Position Statement: Nasal Surgery and OSAS

Nasal surgery is a beneficial modality for the treatment of obstructive sleep apnea (OSA).

Nasal surgery can facilitate the treatment of OSA by improving compliance with CPAP (Continuous Positive Airway Pressure). There is significant correlation between nasal resistance or obstruction and CPAP non-acceptance where for each 0.1 Pa/cm3/s increase in resistance the odds ratio of non-acceptance increases 1.48-fold (Sugiura 2007). Nasal surgery lowers nasal resistance. Nakata & coworkers (Nakata et al 2008) showed that using septoplasty and inferior turbinate reduction for CPAP non-adherent patients demonstrated that there was a reduction in nasal resistance from 0.57 to 0.16 Pa/cm3/s, and postoperatively all patients became CPAP adherent. Nasal surgery may lower CPAP pressures by 2-3cm H2O (Friedman 2000; Zonato 2006 ). Nasal surgery (septoplasty and turbinoplasty) led to increased CPAP use and decreased CPAP pressure (Poirrier et al, 2014).

Nasal surgery may facilitate the treatment of OSA by improving the use of oral appliances. Non-responders to oral appliance therapy have higher nasal resistance compared with responders (Zeng 2008). Similarly, in a study of 630 patients treated with mandibular advancement devices (Marklund 2004), women with complaints of nasal obstruction had an odds ratio for successful treatment of only 0.1.  Since nasal surgery lowers nasal airway resistance, oral appliance therapy may be facilitated in subjects with nasal obstruction.

Nasal surgery can improve quality of life in patients with sleep apnea.  With nasal surgery, the Epworth Sleepiness Scale (ESS), has been shown to decline from levels associated with excessive sleepiness (>10) to levels consistent with normal function (Nakata 2005; Li 2008; Park 2014).  Quality of life measured by SF-36 scores of OSA patients significantly improved in the role of physical, emotional, vitality, social functioning, generic health and mental health domains, following nasal surgery (Li 2008).

Nasal surgery as the sole intervention may effectively treat OSA in a subset of patients.  Nasal surgery improved nasal airway patency and reduced OSA severity in 56% of patients and led to statistically significant decreases in AHI and ESS (Park 2014; Morinaga 2009) and in a randomized, placebo controlled study by Koutsourelakis (2008).

Adopted 5/3/2010
Revised 12/8/2012
Revised 9/8/2017

References:

1. Sugiura T, Noda A, Nakata S, Yasuda Y, Soga T, Miyata S, Nakai S, Koike Y. Influence of nasal resistance on initial acceptance of continuous positive airway pressure in treatment for obstructive sleep apnea syndrome. Respiration. 2007;74(1):56-60.PMID: 16299414
2. Nakata S, Noda A, Yasuma F, Morinaga M, Sugiura M, Katayama N, Sawaki M, Teranishi M, Nakashima T. Effects of nasal surgery on sleep quality in obstructive sleep apnea syndrome with nasal obstruction. Am J Rhinol. 2008 Jan-Feb;22(1):59-63. PMID: 18284861
3. 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 Jan;122(1):71-4. PMID: 10629486
4. Poirrier J, George C, Rotenberg B. The effect of nasal surgery on nasal continuous positive airway pressure compliance. Laryngoscope. 2014;129:81-87.
5. Zonato AI, Bittencourt LR, Martinho FL, Gregório LC, Tufik S.  Upper airway surgery: the effect on nasal continuous positive airway pressure titration on obstructive sleep apnea patients.
   Eur Arch Otorhinolaryngol. 2006 May;263(5):481-6. PMID: 16450157
6. Zeng B, Ng AT, Qian J, Petocz P, Darendeliler MA, Cistulli PA. Influence of nasal resistance on oral appliance treatment outcome in obstructive sleep apnea.  Sleep. 2008 Apr 1;31(4):543-7. PMID: 18457242
7. Marklund M, Stenlund H, Franklin KA. Mandibular advancement devices in 630 men and women with obstructive sleep apnea  and snoring: tolerability and predictors of treatment success.  Chest. 2004 Apr;125(4):1270-8.  PMID: 15078734
8. Li HY, Lin Y, Chen NH, Lee LA, Fang TJ, Wang PC.  Improvement in quality of life after nasal surgery alone for patients with obstructive sleep apnea and nasal obstruction. Arch Otolaryngol Head Neck Surg. 2008 Apr;134(4):429-33. PMID: 18427011
9. 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:e98765.
10. Verse T, Pirsig W.  Impact of impaired nasal breathing on sleep-disordered breathing. Sleep Breath. 2003 Jun;7(2):63-76. PMID: 12861486
11. Morinaga M, Nakata S, Yasuma F, Noda A, Yagi H, Tagaya M, Sugiura M, Teranishi M, Nakashima T. Pharyngeal morphology: a determinant of successful nasal surgery  for sleep apnea. Laryngoscope. 2009 May;119(5):1011-6. PMID: 19301414
12. Sériès F, St Pierre S, Carrier G.  Effects of surgical correction of nasal obstruction in the treatment of obstructive sleep apnea. Am Rev Respir Dis. 1992 Nov;146(5 Pt 1):1261-5. PMID: 1443882
13. 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 Jan;31(1):110-7. PMID: 17898015
14. Victores AJ, Takashima M. Effects of nasal surgery on the upper airway: A drug-induced sleep endoscopy study. Laryngoscope. 2012 Aug 8. doi: 10.1002/lary.23584. [Epub ahead of print] PubMed PMID: 22886986.
15. Sufioglu M, Ozmen OA, Kasapoglu F, Demir UL, Ursavas A, Erisen L, Onart S. The efficacy of nasal surgery in obstructive sleep apnea syndrome: a prospective clinical study. Eur Arch Otorhinolaryngol. 2012 Feb;269(2):487-94. Epub 2011 Jul 15. PubMed PMID: 21761192.
16. Friedman M, Maley A, Kelley K, Leesman C, Patel A, Pulver T, Joseph N, Catli T. Impact of nasal obstruction on obstructive sleep apnea. Otolaryngol Head Neck Surg. 2011 Jun;144(6):1000-4. Epub 2011 Mar 3. PubMed PMID: 21493302.
17. Li H, Wang PC, Chen YP, Lee LA, Fang TJ, Lin HC. Critical appraisal and meta-analysis of nasal surgery for obstructive sleep apnea. Am J Rhinol Allergy. 2010 Dec 17. [Epub ahead of print] PubMed PMID: 21172121.

Important Disclaimer Notice (Updated 7/31/14)

Position statements are approved by the American Academy of Otolaryngology—Head and Neck Surgery or Foundation (AAO-HNS/F) Boards of Directors and are typically generated from AAO-HNS/F committees. Once approved by the Academy or Foundation Board of Directors, they become official position statements and are added to the existing position statement library. In no sense do they represent a standard of care. The applicability of position statements, as guidance for a procedure, must be determined by the responsible physician in light of all the circumstances presented by the individual patient. Adherence to these clinical position statements will not ensure successful treatment in every situation. As with all AAO-HNS/F guidance, this position statement should not be deemed inclusive of all proper treatment decisions or methods of care, nor exclusive of other treatment decisions or methods of care reasonably directed to obtaining the same results. Position statements are not intended to and should not be treated as legal, medical, or business advice.