, although this treatment was correlated with a slight benefit in the use of CPAP, there was no statistically significant difference in the time of use of CPAP or the nasal symptoms between the therapy and control groups. Meen and Chandra[102] compared the medical and surgical treatments for OSA, concluding that pharmacological therapy can improve sleep quality and snoring, but has no impact on the AHI.
In 2021, Kim et al.[103] reported that OSA patients subjected to isolated nasal surgery presented postoperative improvement on the 6-month follow-up. The authors[103] identified a success rate of 14.3% in the surgical group, but in the subgroup of patients with diagnosed AR (measured by history, prick test, and serum immunoglobulin E, IgE), that rate was increased to 50%, and they concluded that concomitant AR affects the surgical results.
We must take into consideration that AR diagnosis is mandatory in every patient candidate to nasal surgery, as it is correlated with a poor quality of sleep, and it also impacts the surgical outcomes.
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Unsatisfactory Surgical Outcomes
Finally, some patients refer no improvement in their nasal breathing after surgery, despite their postoperative endoscopy evidencing a satisfactory outcome with objective permeability. Breathing dysfunction is estimated to affect 9,5% of the general population.[104] It has been correlated with OSA pathophysiology, specifically with reduced ventilatory control stability, and an elevated loop gain,[105] a non-anatomical contributor trait to OSA.[106]
Although the literature regarding functional breathing evaluation in OSA patients is still scarce, Messineo et al.[107] have published a simplified breath-holding maneuver to be performed in the office, demonstrating a strong correlation between ventilatory response during wakefulness and the estimation of a high loop gain.[108]
We must consider breathing dysfunction an underlying factor in patients with no improvement after nasal surgery. They may be candidates for breathing therapies, which have shown promising outcomes and may benefit our unsatisfied patients in terms of restoring nasal breathing.[104]
To approach an OSA patient with a nasal obstruction focusing only on surgical pathology is a failure, as we must take into consideration functional factors, such as low muscle effectiveness, high loop, AR, and breathing disfunction.
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Final Considerations
All of the studies included in the present review used the AHI as the objective OSA diagnostic and follow-up parameter. Nevertheless, recent advances in the knowledge regarding the pathophysiology of OSA have enabled the establishment of new indicators of severity, such as the body mass index, cardiovascular comorbidities, and the time spent with oxygen saturation below 90% (CT90), which have been included in the latest international consensus.[7] Thereby, we consider that further investigation must be performed, including all of these parameters by standard, for a more comprehensive approach to the OSA patient.
The nose plays a vital role in respiratory physiology and the pathogenesis of UA obstruction. The scientific literature has widely shown the negative impact of nasal obstruction on the quality of sleep and OSA severity. During the evaluation of an OSA patient, both anatomical and functional assessments are of radical relevance, as is the knowledge of all the therapeutic strategies. To date, it is inadmissible to prescribe CPAP therapy without prior UA evaluation.
Although non-surgical therapy has been shown to improve the symptoms of OSA patients, it does not have a place in the primary treatment of OSA. At the same time, surgical treatment has been demonstrated to widely improve the quality of sleep and associated symptoms, although the benefits on the PSG parameters are not statistically significant. To date, it has not been shown that nasal surgical treatment can objectively benefit OSA patients. Nevertheless, the available literature strongly indicates that nasal surgery significantly improves CPAP adherence, even in patients who are reluctant to begin the therapy.
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#
Conclusion
Isolated nasal surgery is not a primary treatment for OSA, but it improves the subjective parameters of quality of sleep and sleepiness, and it also reduces nasal resistance and snoring, with no significant changes in objective PSG parameters. At the same time, it reduces the required CPAP titration pressures and increases its time of use, improving the adherence to and effectiveness of this therapy.
Isolated nasal surgery does not critically modify the evolution of this disease. Still, it can lead to the success or failure of the CPAP therapy by increasing its effectiveness and long-term compliance, thereby finding its role as an adjuvant of isolated nasal surgery. In OSA, the recommendation of nasal surgery will be offered to a patient with a suboptimal use of CPAP, or whose titration pressure is too high. Given the high abandonment rate of CPAP, we must prioritize a correct evaluation and treatment of the nose as a first stage before starting the CPAP therapy.
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Conflict of Interests
The authors have no conflict of interests to declare.
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References
- 1 Benjafield AV, Ayas NT, Eastwood PR. et al. Estimation of the global prevalence and burden of obstructive sleep apnoea: a literature-based analysis. Lancet Respir Med 2019; 7 (08) 687-698
- 2 Salman LA, Shulman R, Cohen JB. Obstructive Sleep Apnea, Hypertension, and Cardiovascular Risk: Epidemiology, Pathophysiology, and Management. Curr Cardiol Rep 2020; 22 (02) 6
- 3 Javaheri S, Barbe F, Campos-Rodriguez F. et al. Sleep Apnea: Types, Mechanisms, and Clinical Cardiovascular Consequences. J Am Coll Cardiol 2017; 69 (07) 841-858
- 4 Reutrakul S, Mokhlesi B. Obstructive Sleep Apnea and Diabetes: A State of the Art Review. Chest 2017; 152 (05) 1070-1086 DOI: 10.1016/j.chest.2017.05.009. [Internet]
- 5 Li M, Li X, Lu Y. Obstructive sleep apnea syndrome and metabolic diseases. Endocrinology 2018; 159 (07) 2670-2675
- 6 Bassetti CLA, Randerath W, Vignatelli L. et al. EAN/ERS/ESO/ESRS statement on the impact of sleep disorders on risk and outcome of stroke. Eur Respir J 2020; 55 (04) 1901104 DOI: 10.1183/13993003.01104-2019. [Internet]
- 7 Mediano O, González Mangado N, Montserrat JM. et al; el Spanish Sleep Network. Documento internacional de consenso sobre apnea obstructiva del sueño. Arch Bronconeumol 2022; 58 (01) 52-68
- 8 Randerath W, Verbraecken J, de Raaff CAL. et al. European Respiratory Society guideline on non-CPAP therapies for obstructive sleep apnoea. Eur Respir Rev 2021; 30 (162) 210200
- 9 de Carlos F, Anitua E, Gonzalez M, Macias E, Cobo J, Monasterio C. et al. Guia española de practica clinica. utilización de los dispositivos de avance mandibular en el tratamiento de pacientes adultos con síndrome de apnea hipopnea del sueño. 2017
- 10 Schwartz M, Acosta L, Hung YL, Padilla M, Enciso R. Effects of CPAP and mandibular advancement device treatment in obstructive sleep apnea patients: a systematic review and meta-analysis. Sleep Breath 2018; 22 (03) 555-568
- 11 Omobomi O, Quan SF. Positional therapy in the management of positional obstructive sleep apnea-a review of the current literature. Sleep Breath 2018; 22 (02) 297-304
- 12 O'Connor-Reina C, Plaza G, Garcia-Iriarte MT. et al. Tongue peak pressure: a tool to aid in the identification of obstruction sites in patients with obstructive sleep apnea/hypopnea syndrome. Sleep Breath 2020; 24 (01) https://www.proquest.com/scholarly-journals/tongue-peak-pressure-tool-aid-identification/docview/2385998486/se-2?accountid=14550 [Internet] 281-286
- 13 O'Connor-Reina C, Ignacio Garcia JM, Rodriguez Ruiz E. et al. Myofunctional therapy app for severe apnea–hypopnea sleep obstructive syndrome: Pilot randomized controlled trial. JMIR Mhealth Uhealth 2020; 8 (11) e23123
- 14 O'Connor-Reina C, Ignacio Garcia JM, Rodriguez Alcala L. et al. Improving adherence to myofunctional therapy in the treatment of sleep-disordered breathing. J Clin Med 2021; 10 (24) 5772
- 15 Mediano O, Romero-Peralta S, Resano P. et al. Obstructive sleep apnea: Emerging treatments targeting the genioglossus muscle. J Clin Med 2019; 8 (10) 1-18
- 16 Kim KB, Movahed R, Malhotra R, Stanley J. Management of Obstructive Sleep Apnea An Evidence-Based, Multidisciplinary Textbook. 1st ed. Ki Beom Kim, Reza Movahed, Raman K. Malhotra JJS, editor. Switzerland:: Springer Cham;; 2021: 646 p.
- 17 Bikov A, Dragonieri S. Obstructive Sleep Apnea Epidemiology, Pathomechanism and Treatment. Switzerland:: MDPI AG PP - Basel;; 2020: 96 p
- 18 Rabie AN, Mady O, El-Shazly AN, Abouzeid A. Systematic Review and Meta-Analysis of the Palatal Surgeries in the Treatment of Obstructive Sleep Apnea. Int J Otolaryngol Head &. Neck Surg. 2021; 10 (02) 61-74
- 19 Guzman MA, Sgambati FP, Pho H. et al. The Efficacy of Low-Level Continuous Positive Airway Pressure for the Treatment of Snoring. J Clin Sleep Med 2017; 13 (05) 703-711
- 20 Patil SP, Ayappa IA, Caples SM, Kimoff RJ, Patel SR, Harrod CG. Treatment of Adult Obstructive Sleep Apnea With Positive Airway Pressure: An American Academy of Sleep Medicine Systematic Review, Meta-Analysis, and GRADE Assessment. J Clin Sleep Med 2019; 15 (02) 301-334
- 21 Plaza G. . O'Connor-Reina, Carlos, Baptista Jardin P. Diagnóstico y Tratamiento de los Trastornos Respiratorios del Sueño. Actualización en Diagnóstico y Tratamiento Quirúrgico [Internet]. 2nd ed. Axon, editor. Madrid; 2022 . 611 p. Available from: https://axon.es/ficha/libros/9788409443635/diagnostico-y-tratamiento-de-los-trastornos-respiratorios-del-sueno-actualizacion-en-diagnostico-y-tratamiento-quirurgico
- 22 Yetkin O, Kunter E, Gunen H. CPAP compliance in patients with obstructive sleep apnea syndrome. Sleep Breath 2008; 12 (04) 365-367
- 23 Hussain SF, Irfan M, Waheed Z, Alam N, Mansoor S, Islam M. Compliance with continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea among privately paying patients- a cross sectional study. BMC Pulm Med 2014; 14: 188
- 24 Weaver TE. Don't start celebrating–CPAP adherence remains a problem. J Clin sleep Med JCSM Off Publ Am Acad. Sleep Med 2013; 9 (06) 551-552
- 25 Chen C, Wang J, Pang L, Wang Y, Ma G, Liao W. Telemonitor care helps CPAP compliance in patients with obstructive sleep apnea: a systemic review and meta-analysis of randomized controlled trials. Ther Adv Chronic Dis 2020; 11: 20 40622320901625
- 26 Mehrtash M, Bakker JP, Ayas N. Predictors of Continuous Positive Airway Pressure Adherence in Patients with Obstructive Sleep Apnea. Lung 2019; 197 (02) 115-121
- 27 Ferris Jr BGJ, Mead J, Opie LH. Partitioning of Respiratory Flow Resistance in Man. J Appl Physiol 1964; 19: 653-658
- 28 Fokkens WJ, Lund VJ, Mullol J. et al. European Position Paper on Rhinosinusitis and Nasal Polyps 2012. Rhinol Suppl 2012; 23: 3 , 1–298
- 29 Fokkens WJ, Lund VJ, Hopkins C. et al. European Position Paper on Rhinosinusitis and Nasal Polyps 2020. Rhinology 2020; 58 (Suppl S29): 1-464
- 30 Fried J, Yuen E, Li A. et al. Rhinologic disease and its impact on sleep: a systematic review. Int Forum Allergy Rhinol 2021; 11 (07) 1074-1086
- 31 Fidan T, Fidan V, Ak M, Sütbeyaz Y. Neuropsychiatric symptoms, quality of sleep and quality of life in patients diagnosed with nasal septal deviation. Kulak Burun Bogaz Ihtis Derg 2011; 21 (06) 312-317
- 32 Bengtsson C, Jonsson L, Holmström M, Svensson M, Theorell-Haglöw J, Lindberg E. Impact of nasal obstruction on sleep quality: a community-based study of women. Eur Arch Otorhinolaryngol 2015; 272 (01) 97-103
- 33 Campbell AP, Phillips KM, Hoehle LP. et al. Depression symptoms and lost productivity in chronic rhinosinusitis. Ann Allergy Asthma Immunol 2017; 118 (03) https://www.scopus.com/inward/record.uri?eid=2-s2.0-85014744242&doi=10.1016%2Fj.anai.2016.12.012&partnerID=40&md5=c25c5488c3a23f7db79bf6bfdc181dc3 [Internet] 286-289
- 34 Page MJ, McKenzie JE, Bossuyt PM. et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372 (71) 1-9
- 35 Clark J, Glasziou P, Del Mar C, Bannach-Brown A, Stehlik P, Scott AM. A full systematic review was completed in 2 weeks using automation tools: a case study. J Clin Epidemiol 2020; 121: 81-90
- 36 Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan-a web and mobile app for systematic reviews. Syst Rev 2016; 5 (01) 210
- 37 Sterne JAC, Hernán MA, Reeves BC. et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 2016; 355: i4919 https://www.bmj.com/content/355/bmj.i4919 [Internet]
- 38 Pham LV, Schwartz AR. The pathogenesis of obstructive sleep apnea. J Thorac Dis 2015; 7 (08) 1358-1372
- 39 Smith PL, Wise RA, Gold AR, Schwartz AR, Permutt S. Upper airway pressure-flow relationships in obstructive sleep apnea. J Appl Physiol 1988; 64 (02) 789-795
- 40 Sistla SK, Paramasivan VK, Agrawal V. Anatomic and Pathophysiologic Considerations in Surgical Treatment of Obstructive Sleep Apnea. Sleep Med Clin 2019; 14 (01) 21-31
- 41 Katz ES, D'Ambrosio CM. Pathophysiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc 2008; 5 (02) 253-262
- 42 Katyal V, Pamula Y, Martin AJ, Daynes CN, Kennedy JD, Sampson WJ. Craniofacial and upper airway morphology in pediatric sleep-disordered breathing: Systematic review and meta-analysis. Am J Orthod Dentofacial Orthop 2013; 143 (01) 20-30.e3
- 43 Fitzpatrick MF, McLean H, Urton AM, Tan A, O'Donnell D, Driver HS. Effect of nasal or oral breathing route on upper airway resistance during sleep. Eur Respir J 2003; 22 (05) https://www.scopus.com/inward/record.uri?eid=2-s2.0-0242720153&doi=10.1183%2F09031936.03.00047903&partnerID=40&md5=66cdd4edb0e278e5b46442db0db8a939 [Internet] 827-832
- 44 Yoo F, Schlosser RJ, Storck KA, Ganjaei KG, Rowan NR, Soler ZM. Effects of endoscopic sinus surgery on objective and subjective measures of cognitive dysfunction in chronic rhinosinusitis. Int Forum Allergy Rhinol 2019; 9 (10) 1135-1143
- 45 Alt JA, Ramakrishnan VR, Platt MP, Schlosser RJ, Storck T, Soler ZM. Impact of chronic rhinosinusitis on sleep: a controlled clinical study. Int Forum Allergy Rhinol 2019; 9 (01) 16-22
- 46 Bengtsson C, Lindberg E, Jonsson L. et al. Chronic rhinosinusitis impairs sleep quality: Results of the GA2LEN study. Sleep 2017;40(01): https://www.scopus.com/inward/record.uri?eid=2-s2.0-85014152157&doi=10.1093%2Fsleep%2Fzsw021&partnerID=40&md5=affa7eb79c5c9b5dbd704e5a4cbef77e [Internet]
- 47 Jiang R-S, Liang K-L. The Influence of Functional Endoscopic Sinus Surgery on Sleep Related Outcomes in Patients with Chronic Rhinosinusitis. Int J Otolaryngol 2019; 2019: 7951045
- 48 Hoffstein V, Viner S, Mateika S, Conway J. Treatment of obstructive sleep apnea with nasal continuous positive airway pressure. Patient compliance, perception of benefits, and side effects. Am Rev Respir Dis 1992; 145 (4 Pt 1): 841-845
- 49 Suratt PM, Turner BL, Wilhoit SC. Effect of intranasal obstruction on breathing during sleep. Chest 1986; 90 (03) 324-329
- 50 Young T, Finn L, Kim H. The University of Wisconsin Sleep and Respiratory Research Group. Nasal obstruction as a risk factor for sleep-disordered breathing. J Allergy Clin Immunol 1997; 99 (02) S757-S762
- 51 Inoue A, Chiba S, Matsuura K, Osafune H, Capasso R, Wada K. Nasal function and CPAP compliance. Auris Nasus Larynx 2019; 46 (04) 548-558
- 52 Sugiura T, Noda A, Nakata S. et al. Influence of nasal resistance on initial acceptance of continuous positive airway pressure in treatment for obstructive sleep apnea syndrome. Respiration 2007; 74 (01) 56-60 https://www.scopus.com/inward/record.uri?eid=2-s2.0-33845733648&doi=10.1159%2F000089836&partnerID=40&md5=850460d4a5d821ee062ceaac6445d094 [Internet]
- 53 Fairbanks DN. Effect of nasal surgery on snoring. South Med J 1985; 78 (03) 268-270
- 54 Verse T, Maurer JT, Pirsig W. Effect of nasal surgery on sleep-related breathing disorders. Laryngoscope 2002; 112 (01) 64-68 https://www.scopus.com/inward/record.uri?eid=2-s2.0-0036137748&doi=10.1097%2F00005537-200201000-00012&partnerID=40&md5=74c96896f5a1783639a62fc659589d4c [Internet]
- 55 Li H-Y, Lin Y, Chen N-H, Lee L-A, Fang T-J, Wang P-C. Improvement in quality of life after nasal surgery alone for patients with obstructive sleep apnea and nasal obstruction. Arch Otolaryngol Head Neck Surg 2008; 134 (04) 429-433 https://www.scopus.com/inward/record.uri?eid=2-s2.0-42549118218&doi=10.1001%2Farchotol.134.4.429&partnerID=40&md5=d68b63fb6bd66fbc0837de0bdd6e48b2 [Internet]
- 56 Johns MW. Daytime sleepiness, snoring, and obstructive sleep apnea. The Epworth Sleepiness Scale. Chest 1993; 103 (01) 30-36
- 57 Koutsourelakis I, Georgoulopoulos G, Perraki E, Vagiakis E, Roussos C, Zakynthinos SG. Randomised trial of nasal surgery for fixed nasal obstruction in obstructive sleep apnoea. Eur Respir J 2008; 31 (01) 110-117 https://www.scopus.com/inward/record.uri?eid=2-s2.0-45849122533&doi=10.1183%2F09031936.00087607&partnerID=40&md5=7f05daa0125a038f4e2d820618317bd3 [Internet]
- 58 Kim ST, Choi JH, Jeon HG, Cha HE, Kim DY, Chung Y-S. Polysomnographic effects of nasal surgery for snoring and obstructive sleep apnea. Acta Otolaryngol 2004; 124 (03) 297-300
- 59 Nakata S, Noda A, Yasuma F. et al. Effects of nasal surgery on sleep quality in obstructive sleep apnea syndrome with nasal obstruction. Am J Rhinol 2008; 22 (01) 59-63 https://www.scopus.com/inward/record.uri?eid=2-s2.0-39749083919&doi=10.2500%2Fajr.2008.22.3120&partnerID=40&md5=efce73a4cad91488fc7046947b5d5449 [Internet]
- 60 Tosun F, Kemikli K, Yetkin S, Ozgen F, Durmaz A, Gerek M. Impact of endoscopic sinus surgery on sleep quality in patients with chronic nasal obstruction due to nasal polyposis. J Craniofac Surg 2009; 20 (02) 446-449
- 61 Park CY, Hong JH, Lee JH. et al. Clinical effect of surgical correction for nasal pathology on the treatment of obstructive sleep apnea syndrome. PLoS One 2014; 9 (06) e98765
- 62 Li H-Y, Lee L-A, Wang P-C, Fang T-J, Chen N-H. Can nasal surgery improve obstructive sleep apnea: subjective or objective?. Am J Rhinol Allergy 2009; 23 (06) e51-e55
- 63 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
- 64 Choi JH, Kim EJ, Kim YS. et al. Effectiveness of nasal surgery alone on sleep quality, architecture, position, and sleep-disordered breathing in obstructive sleep apnea syndrome with nasal obstruction. Am J Rhinol Allergy 2011; 25 (05) 338-341 https://www.scopus.com/inward/record.uri?eid=2-s2.0-80053262126&doi=10.2500%2Fajra.2011.25.3654&partnerID=40&md5=8d3eb12dbc6d426519d550f3fede7efd [Internet]
- 65 Virkkula P, Bachour A, Hytönen M. et al. Snoring is not relieved by nasal surgery despite improvement in nasal resistance. Chest 2006; 129 (01) 81-87 https://www.scopus.com/inward/record.uri?eid=2-s2.0-33144475991&doi=10.1378%2Fchest.129.1.81&partnerID=40&md5=d84d9b73ef123ae3cc95e2588e3d0e48 [Internet]
- 66 Kalam I. Objective assessment of nasal obstruction in snoring and obstructive sleep apnea patients: experience of a Police Authority Hospital. Ann Saudi Med 2002; 22 (3-4): 158-162
- 67 Schoustra E, van Maanen P, den Haan C, Ravesloot MJL, de Vries N. The Role of Isolated Nasal Surgery in Obstructive Sleep Apnea Therapy-A Systematic Review. Brain Sci 2022; 12 (11) 1446
- 68 Newsome H. Evidence-Based Medicine: The role of nasal surgery in treatment of obstructive sleep apnea. Facial Plast Surg 2023; 39 (03) 279-283
- 69 Sukato DC, Abramowitz JM, Boruk M, Goldstein NA, Rosenfeld RM. Endoscopic Sinus Surgery Improves Sleep Quality in Chronic Rhinosinusitis: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg 2018; 158 (02) 249-256
- 70 Wu J, Zhao G, Li Y. et al. Apnea-hypopnea index decreased significantly after nasal surgery for obstructive sleep apnea: A meta-analysis. Medicine (Baltimore) 2017; 96 (05) e6008
- 71 Wang M, Liu SY-C, Zhou B, Li Y, Cui S, Huang Q. Effect of nasal and sinus surgery in patients with and without obstructive sleep apnea. Acta Otolaryngol 2019; 139 (05) 467-472
- 72 Ishii L, Roxbury C, Godoy A, Ishman S, Ishii M. Does Nasal Surgery Improve OSA in Patients with Nasal Obstruction and OSA? A Meta-analysis. Otolaryngol Head Neck Surg 2015; 153 (03) 326-333
- 73 Sharma S, Wormald JCR, Fishman JM, Andrews P, Kotecha BT. Rhinological interventions for obstructive sleep apnoea - a systematic review and descriptive meta-analysis. J Laryngol Otol 2019; 133 (03) 168-176
- 74 Rotenberg BW, Murariu D, Pang KP. Trends in CPAP adherence over twenty years of data collection: a flattened curve. J Otolaryngol Head Neck Surg 2016; 45 (01) 43
- 75 Camacho M, Riaz M, Capasso R. et al. The effect of nasal surgery on continuous positive airway pressure device use and therapeutic treatment pressures: a systematic review and meta-analysis. Sleep 2015; 38 (02) 279-286
- 76 Mickelson SA. Nasal Surgery for Obstructive Sleep Apnea Syndrome. Otolaryngol Clin North Am 2016; 49 (06) 1373-1381
- 77 Cai Y, Goldberg AN, Chang JL. The Nose and Nasal Breathing in Sleep Apnea. Otolaryngol Clin North Am 2020; 53 (03) 385-395
- 78 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
- 79 Sufioğlu M, Ozmen OA, Kasapoglu F. et al. The efficacy of nasal surgery in obstructive sleep apnea syndrome: a prospective clinical study. Eur Arch Otorhinolaryngol 2012; 269 (02) 487-494
- 80 Iwata N, Nakata S, Inada H, Kimura A, Hirata M, Yasuma F. Clinical indication of nasal surgery for the CPAP intolerance in obstructive sleep apnea with nasal obstruction. Auris Nasus Larynx 2020; 47 (06) 1018-1022
- 81 Brimioulle M, Chaidas K. Nasal function and CPAP use in patients with obstructive sleep apnoea: a systematic review. Sleep Breath 2022; 26 (03) 1321-1332
- 82 Poirier J, George C, Rotenberg B. The effect of nasal surgery on nasal continuous positive airway pressure compliance. Laryngoscope 2014; 124 (01) 317-319 https://www.scopus.com/inward/record.uri?eid=2-s2.0-84895847843&doi=10.1002%2Flary.24131&partnerID=40&md5=cba24efbd941f77e89483095bb08c0e4 [Internet]
- 83 Stewart MG, Witsell DL, Smith TL, Weaver EM, Yueh B, Hannley MT. Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) scale. Otolaryngol Head Neck Surg 2004; 130 (02) 157-163
- 84 Ishii L, Godoy A, Ishman SL, Gourin CG, Ishii M. The nasal obstruction symptom evaluation survey as a screening tool for obstructive sleep apnea. Arch Otolaryngol Head Neck Surg 2011; 137 (02) 119-123 https://www.scopus.com/inward/record.uri?eid=2-s2.0-79952009984&doi=10.1001%2Farchoto.2010.251&partnerID=40&md5=bfe9d21cb2340255f0007cfa8cfb7e48 [Internet]
- 85 O'Connor-Reina C, Rodriguez-Alcala L, Ignacio JM, Baptista P, Garcia-Iriarte MT, Plaza G. Assessment of Muscular Weakness in Severe Sleep Apnea Patients: A Prospective Study. Otolaryngol Head Neck Surg 2023; 169 (03) 725-733 DOI: 10.1002/ohn.283.
- 86 Owens RL, Eckert DJ, Yeh SY, Malhotra A. Upper airway function in the pathogenesis of obstructive sleep apnea: a review of the current literature. Curr Opin Pulm Med 2008; 14 (06) 519-524 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3624763/pdf/nihms412728.pdf [Internet]
- 87 Malhotra A, Mesarwi O, Pepin J-L, Owens RL. Endotypes and phenotypes in obstructive sleep apnea. Curr Opin Pulm Med 2020; 26 (06) 609-614
- 88 Rizzatti FG, Mazzotti DR, Mindel J. et al. Defining Extreme Phenotypes of OSA Across International Sleep Centers. Chest 2020; 158 (03) 1187-1197
- 89 Iannella G, Magliulo G, Cammaroto G. et al. Effectiveness of drug-induced sleep endoscopy in improving outcomes of barbed pharyngoplasty for obstructive sleep apnea surgery: a prospective randomized trial. Sleep Breath 2022; 26 (04) 1621-1632 https://www.scopus.com/inward/record.uri?eid=2-s2.0-85120613240&doi=10.1007%2Fs11325-021-02528-4&partnerID=40&md5=d73a3c9ab406746a670ef1d511ad70f2 [Internet]
- 90 De Vito A, Carrasco Llatas M, Vanni A. et al. European position paper on drug-induced sedation endoscopy (DISE). Sleep Breath 2014; 18 (03) 453-465
- 91 De Vito A, Carrasco Llatas M, Ravesloot MJ. et al. European position paper on drug-induced sleep endoscopy: 2017 Update. Clin Otolaryngol 2018; 43 (06) 1541-1552 https://pubmed.ncbi.nlm.nih.gov/30133943/ cited 2022Jun8 [Internet]
- 92 Abdulatif J, Camacho M, Capasso R, Lugo Saldana R. Evaluación de las vías aéreas superiores. In: Dade Reyes. , editor. Manejo médico y quirúrgico de los trastornos respiratorios del sueño y ronquido. 1st ed. Panamá:: Jaypee Brothers Medical Publishing (P) Ltd.;; 2017. . p. 15-42
- 93 Pérez-Martín N, Bosco G, Navarro A. et al. Drug Induced Sleep Endoscopy Versus Awake Endoscopy in Retrolingual Obstruction Assessment in Obstructive Sleep Apnea Patients: A Comparative Study. J Craniofac Surg 2022; 33 (05) e499-e503
- 94 Victores AJ, Takashima M. Effects of nasal surgery on the upper airway: a drug-induced sleep endoscopy study. Laryngoscope 2012; 122 (11) 2606-2610
- 95 Bosco G, Pérez-Martín N, Morato M, Racionero MA, Plaza G. Nasal Surgery May Improve Upper Airway Collapse in Patients With Obstructive Sleep Apnea: A Drug-Induced Sleep Endoscopy Study. J Craniofac Surg 2020; 31 (01) 68-71 https://www.scopus.com/inward/record.uri?eid=2-s2.0-85071655226&doi=10.1097%2FSCS.0000000000005865&partnerID=40&md5=648b13dffec3935dd3ae676ae0e7c4f0 [Internet]
- 96 Orlandi RR, Kingdom TT, Hwang PH. et al. International Consensus Statement on Allergy and Rhinology: Rhinosinusitis. Int Forum Allergy Rhinol 2016; 6 (Suppl. 01) S22-S209 https://www.scopus.com/inward/record.uri?eid=2-s2.0-84959312900&doi=10.1002%2Falr.21695&partnerID=40&md5=3a5ab57b17dc88a53389eca01672e192 [Internet]
- 97 American Academy of Allergy Asthma & Immunology. Allergy Statistics [Internet]. 2022 [cited 2022 Dec 31]. Available from: https://www.aaaai.org/About/News/For-Media/Allergy-Statistics
- 98 Savouré M, Bousquet J, Jaakkola JJK, Jaakkola MS, Jacquemin B, Nadif R. Worldwide prevalence of rhinitis in adults: A review of definitions and temporal evolution. Clin Transl Allergy 2022; 12 (03) e12130
- 99 Colás C, Galera H, Añibarro B. et al. Disease severity impairs sleep quality in allergic rhinitis (The SOMNIAAR study). Clin Exp Allergy 2012; 42 (07) 1080-1087
- 100 Craig TJ, McCann JL, Gurevich F, Davies MJ. The correlation between allergic rhinitis and sleep disturbance. J Allergy Clin Immunol 2004; 114 (05) S139-S145
- 101 Charakorn N, Hirunwiwatkul P, Chirakalwasan N, Chaitusaney B, Prakassajjatham M. The effects of topical nasal steroids on continuous positive airway pressure compliance in patients with obstructive sleep apnea: a systematic review and meta-analysis. Sleep Breath 2017; 21 (01) 3-8 DOI: 10.1007/s11325-016-1375-3. [Internet]
- 102 Meen EK, Chandra RK. The role of the nose in sleep-disordered breathing. Am J Rhinol Allergy 2013; 27 (03) 213-220
- 103 Kim S-D, Jung D-W, Lee J-W, Park J-H, Mun S-J, Cho K-S. Relationship between allergic rhinitis and nasal surgery success in patients with obstructive sleep apnea. Am J Otolaryngol 2021; 42 (06) 103079
- 104 McKeown P, O'Connor-Reina C, Plaza G. Breathing Re-Education and Phenotypes of Sleep Apnea: A Review. J Clin Med 2021; 10 (03) 471
- 105 Pal A, Martinez F, Akey MA. et al. Breathing rate variability in obstructive sleep apnea during wakefulness. J Clin Sleep Med 2022; 18 (03) 825-833
- 106 Deacon-Diaz NL, Sands SA, McEvoy RD, Catcheside PG. Daytime loop gain is elevated in obstructive sleep apnea but not reduced by CPAP treatment. J Appl Physiol 2018; 125 (05) 1490-1497
- 107 Messineo L, Taranto-Montemurro L, Azarbarzin A. et al. Breath-holding as a means to estimate the loop gain contribution to obstructive sleep apnoea. J Physiol 2018; 596 (17) 4043-4056
- 108 Pham LV, Schwartz AR, Polotsky VY. Integrating loop gain into the understanding of obstructive sleep apnoea mechanisms. J Physiol 2018; 596 (17) 3819-3820
- 109 Guilleminault C, Huseni S, Lo L. A frequent phenotype for paediatric sleep apnoea: short lingual frenulum. ERJ Open Res 2016; Jul 29; 2 (03) 00043-2016 DOI: 10.1183/23120541.00043-2016. . PMID: 27730205; PMCID: PMC5034598
Address for correspondence
Publication History
Received: 15 April 2023
Accepted: 27 September 2023
Article published online:
10 May 2024
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References
- 1 Benjafield AV, Ayas NT, Eastwood PR. et al. Estimation of the global prevalence and burden of obstructive sleep apnoea: a literature-based analysis. Lancet Respir Med 2019; 7 (08) 687-698
- 2 Salman LA, Shulman R, Cohen JB. Obstructive Sleep Apnea, Hypertension, and Cardiovascular Risk: Epidemiology, Pathophysiology, and Management. Curr Cardiol Rep 2020; 22 (02) 6
- 3 Javaheri S, Barbe F, Campos-Rodriguez F. et al. Sleep Apnea: Types, Mechanisms, and Clinical Cardiovascular Consequences. J Am Coll Cardiol 2017; 69 (07) 841-858
- 4 Reutrakul S, Mokhlesi B. Obstructive Sleep Apnea and Diabetes: A State of the Art Review. Chest 2017; 152 (05) 1070-1086 DOI: 10.1016/j.chest.2017.05.009. [Internet]
- 5 Li M, Li X, Lu Y. Obstructive sleep apnea syndrome and metabolic diseases. Endocrinology 2018; 159 (07) 2670-2675
- 6 Bassetti CLA, Randerath W, Vignatelli L. et al. EAN/ERS/ESO/ESRS statement on the impact of sleep disorders on risk and outcome of stroke. Eur Respir J 2020; 55 (04) 1901104 DOI: 10.1183/13993003.01104-2019. [Internet]
- 7 Mediano O, González Mangado N, Montserrat JM. et al; el Spanish Sleep Network. Documento internacional de consenso sobre apnea obstructiva del sueño. Arch Bronconeumol 2022; 58 (01) 52-68
- 8 Randerath W, Verbraecken J, de Raaff CAL. et al. European Respiratory Society guideline on non-CPAP therapies for obstructive sleep apnoea. Eur Respir Rev 2021; 30 (162) 210200
- 9 de Carlos F, Anitua E, Gonzalez M, Macias E, Cobo J, Monasterio C. et al. Guia española de practica clinica. utilización de los dispositivos de avance mandibular en el tratamiento de pacientes adultos con síndrome de apnea hipopnea del sueño. 2017
- 10 Schwartz M, Acosta L, Hung YL, Padilla M, Enciso R. Effects of CPAP and mandibular advancement device treatment in obstructive sleep apnea patients: a systematic review and meta-analysis. Sleep Breath 2018; 22 (03) 555-568
- 11 Omobomi O, Quan SF. Positional therapy in the management of positional obstructive sleep apnea-a review of the current literature. Sleep Breath 2018; 22 (02) 297-304
- 12 O'Connor-Reina C, Plaza G, Garcia-Iriarte MT. et al. Tongue peak pressure: a tool to aid in the identification of obstruction sites in patients with obstructive sleep apnea/hypopnea syndrome. Sleep Breath 2020; 24 (01) https://www.proquest.com/scholarly-journals/tongue-peak-pressure-tool-aid-identification/docview/2385998486/se-2?accountid=14550 [Internet] 281-286
- 13 O'Connor-Reina C, Ignacio Garcia JM, Rodriguez Ruiz E. et al. Myofunctional therapy app for severe apnea–hypopnea sleep obstructive syndrome: Pilot randomized controlled trial. JMIR Mhealth Uhealth 2020; 8 (11) e23123
- 14 O'Connor-Reina C, Ignacio Garcia JM, Rodriguez Alcala L. et al. Improving adherence to myofunctional therapy in the treatment of sleep-disordered breathing. J Clin Med 2021; 10 (24) 5772
- 15 Mediano O, Romero-Peralta S, Resano P. et al. Obstructive sleep apnea: Emerging treatments targeting the genioglossus muscle. J Clin Med 2019; 8 (10) 1-18
- 16 Kim KB, Movahed R, Malhotra R, Stanley J. Management of Obstructive Sleep Apnea An Evidence-Based, Multidisciplinary Textbook. 1st ed. Ki Beom Kim, Reza Movahed, Raman K. Malhotra JJS, editor. Switzerland:: Springer Cham;; 2021: 646 p.
- 17 Bikov A, Dragonieri S. Obstructive Sleep Apnea Epidemiology, Pathomechanism and Treatment. Switzerland:: MDPI AG PP - Basel;; 2020: 96 p
- 18 Rabie AN, Mady O, El-Shazly AN, Abouzeid A. Systematic Review and Meta-Analysis of the Palatal Surgeries in the Treatment of Obstructive Sleep Apnea. Int J Otolaryngol Head &. Neck Surg. 2021; 10 (02) 61-74
- 19 Guzman MA, Sgambati FP, Pho H. et al. The Efficacy of Low-Level Continuous Positive Airway Pressure for the Treatment of Snoring. J Clin Sleep Med 2017; 13 (05) 703-711
- 20 Patil SP, Ayappa IA, Caples SM, Kimoff RJ, Patel SR, Harrod CG. Treatment of Adult Obstructive Sleep Apnea With Positive Airway Pressure: An American Academy of Sleep Medicine Systematic Review, Meta-Analysis, and GRADE Assessment. J Clin Sleep Med 2019; 15 (02) 301-334
- 21 Plaza G. . O'Connor-Reina, Carlos, Baptista Jardin P. Diagnóstico y Tratamiento de los Trastornos Respiratorios del Sueño. Actualización en Diagnóstico y Tratamiento Quirúrgico [Internet]. 2nd ed. Axon, editor. Madrid; 2022 . 611 p. Available from: https://axon.es/ficha/libros/9788409443635/diagnostico-y-tratamiento-de-los-trastornos-respiratorios-del-sueno-actualizacion-en-diagnostico-y-tratamiento-quirurgico
- 22 Yetkin O, Kunter E, Gunen H. CPAP compliance in patients with obstructive sleep apnea syndrome. Sleep Breath 2008; 12 (04) 365-367
- 23 Hussain SF, Irfan M, Waheed Z, Alam N, Mansoor S, Islam M. Compliance with continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea among privately paying patients- a cross sectional study. BMC Pulm Med 2014; 14: 188
- 24 Weaver TE. Don't start celebrating–CPAP adherence remains a problem. J Clin sleep Med JCSM Off Publ Am Acad. Sleep Med 2013; 9 (06) 551-552
- 25 Chen C, Wang J, Pang L, Wang Y, Ma G, Liao W. Telemonitor care helps CPAP compliance in patients with obstructive sleep apnea: a systemic review and meta-analysis of randomized controlled trials. Ther Adv Chronic Dis 2020; 11: 20 40622320901625
- 26 Mehrtash M, Bakker JP, Ayas N. Predictors of Continuous Positive Airway Pressure Adherence in Patients with Obstructive Sleep Apnea. Lung 2019; 197 (02) 115-121
- 27 Ferris Jr BGJ, Mead J, Opie LH. Partitioning of Respiratory Flow Resistance in Man. J Appl Physiol 1964; 19: 653-658
- 28 Fokkens WJ, Lund VJ, Mullol J. et al. European Position Paper on Rhinosinusitis and Nasal Polyps 2012. Rhinol Suppl 2012; 23: 3 , 1–298
- 29 Fokkens WJ, Lund VJ, Hopkins C. et al. European Position Paper on Rhinosinusitis and Nasal Polyps 2020. Rhinology 2020; 58 (Suppl S29): 1-464
- 30 Fried J, Yuen E, Li A. et al. Rhinologic disease and its impact on sleep: a systematic review. Int Forum Allergy Rhinol 2021; 11 (07) 1074-1086
- 31 Fidan T, Fidan V, Ak M, Sütbeyaz Y. Neuropsychiatric symptoms, quality of sleep and quality of life in patients diagnosed with nasal septal deviation. Kulak Burun Bogaz Ihtis Derg 2011; 21 (06) 312-317
- 32 Bengtsson C, Jonsson L, Holmström M, Svensson M, Theorell-Haglöw J, Lindberg E. Impact of nasal obstruction on sleep quality: a community-based study of women. Eur Arch Otorhinolaryngol 2015; 272 (01) 97-103
- 33 Campbell AP, Phillips KM, Hoehle LP. et al. Depression symptoms and lost productivity in chronic rhinosinusitis. Ann Allergy Asthma Immunol 2017; 118 (03) https://www.scopus.com/inward/record.uri?eid=2-s2.0-85014744242&doi=10.1016%2Fj.anai.2016.12.012&partnerID=40&md5=c25c5488c3a23f7db79bf6bfdc181dc3 [Internet] 286-289
- 34 Page MJ, McKenzie JE, Bossuyt PM. et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372 (71) 1-9
- 35 Clark J, Glasziou P, Del Mar C, Bannach-Brown A, Stehlik P, Scott AM. A full systematic review was completed in 2 weeks using automation tools: a case study. J Clin Epidemiol 2020; 121: 81-90
- 36 Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan-a web and mobile app for systematic reviews. Syst Rev 2016; 5 (01) 210
- 37 Sterne JAC, Hernán MA, Reeves BC. et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 2016; 355: i4919 https://www.bmj.com/content/355/bmj.i4919 [Internet]
- 38 Pham LV, Schwartz AR. The pathogenesis of obstructive sleep apnea. J Thorac Dis 2015; 7 (08) 1358-1372
- 39 Smith PL, Wise RA, Gold AR, Schwartz AR, Permutt S. Upper airway pressure-flow relationships in obstructive sleep apnea. J Appl Physiol 1988; 64 (02) 789-795
- 40 Sistla SK, Paramasivan VK, Agrawal V. Anatomic and Pathophysiologic Considerations in Surgical Treatment of Obstructive Sleep Apnea. Sleep Med Clin 2019; 14 (01) 21-31
- 41 Katz ES, D'Ambrosio CM. Pathophysiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc 2008; 5 (02) 253-262
- 42 Katyal V, Pamula Y, Martin AJ, Daynes CN, Kennedy JD, Sampson WJ. Craniofacial and upper airway morphology in pediatric sleep-disordered breathing: Systematic review and meta-analysis. Am J Orthod Dentofacial Orthop 2013; 143 (01) 20-30.e3
- 43 Fitzpatrick MF, McLean H, Urton AM, Tan A, O'Donnell D, Driver HS. Effect of nasal or oral breathing route on upper airway resistance during sleep. Eur Respir J 2003; 22 (05) https://www.scopus.com/inward/record.uri?eid=2-s2.0-0242720153&doi=10.1183%2F09031936.03.00047903&partnerID=40&md5=66cdd4edb0e278e5b46442db0db8a939 [Internet] 827-832
- 44 Yoo F, Schlosser RJ, Storck KA, Ganjaei KG, Rowan NR, Soler ZM. Effects of endoscopic sinus surgery on objective and subjective measures of cognitive dysfunction in chronic rhinosinusitis. Int Forum Allergy Rhinol 2019; 9 (10) 1135-1143
- 45 Alt JA, Ramakrishnan VR, Platt MP, Schlosser RJ, Storck T, Soler ZM. Impact of chronic rhinosinusitis on sleep: a controlled clinical study. Int Forum Allergy Rhinol 2019; 9 (01) 16-22
- 46 Bengtsson C, Lindberg E, Jonsson L. et al. Chronic rhinosinusitis impairs sleep quality: Results of the GA2LEN study. Sleep 2017;40(01): https://www.scopus.com/inward/record.uri?eid=2-s2.0-85014152157&doi=10.1093%2Fsleep%2Fzsw021&partnerID=40&md5=affa7eb79c5c9b5dbd704e5a4cbef77e [Internet]
- 47 Jiang R-S, Liang K-L. The Influence of Functional Endoscopic Sinus Surgery on Sleep Related Outcomes in Patients with Chronic Rhinosinusitis. Int J Otolaryngol 2019; 2019: 7951045
- 48 Hoffstein V, Viner S, Mateika S, Conway J. Treatment of obstructive sleep apnea with nasal continuous positive airway pressure. Patient compliance, perception of benefits, and side effects. Am Rev Respir Dis 1992; 145 (4 Pt 1): 841-845
- 49 Suratt PM, Turner BL, Wilhoit SC. Effect of intranasal obstruction on breathing during sleep. Chest 1986; 90 (03) 324-329
- 50 Young T, Finn L, Kim H. The University of Wisconsin Sleep and Respiratory Research Group. Nasal obstruction as a risk factor for sleep-disordered breathing. J Allergy Clin Immunol 1997; 99 (02) S757-S762
- 51 Inoue A, Chiba S, Matsuura K, Osafune H, Capasso R, Wada K. Nasal function and CPAP compliance. Auris Nasus Larynx 2019; 46 (04) 548-558
- 52 Sugiura T, Noda A, Nakata S. et al. Influence of nasal resistance on initial acceptance of continuous positive airway pressure in treatment for obstructive sleep apnea syndrome. Respiration 2007; 74 (01) 56-60 https://www.scopus.com/inward/record.uri?eid=2-s2.0-33845733648&doi=10.1159%2F000089836&partnerID=40&md5=850460d4a5d821ee062ceaac6445d094 [Internet]
- 53 Fairbanks DN. Effect of nasal surgery on snoring. South Med J 1985; 78 (03) 268-270
- 54 Verse T, Maurer JT, Pirsig W. Effect of nasal surgery on sleep-related breathing disorders. Laryngoscope 2002; 112 (01) 64-68 https://www.scopus.com/inward/record.uri?eid=2-s2.0-0036137748&doi=10.1097%2F00005537-200201000-00012&partnerID=40&md5=74c96896f5a1783639a62fc659589d4c [Internet]
- 55 Li H-Y, Lin Y, Chen N-H, Lee L-A, Fang T-J, Wang P-C. Improvement in quality of life after nasal surgery alone for patients with obstructive sleep apnea and nasal obstruction. Arch Otolaryngol Head Neck Surg 2008; 134 (04) 429-433 https://www.scopus.com/inward/record.uri?eid=2-s2.0-42549118218&doi=10.1001%2Farchotol.134.4.429&partnerID=40&md5=d68b63fb6bd66fbc0837de0bdd6e48b2 [Internet]
- 56 Johns MW. Daytime sleepiness, snoring, and obstructive sleep apnea. The Epworth Sleepiness Scale. Chest 1993; 103 (01) 30-36
- 57 Koutsourelakis I, Georgoulopoulos G, Perraki E, Vagiakis E, Roussos C, Zakynthinos SG. Randomised trial of nasal surgery for fixed nasal obstruction in obstructive sleep apnoea. Eur Respir J 2008; 31 (01) 110-117 https://www.scopus.com/inward/record.uri?eid=2-s2.0-45849122533&doi=10.1183%2F09031936.00087607&partnerID=40&md5=7f05daa0125a038f4e2d820618317bd3 [Internet]
- 58 Kim ST, Choi JH, Jeon HG, Cha HE, Kim DY, Chung Y-S. Polysomnographic effects of nasal surgery for snoring and obstructive sleep apnea. Acta Otolaryngol 2004; 124 (03) 297-300
- 59 Nakata S, Noda A, Yasuma F. et al. Effects of nasal surgery on sleep quality in obstructive sleep apnea syndrome with nasal obstruction. Am J Rhinol 2008; 22 (01) 59-63 https://www.scopus.com/inward/record.uri?eid=2-s2.0-39749083919&doi=10.2500%2Fajr.2008.22.3120&partnerID=40&md5=efce73a4cad91488fc7046947b5d5449 [Internet]
- 60 Tosun F, Kemikli K, Yetkin S, Ozgen F, Durmaz A, Gerek M. Impact of endoscopic sinus surgery on sleep quality in patients with chronic nasal obstruction due to nasal polyposis. J Craniofac Surg 2009; 20 (02) 446-449
- 61 Park CY, Hong JH, Lee JH. et al. Clinical effect of surgical correction for nasal pathology on the treatment of obstructive sleep apnea syndrome. PLoS One 2014; 9 (06) e98765
- 62 Li H-Y, Lee L-A, Wang P-C, Fang T-J, Chen N-H. Can nasal surgery improve obstructive sleep apnea: subjective or objective?. Am J Rhinol Allergy 2009; 23 (06) e51-e55
- 63 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
- 64 Choi JH, Kim EJ, Kim YS. et al. Effectiveness of nasal surgery alone on sleep quality, architecture, position, and sleep-disordered breathing in obstructive sleep apnea syndrome with nasal obstruction. Am J Rhinol Allergy 2011; 25 (05) 338-341 https://www.scopus.com/inward/record.uri?eid=2-s2.0-80053262126&doi=10.2500%2Fajra.2011.25.3654&partnerID=40&md5=8d3eb12dbc6d426519d550f3fede7efd [Internet]
- 65 Virkkula P, Bachour A, Hytönen M. et al. Snoring is not relieved by nasal surgery despite improvement in nasal resistance. Chest 2006; 129 (01) 81-87 https://www.scopus.com/inward/record.uri?eid=2-s2.0-33144475991&doi=10.1378%2Fchest.129.1.81&partnerID=40&md5=d84d9b73ef123ae3cc95e2588e3d0e48 [Internet]
- 66 Kalam I. Objective assessment of nasal obstruction in snoring and obstructive sleep apnea patients: experience of a Police Authority Hospital. Ann Saudi Med 2002; 22 (3-4): 158-162
- 67 Schoustra E, van Maanen P, den Haan C, Ravesloot MJL, de Vries N. The Role of Isolated Nasal Surgery in Obstructive Sleep Apnea Therapy-A Systematic Review. Brain Sci 2022; 12 (11) 1446
- 68 Newsome H. Evidence-Based Medicine: The role of nasal surgery in treatment of obstructive sleep apnea. Facial Plast Surg 2023; 39 (03) 279-283
- 69 Sukato DC, Abramowitz JM, Boruk M, Goldstein NA, Rosenfeld RM. Endoscopic Sinus Surgery Improves Sleep Quality in Chronic Rhinosinusitis: A Systematic Review and Meta-analysis. Otolaryngol Head Neck Surg 2018; 158 (02) 249-256
- 70 Wu J, Zhao G, Li Y. et al. Apnea-hypopnea index decreased significantly after nasal surgery for obstructive sleep apnea: A meta-analysis. Medicine (Baltimore) 2017; 96 (05) e6008
- 71 Wang M, Liu SY-C, Zhou B, Li Y, Cui S, Huang Q. Effect of nasal and sinus surgery in patients with and without obstructive sleep apnea. Acta Otolaryngol 2019; 139 (05) 467-472
- 72 Ishii L, Roxbury C, Godoy A, Ishman S, Ishii M. Does Nasal Surgery Improve OSA in Patients with Nasal Obstruction and OSA? A Meta-analysis. Otolaryngol Head Neck Surg 2015; 153 (03) 326-333
- 73 Sharma S, Wormald JCR, Fishman JM, Andrews P, Kotecha BT. Rhinological interventions for obstructive sleep apnoea - a systematic review and descriptive meta-analysis. J Laryngol Otol 2019; 133 (03) 168-176
- 74 Rotenberg BW, Murariu D, Pang KP. Trends in CPAP adherence over twenty years of data collection: a flattened curve. J Otolaryngol Head Neck Surg 2016; 45 (01) 43
- 75 Camacho M, Riaz M, Capasso R. et al. The effect of nasal surgery on continuous positive airway pressure device use and therapeutic treatment pressures: a systematic review and meta-analysis. Sleep 2015; 38 (02) 279-286
- 76 Mickelson SA. Nasal Surgery for Obstructive Sleep Apnea Syndrome. Otolaryngol Clin North Am 2016; 49 (06) 1373-1381
- 77 Cai Y, Goldberg AN, Chang JL. The Nose and Nasal Breathing in Sleep Apnea. Otolaryngol Clin North Am 2020; 53 (03) 385-395
- 78 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
- 79 Sufioğlu M, Ozmen OA, Kasapoglu F. et al. The efficacy of nasal surgery in obstructive sleep apnea syndrome: a prospective clinical study. Eur Arch Otorhinolaryngol 2012; 269 (02) 487-494
- 80 Iwata N, Nakata S, Inada H, Kimura A, Hirata M, Yasuma F. Clinical indication of nasal surgery for the CPAP intolerance in obstructive sleep apnea with nasal obstruction. Auris Nasus Larynx 2020; 47 (06) 1018-1022
- 81 Brimioulle M, Chaidas K. Nasal function and CPAP use in patients with obstructive sleep apnoea: a systematic review. Sleep Breath 2022; 26 (03) 1321-1332
- 82 Poirier J, George C, Rotenberg B. The effect of nasal surgery on nasal continuous positive airway pressure compliance. Laryngoscope 2014; 124 (01) 317-319 https://www.scopus.com/inward/record.uri?eid=2-s2.0-84895847843&doi=10.1002%2Flary.24131&partnerID=40&md5=cba24efbd941f77e89483095bb08c0e4 [Internet]
- 83 Stewart MG, Witsell DL, Smith TL, Weaver EM, Yueh B, Hannley MT. Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) scale. Otolaryngol Head Neck Surg 2004; 130 (02) 157-163
- 84 Ishii L, Godoy A, Ishman SL, Gourin CG, Ishii M. The nasal obstruction symptom evaluation survey as a screening tool for obstructive sleep apnea. Arch Otolaryngol Head Neck Surg 2011; 137 (02) 119-123 https://www.scopus.com/inward/record.uri?eid=2-s2.0-79952009984&doi=10.1001%2Farchoto.2010.251&partnerID=40&md5=bfe9d21cb2340255f0007cfa8cfb7e48 [Internet]
- 85 O'Connor-Reina C, Rodriguez-Alcala L, Ignacio JM, Baptista P, Garcia-Iriarte MT, Plaza G. Assessment of Muscular Weakness in Severe Sleep Apnea Patients: A Prospective Study. Otolaryngol Head Neck Surg 2023; 169 (03) 725-733 DOI: 10.1002/ohn.283.
- 86 Owens RL, Eckert DJ, Yeh SY, Malhotra A. Upper airway function in the pathogenesis of obstructive sleep apnea: a review of the current literature. Curr Opin Pulm Med 2008; 14 (06) 519-524 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3624763/pdf/nihms412728.pdf [Internet]
- 87 Malhotra A, Mesarwi O, Pepin J-L, Owens RL. Endotypes and phenotypes in obstructive sleep apnea. Curr Opin Pulm Med 2020; 26 (06) 609-614
- 88 Rizzatti FG, Mazzotti DR, Mindel J. et al. Defining Extreme Phenotypes of OSA Across International Sleep Centers. Chest 2020; 158 (03) 1187-1197
- 89 Iannella G, Magliulo G, Cammaroto G. et al. Effectiveness of drug-induced sleep endoscopy in improving outcomes of barbed pharyngoplasty for obstructive sleep apnea surgery: a prospective randomized trial. Sleep Breath 2022; 26 (04) 1621-1632 https://www.scopus.com/inward/record.uri?eid=2-s2.0-85120613240&doi=10.1007%2Fs11325-021-02528-4&partnerID=40&md5=d73a3c9ab406746a670ef1d511ad70f2 [Internet]
- 90 De Vito A, Carrasco Llatas M, Vanni A. et al. European position paper on drug-induced sedation endoscopy (DISE). Sleep Breath 2014; 18 (03) 453-465
- 91 De Vito A, Carrasco Llatas M, Ravesloot MJ. et al. European position paper on drug-induced sleep endoscopy: 2017 Update. Clin Otolaryngol 2018; 43 (06) 1541-1552 https://pubmed.ncbi.nlm.nih.gov/30133943/ cited 2022Jun8 [Internet]
- 92 Abdulatif J, Camacho M, Capasso R, Lugo Saldana R. Evaluación de las vías aéreas superiores. In: Dade Reyes. , editor. Manejo médico y quirúrgico de los trastornos respiratorios del sueño y ronquido. 1st ed. Panamá:: Jaypee Brothers Medical Publishing (P) Ltd.;; 2017. . p. 15-42
- 93 Pérez-Martín N, Bosco G, Navarro A. et al. Drug Induced Sleep Endoscopy Versus Awake Endoscopy in Retrolingual Obstruction Assessment in Obstructive Sleep Apnea Patients: A Comparative Study. J Craniofac Surg 2022; 33 (05) e499-e503
- 94 Victores AJ, Takashima M. Effects of nasal surgery on the upper airway: a drug-induced sleep endoscopy study. Laryngoscope 2012; 122 (11) 2606-2610
- 95 Bosco G, Pérez-Martín N, Morato M, Racionero MA, Plaza G. Nasal Surgery May Improve Upper Airway Collapse in Patients With Obstructive Sleep Apnea: A Drug-Induced Sleep Endoscopy Study. J Craniofac Surg 2020; 31 (01) 68-71 https://www.scopus.com/inward/record.uri?eid=2-s2.0-85071655226&doi=10.1097%2FSCS.0000000000005865&partnerID=40&md5=648b13dffec3935dd3ae676ae0e7c4f0 [Internet]
- 96 Orlandi RR, Kingdom TT, Hwang PH. et al. International Consensus Statement on Allergy and Rhinology: Rhinosinusitis. Int Forum Allergy Rhinol 2016; 6 (Suppl. 01) S22-S209 https://www.scopus.com/inward/record.uri?eid=2-s2.0-84959312900&doi=10.1002%2Falr.21695&partnerID=40&md5=3a5ab57b17dc88a53389eca01672e192 [Internet]
- 97 American Academy of Allergy Asthma & Immunology. Allergy Statistics [Internet]. 2022 [cited 2022 Dec 31]. Available from: https://www.aaaai.org/About/News/For-Media/Allergy-Statistics
- 98 Savouré M, Bousquet J, Jaakkola JJK, Jaakkola MS, Jacquemin B, Nadif R. Worldwide prevalence of rhinitis in adults: A review of definitions and temporal evolution. Clin Transl Allergy 2022; 12 (03) e12130
- 99 Colás C, Galera H, Añibarro B. et al. Disease severity impairs sleep quality in allergic rhinitis (The SOMNIAAR study). Clin Exp Allergy 2012; 42 (07) 1080-1087
- 100 Craig TJ, McCann JL, Gurevich F, Davies MJ. The correlation between allergic rhinitis and sleep disturbance. J Allergy Clin Immunol 2004; 114 (05) S139-S145
- 101 Charakorn N, Hirunwiwatkul P, Chirakalwasan N, Chaitusaney B, Prakassajjatham M. The effects of topical nasal steroids on continuous positive airway pressure compliance in patients with obstructive sleep apnea: a systematic review and meta-analysis. Sleep Breath 2017; 21 (01) 3-8 DOI: 10.1007/s11325-016-1375-3. [Internet]
- 102 Meen EK, Chandra RK. The role of the nose in sleep-disordered breathing. Am J Rhinol Allergy 2013; 27 (03) 213-220
- 103 Kim S-D, Jung D-W, Lee J-W, Park J-H, Mun S-J, Cho K-S. Relationship between allergic rhinitis and nasal surgery success in patients with obstructive sleep apnea. Am J Otolaryngol 2021; 42 (06) 103079
- 104 McKeown P, O'Connor-Reina C, Plaza G. Breathing Re-Education and Phenotypes of Sleep Apnea: A Review. J Clin Med 2021; 10 (03) 471
- 105 Pal A, Martinez F, Akey MA. et al. Breathing rate variability in obstructive sleep apnea during wakefulness. J Clin Sleep Med 2022; 18 (03) 825-833
- 106 Deacon-Diaz NL, Sands SA, McEvoy RD, Catcheside PG. Daytime loop gain is elevated in obstructive sleep apnea but not reduced by CPAP treatment. J Appl Physiol 2018; 125 (05) 1490-1497
- 107 Messineo L, Taranto-Montemurro L, Azarbarzin A. et al. Breath-holding as a means to estimate the loop gain contribution to obstructive sleep apnoea. J Physiol 2018; 596 (17) 4043-4056
- 108 Pham LV, Schwartz AR, Polotsky VY. Integrating loop gain into the understanding of obstructive sleep apnoea mechanisms. J Physiol 2018; 596 (17) 3819-3820
- 109 Guilleminault C, Huseni S, Lo L. A frequent phenotype for paediatric sleep apnoea: short lingual frenulum. ERJ Open Res 2016; Jul 29; 2 (03) 00043-2016 DOI: 10.1183/23120541.00043-2016. . PMID: 27730205; PMCID: PMC5034598