Nasal Surgery

and Wolfgang Pirsig²

(1)

Department of Otorhinolaryngology Head and Neck Surgery, Asklepios Clinic Harburg, Eissendorfer Pferdeweg 52, 21075 Hamburg, Germany

(2)

Department of Otorhinolaryngology Head and Neck Surgery, Mozartstrasse 22/1, Ulm, 89075, Germany

Abstract

A clearly defined connection between nasal breathing or nasal resistance and sleep-disordered breathing does not exist; instead, the relationship is a very complex one. It is difficult to measure snoring objectively. The available measurement methods are cost-intensive. Many nasal appliances are available. But in contrast to the advertised promises, all of them have virtually no influence on the severity of obstructive sleep apnea (OSA) and are only partially successful in the case of primary snoring. The studies for primary snoring have not been standardized. Usually, the success is measured with the help of questionnaires filled out by the bed partner. The success rate is estimated to be about 40%. In the case of OSA, the success rate of isolated nasal surgery (correlated with the severity measured with the AHI) is approximately 10%. The subjective success rate in relation to sleep quality and daytime symptoms is significantly higher. Surgery improving the nasal air passage can improve the success of continuous positive airway pressure (CPAP) therapy; and in some cases, CPAP therapy is only made possible if this kind of surgery is performed.

Core Features

A clearly defined connection between nasal breathing or nasal resistance and sleep-disordered breathing does not exist; instead, the relationship is a very complex one.
It is difficult to measure snoring objectively. The available measurement methods are cost-intensive.
Many nasal appliances are available. But in contrast to the advertised promises, all of them have virtually no influence on the severity of obstructive sleep apnea (OSA) and are only partially successful in the case of primary snoring.
The studies for primary snoring have not been standardized. Usually, the success is measured with the help of questionnaires filled out by the bed partner. The success rate is estimated to be about 40%. In the case of OSA, the success rate of isolated nasal surgery (correlated with the severity measured with the AHI) is approximately 10%. The subjective success rate in relation to sleep quality and daytime symptoms is significantly higher.
Surgery improving the nasal air passage can improve the success of continuous positive airway pressure (CPAP) therapy; and in some cases, CPAP therapy is only made possible if this kind of surgery is performed.

Already in the ancient world, it was known that impaired nasal airflow may lead to sleep-disordered breathing. Hippocrates (de morbis, Liber II Sect V) described snoring, besides enlargement of the lateral nasal walls and croaky voice, as symptom of nasal polyposis. In 1581, Levinus [394] reported that mouth breathing in supine position causes restless sleep. In 1886, Krieg [372] successfully performed a submucous septal resection under cocaine anesthesia in an 8-year-old girl with obstructed nose, snoring, and attacks of suffocation during sleep. In 1892, Cline [113] published a first case study of relief of excessive daytime sleepiness following nasal surgery. In 1898, Wells [807] reported an increase of daytime vigilance in 8 of 40 patients after nasal surgery.

Still today, ENT physicians are often confronted with the expectation that the restoration of the nasal airway leads to an elimination or reduction of sleep-related breathing disorders. But the relation between nasal airway and SDB is very complex and, at present, still not completely understood in every detail. Several excellent review articles summarize the current state of knowledge in regard to the role of the nose in the pathophysiology of SDB [590, 625, 778]. From these reviews, it can be concluded that nasal obstruction may have a negative impact on sleep quality; however, it can only be considered as a cofactor in the pathophysiology of SDB.

4.1 Effectiveness of Treatment

4.1.1 Effectiveness of conservative treatment

Currently, no scientific data exist in regard to the multitude of nasal oils, which are mainly offered over the Internet [460]. What have been researched are antiinflammatory nose drops [351], nasal corticosteroids [77, 128, 359], and nasal dilators [77, 128, 359]. The objective data are inconsistent. Some series reported a significant reduction of the respiratory arousals or of the AHI; but most series did not produce a significant effect. Djupesland et al. [157] even reported a significant increase of the AHI from 9.3 without dilators to 12.2 with dilators in 18 patients with UARS.

The subjective data present a more consistent picture. For the most part, improvements in subjective sleep quality, daytime sleepiness, quality of life, and nonapneic snoring are reported [157].

4.1.2 Effectiveness for Simple Snoring

Up to now, no long-term results exist concerning the effectiveness of nasal surgery in the treatment of SDB. Present data are mostly based on noncontrolled and nonrandomized studies, and do maximally fulfill a grade B of recommendation according to the criteria of evidence-based medicine. Some working groups provide subjective data regarding the impact of nasal surgery on simple snoring.

Summarizing these very inhomogeneous data which usually lack polygraphic or polysomnographic investigation, a noteworthy reduction or disappearance of snoring is reported in a few studies (Table 4.1).

Table 4.1

Effect of nasal surgery for simple snoring

Author	N	Follow-up (months]	Method	Cessation of snoring (%)	Reduction of snoring (%)	EBM
Fairbanks [188]	13	12	Q	53.8	38.5	4
Fairbanks [187]	47	No data	Q		76.6	4
Ellis et al. [169]	126	6-24	Q	31.0	57.1	4
Low [425]	30	4-12	VAS (0-10)	50.0		3b
Woodhead and Allen [821]	29	1.5	VAS (0-10)		69.0	3b
Grymer et al. [245]	26	3-6	Q	50.0		3b
Elsherif and Hussein [171]	96	6-9	Q	50.0	39.6	4
Bertrand et al. [50]	8	12	VAS (1-4)		87.5	3b
All	375	1.5-24		41.9	85.3	B

VAS Visual Analogue Scale; Q questionnaire; EBM Evidence based-medicine

Furthermore, Illum [316] reported that of the 50 patients who underwent septoplasty and conchal surgery 58% were snoring preoperatively and 41.5% complained of snoring 5 years postoperatively. From these few examples (often cited) and similar publications it is virtually impossible to estimate a success rate percentage of nasal surgery in primary snorers.

Nasal surgery may reduce the sound intensity of snoring by 5-10 dB [645]. Nasal surgery improves nasal ventilation, sleep quality, and daytime vigilance [202].

4.1.3 Effectiveness for OSA

Only few case reports exist on cures of OSA after nasal surgery [163, 272, 677]. On the other hand, already in 1977, Simmons et al. [675] reported about cases with no significant AI reduction despite considerable subjective improvement of nasal breathing and sleep quality.

Up to the year 2008, 14 studies on nasal surgery for OSA have been found which provide data on pre and postoperative AI or AHI (Table 4.2). Altogether, 272 patients were included in the studies. For the entire group the postoperative AHI showed hardly any changes compared to baseline. The follow-up periods were for the most part short and lasted from 1 [629] to 50 months [770]. In only two studies [361, 629], a statistically significant improvement of the severity of OSA after nasal surgery alone was found. In four other studies with a total of 30 patients, an increase in the severity of OSA was noticed postoperatively (Table 4.2), which was not statistically significant in all studies. We recorded a noticeable worsening of OSA in two patients with polyposis nasi after paranasal sinus surgery [771]. Despite the reconstitution of nasal breathing, the AHI rose from 14.0 before to 57.7 after surgery. Both patients developed excessive daytime sleepiness and required nasal continuous positive airway pressure (CPAP) therapy. Similar cases after septorhinoplasty have been reported by Dagan [132] and Balcerzak et al. [36].

Table 4.2

Effect of nasal surgery on the severity of obstructive sleep apnea

Author	N	Follow-up	AHI pre	AHI post	p-Value	EBM
Rubin et al. [629]	9	1-6	37.8*	26.7*	<0.05	4
Dayal and Phillipson [138]	6	4-44	46.8	28.2	n.s.	4
Caldarelli et al. [89]	23	No data	44.2*	41.5*	n.s.	4
Aubert-Tulkens et al. [28]	2	2-3	47.5*	48.5*	–	4
Sériès et al. [658]	20	2-3	39.8	36.8	n.s.	4
Sériès et al. [659]	14	2-3	17.8*	16*	n.s.	4
Utley et al. [760]	4	No data	11.9	27	–	4
Verse et al. [771]	2	3-4	14	57.7	–	4
Friedman et al. [221]	22	>1.5	31.6	39.5	n.s.	4
Verse et al. [770]	26	3-50	31.6	28.9	n.s.	4
Kim et al. [361]	21	1	39	29	<0.0001	4
Balcerzak et al. [36]	22	2	48.1	48.8	n.s.	4
Nakata et al. [490]	12	No data	55.9	47.8	n.s.	4
Virkkula et al. [785]	40	2-6	13.6	14.9	n.s.	4
Koutsourelakis et al. [367]	49	3-4	31	31	n.s.	4
All	272	1-50	33.0	31.8		C

AHI Apnea Hypopnea Index; n.s. not statistically significant; EBM level of evidence-based medicine;

*Apnea Index

Lavie et al. [388] reported on 14 patients with OSA who all underwent only septoplasty. OSA severity did not change after surgery, but 12 of their 14 subjects showed improved sleep quality in the polysomnography and reported less daytime fatigue.

In our prospective study including 26 patients we did not observe any significant change in AHI as well [770]. In contrast, nasal resistance (anterior rhinomanometry at 150 Pa) was significantly reduced after surgery (p = 0.0089) and daytime sleepiness decreased as well. The Epworth Sleepiness Scale (ESS) was ranked 11.9 before surgery and fell to 7.7 after nasal surgery (p = 0.0004). Despite a reduced nasal resistance, the severity of OSA increased in four patients. Using Sher’s criteria [665] (reduction of AHI > 50% and to values <20), only 3 of 19 patients with OSA (15.8%) were classified as cured after isolated nasal surgery.

Other studies report cure rates of nasal surgery for OSA between 0 [28, 771] and 33% [138]. In the literature, raw data for 76 patients with OSA are available. Using Sher’s criteria the cure rate of these patients is only 17.5%.

To sum it up, patients may be allocated to two groups. With the vast majority of patients, the normalization of nasal resistance leads to a positive impact on the well-being and the sleep quality, however not on the severity of OSA. Even a worsening of the condition has been described. In a smaller number of patients, an improvement, in some cases even healing, of an existing OSA can be achieved. Reliable criteria to identify responders have not yet been found. Therefore, the prediction of success of a rhinosurgical treatment for an individual with sleep-disordered breathing is currently not possible.

4.2 Postoperative Care and Complications

A discussion of the complications and the specific postoperative follow-up treatment after rhinosurgery lies beyond the scope of this book. For this, we refer the reader to the specialized rhinological literature.

Yet in connection with SDB the issue of nasal packing needs to be addressed. In the case of primary snoring and mild OSA, nasal packing usually does not present a problem [84]. However, in the elderly patient with moderate-to-severe OSA (AHI > 30), the AHI may increase if nasal packing is used for epistaxis or after surgery. In older publications, even vital complications have been reported [93, 812]. The danger is especially prevalent in the first 6 h postoperatively [46]; therefore, the patient needs to be postoperatively monitored during this phase. Yet in the opinion of the authors, a monitoring in an intensive care unit, even in the case of severe sleep apnea after multiple surgeries on the upper airway with nasal packings in situ, is only necessary in individual cases. For the specific anesthesiological procedures in the case of sleep-apneics, see Chap. 13.

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