Study Finds Surgical Intervention for Nasal Obstruction Improves CPAP Adherence, Outcomes in Patients With OSA

Nasal surgical intervention led patients with obstructive sleep apnea (OSA) who historically were nonadherent to continuous positive airway pressure (CPAP) treatment to become adherent and experience improvements in objective and subjective severity measures.

Continuous positive airway pressure (CPAP) therapy is the standard first-line therapy for obstructive sleep apnea (OSA), but low long-term patient adherence diminishes its effectiveness. A study published in the Irish Journal of Medical Science found that nasal surgical intervention, which has been shown to improve patient quality of life in previous studies, had a positive effect on CPAP outcomes and patient compliance.

Long-term CPAP adherence among patients with OSA is typically about 50%, according to the study. This nonadherence is likely partially due to the high CPAP titration pressures needed for the treatment to be effective.

Past study findings suggest that nasal surgical intervention may relieve sleep issues and improve quality of life for patients with operable nasal obstruction. But no studies to the authors’ knowledge have specifically addressed outcomes related to nasal cross-sectional area changes in OSA patients undergoing surgical correction of nasal obstruction.

Upper airway narrowing, which leads to periodic collapse while a patient sleeps, is the underlying cause of the pathophysiological mechanism of OSA. The nasal passage is responsible for up to two-thirds of airway resistance, and even small changes to a septal deviation or turbinate hypertrophy can have significant effects on airway resistance.

This study aimed to assess the outcomes of nasal surgery to relieve obstruction and identify potential correlations between those outcomes and postoperative CPAP pressure needs for patients. Objective outcomes were assessed with acoustic rhinometry to determine minimal cross-sectional area of the nose (MCA1 and MCA2) and via standard polysomnography, while subjective measures included Nasal Obstruction Symptom Evaluation (NOSE) score and the Epworth Sleepiness Scale (ESS).

A cohort of 49 patients (37 male and 12 female) with OSA related to surgically correctable nasal obstruction who were intolerant to CPAP were enrolled in the study. The mean patient age was 52 years, and mean body mass index was 24.82. Of the overall cohort, 33 patients had nasal obstruction due to inferior turbinate hypertrophy and 16 had inferior turbinate hypertrophy as well as septal deviation.

At postsurgical evaluation between 3 and 6 months later, all patients were able to tolerate CPAP for 4 or more hours per night for 70% or more of the nighttime. The mean NOSE score improved significantly from 66.36 before surgery to 34.3 at postsurgical follow-up. Mean ESS score also improved, dropping from 10.45 before surgery to 4.98 at follow-up. The mean lowest nocturnal oxygen saturation also significantly increased by the postsurgical follow-up.

MCA1 and MCA2 also increased after surgery, which correlated significantly with a decrease in necessary CPAP titration pressure. “This improvement in the MCA correlated positively with the decline in the optimal CPAP pressure requirements and rendered non-adherent OSA patients tolerant to CPAP therapy,” study authors wrote.

In line with previous studies, there was no statistically significant improvement in apnea-hypopnea index (AHI) scores after surgical intervention. This has been a barrier to wider adoption of surgical intervention for OSA, but study authors reiterate that independent of the AHI, a longtime standard for measuring sleep apnea severity, nasal surgery appears to improve sleep quality and reduce daytime sleepiness in patients with sleep-related breathing disorders.

Given the results of this and previous studies, “it seems that when combined with CPAP, surgical relief of nasal obstruction provides a remarkable improvement in subjective daytime sleepiness,” the authors concluded. These findings suggest surgical intervention to remedy nasal obstruction should be considered as a potentially crucial treatment option for patients with OSA.

Reference

Elwany S, Bahgat AY, Ibrahim M, et al. Surgical correction of nasal obstruction in obstructive sleep apnea improves CPAP outcomes and compliance. Ir J Med Sci. Published online January 27, 2022. doi:10.1007/s11845-021-02896-6