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Holistic care for obstructive sleep apnea (OSA) with an emphasis on restoring nasal breathing: A review and perspective

Tsai, Ming-Shaoa,b,c,d; Chen, Hung-China,b; Liu, Stanley Yung-Chuane; Lee, Li-Angb,f; Lin, Cheng-Yug,h,i; Chang, Geng-Hea,b,c,d; Tsai, Yao-Tea,b; Lee, Yi-Chanb,j; Hsu, Cheng-Minga,b; Li, Hsueh-Yub,f,*

Author Information
Journal of the Chinese Medical Association: June 2022 - Volume 85 - Issue 6 - p 672-678
doi: 10.1097/JCMA.0000000000000737
  • Open

Abstract

1. INTRODUCTION

Nasal surgery, including correction of the deviated nasal septum and volume reduction of inferior turbinates, could be effective for improving nasal patency and restoring nasal breathing.1 In addition, it is helpful in mitigating daytime sleepiness and reducing snoring intensity.2 A decrease in nasal resistance consequently lowers the pressure level of continuous positive airway pressure (CPAP) therapy, which benefits CPAP compliance.3 However, the ability of isolated nasal surgery to reduce the apnea–hypopnea index (AHI) remains controversial. Three systemic reviews have addressed the effect of nasal surgery on AHI. A meta-analysis by Wu et al4 reported improvement in AHI after nasal surgery alone, whereas Li et al5 and Ishii et al6 reported no significant reduction in AHI following nasal surgery. Our previous study found that multilevel airway obstruction was common in patients with obstructive sleep apnea (OSA), especially in those with moderate-to-severe OSA.7 Therefore, multilevel surgery or multimodality treatment had become mainstream in the holistic care of OSA.8 To achieve better outcomes, nasal surgery should be a part of the multilevel integrated treatment rather than being a single modality therapy by itself. In this review, we introduce nasal surgical procedures and the practice of nasal irrigation and focus on the role of nasal surgery in the holistic care for OSA.

2. ETIOLOGY OF OSA

OSA is caused by repeated partial or complete airway blockage during sleep.9 Anatomical obstruction due to soft-tissue hypertrophy (eg, enlarged tonsil and elongated epiglottis) or dynamic collapse (eg, velopharyngeal collapse and tongue base collapse) related to pharyngeal hypotonia can occur at any site along the upper respiratory tract.10 Blockage of nasal passages at night usually results in mouth breathing while sleeping. Findings from drug-induced sleep endoscopy support that mouth breathing can aggravate tongue base and lateral pharyngeal wall collapse, consequently exacerbating sleep apnea.11 Moreover, studies have demonstrated numerous phenotypic and genotypic risk factors that precipitate OSA. Aging process is associated with a decrease in the negative pressure reflex of genioglossus muscle, which predisposes older individuals to pharyngeal collapse.12 The prevalence rate of OSA in men was estimated to be 1.67- to 5-fold higher than that in women.13,14 Men are suggested to have a long and floppy oropharynx owing to greater laryngeal descent, which increases the vulnerability and collapsibility of the upper airway.13 By contrast, in women, estrogen and progesterone play protective roles against OSA by improving the activity of the pharyngeal dilator muscle. Menopause is considered an independent risk factor for the development of OSA in women.15 Obesity correlates closely with the progression and severity of OSA. The risk of OSA is approximately six times higher among individuals who gain 10% of their baseline weight.16 Enlarged volume of parapharyngeal fat pads may worsen OSA by increasing the collapsibility of the lateral pharyngeal wall.17 Craniofacial anomalies such as retrognathic mandible may lead to sleep apnea owing to tongue base and/or hyolaryngeal collapse.18 In summary, the pathogenesis of OSA is multifactorial and the precipitating factors are diverse and variable among individuals.

3. THE DILEMMA IN THE TREATMENT OF OSA

Although CPAP is considered the first-line therapy for patients with OSA, its adherence rate remains a challenge. The long-term compliance rate of CPAP therapy is approximately 50% to 60%.19 A previous study reported that 56% of patients who underwent CPAP therapy experienced chronic nasal irritation.20 Pathological conditions affecting nasal patency such as septal deviation and nasal polyposis can cause nasal discomfort during CPAP application. In addition, elongated and flaccid epiglottis may be pushed downward by CPAP flow, which accentuates supraglottic collapse.21 Other adverse effects that reduce CPAP adherence include claustrophobia, inconvenience, nocturnal awakening, and partner complaints.22 Application of oral appliances is an alternative noninvasive treatment for OSA with good compliance and wide variation of the treatment effect in clinical use. However, CPAP yielded better polysomnography outcomes in reducing AHI and improving lowest oxygen saturation than oral appliances.23 Maxillomandibular advancement (MMA), which repositions the upper and lower jaw and directly expands the upper airway, is highly effective for treating OSA. Stretching of the lateral pharyngeal wall after MMA further reduces its flaccidity and prevents it from collapse.24 A meta-analysis study reported 85.5% and 38.5% surgical success rate and cure rate of MMA in treating OSA, respectively.25 However, MMA is more invasive, involves a longer recovery period, and requires a comprehensive assessment of dental occlusion. Intrapharyngeal surgeries target the soft tissue of the upper airway and include uvulopalatopharyngoplasty (UPPP), midline glossectomy, tongue suspension, and epiglottidectomy. The success rates of soft-tissue surgery vary from 25% to 85% depending on several factors, of which local anatomical structure is the most important factor.26 Obesity, retrognathia, high Mallampati score, and small palatine tonsils negatively affect the surgical outcome.27 Decreased therapeutic efficacy of soft-tissue surgery over time is also a matter of concern.28 Each therapy has its own strength and weakness. Multimodality and integrated treatment based on each individual’s condition and requirement should be applied as a holistic care for patients with OSA.

4. HOLISTIC CARE FOR OSA

The treatment flowchart of holistic care for OSA is shown in Fig. 1. Conservative treatment, including alcohol avoidance before sleep, maintenance of a consistent circadian rhythm, and lateral sleep as positional therapy can be informed during the initial consultation and performed immediately after the clinic visit. A combination of topical nasal spray use and mouth sealing increases the proportion of nasal breathing and reduces the intensity of snoring.29 CPAP remains the gold standard therapy for OSA. Different mask types and sizes should be provided for optimal performance and comfort. Proper humidification with intranasal steroid spray use can relieve nasal dryness and irritation.10 Oral appliances are also considered an effective device therapy for mild or moderate OSA. When the patient cannot be cured by conservative treatment and device treatment, the feasibility of extrapharyngeal surgery should be considered before intrapharyngeal surgery. Extrapharyngeal surgery includes bariatric surgery, MMA, and distraction osteogenesis maxillary expansion (DOME). Bariatric surgery significantly improves not only the AHI but also blood pressure control and lipid profile of individuals with morbid obesity (BMI ≥ 40 kg/m2).30 In obese patients, weight loss is helpful in alleviating the severity of OSA, and a 10% weight loss can lead to a >20% decrease in AHI.31 Furthermore, weight loss causes greater reduction in nonsupine AHI than in supine AHI. Adoption of the lateral sleeping posture would be beneficial for these patients.32 MMA should be considered for patients with craniofacial anomalies (mandibular retrognathia) and moderate-to-severe OSA. It can also be reserved as a salvage surgery in case soft-tissue surgery fails.33 DOME is a targeted anatomical intervention for patients with OSA with a narrow maxilla and nasal floor.34 For patients with large tonsils and low tongue resting position (Friedman Stage I), tonsillectomy with suspension palatoplasty yields a favorable outcome through the suspension of the palatopharyngeus muscle anteriorly and laterally to the tenacious pterygomandibular raphe.35 While numerous modifications of UPPP have been described, we suggested the following principles: lymphoid tissue for excision, muscle for suspension, adipose tissue for ablation, and mucosa for preservation.8 For patients who are unable to tolerate CPAP and have tongue base or multilevel obstruction, transoral robotic surgery (TORS) for tongue base reduction, and/or partial epiglottidectomy are alternative treatment methods with high efficacy.36 Tongue base suspension can be applied to patients with a small and collapsible tongue with a retracted mandible.37 The implanted upper airway stimulation device eliminated adherence issues associated with wearing a CPAP mask and led to significant improvements in objective and subjective measurements of the severity of OSA.29 Postoperative myofunctional therapy, positional therapy, and control of body weight would be helpful in maintaining and enhancing the long-term surgical outcomes.38

F1
Fig. 1:
Flow chart of holistic management for obstructive sleep apnea. Conservative treatment can be used as the initial treatment for OSA. Device treatment includes CPAP therapy and oral appliance. Extrapharyngeal surgery should be a priority for patients with morbid obesity or craniofacial deformities. Intrapharyngeal and nasal surgery is suitable for patients with OSA with soft-tissue obstruction or collapse and nasal obstruction. Integrated treatment after surgery can help maintain and prolong the effect of surgery. BMI = body mass index; DOME = distraction osteogenesis maxillary expansion; MMA = maxillomandibular advancement; OSA = obstructive sleep apnea.

5. ROLE OF NASAL SURGERY IN HOLISTIC CARE OF OSA

Nasal surgery is a part of the holistic care for treating OSA (Fig. 2). Septoplasty is indicated when the septum is crooked to one or both sides, which causes narrowing of the nasal passage.39 Chronic swelling of the turbinates can be treated through traditional turbinectomy, radiofrequency ablation, microdebrider-assisted inferior turbinoplasty, or laser turbinoplasty.40 For patients with chronic rhinosinusitis or nasal polyposis, functional endoscopic sinus surgery is effective in restoring sinus ventilation and re-establishing the patency of the nasal meatus.41

F2
Fig. 2:
Role and importance of nasal surgery in the treatment of OSA. AHI = apnea–hypopnea index; CPAP = continuous positive airway pressure; OSA = obstructive sleep apnea; RDI = respiratory disturbance index.

5.1. Nasal obstruction contributes to OSA

A clinical study showed that unilateral higher nasal resistance was significantly associated with respiratory disturbance index (RDI) and minimal oxygen saturation; total nasal resistance was also correlated with the snoring index.42 The results of stepwise multivariate regression suggested that unilateral increased nasal resistance was predictive of higher RDI (p = 0.006).42 This implied that nasal resistance is a possible contributing factor to snoring and the severity of OSA.

5.2. Changes in airflow and volume from oral breathing to nasal breathing

Oral breathing during sleep commonly induces unstable airway and exacerbates OSA, which may be improved by shifting to nasal breathing. Suzuki and Tanuma43 used computational fluid dynamics analyses to analyze the changes in airflow and volume from oral breathing to nasal breathing. The study revealed that oral breathing leads to more pharyngeal airway collapse and less air volume than nasal breathing. Furthermore, airflow throughout the breathing route was smoother during nasal breathing with closed mouth than oral breathing.43 These results emphasized the necessity of nasal breathing in patients with OSA and the crucial role of nasal surgery in comprehensive treatment of OSA.

5.3. Nasal surgery for snoring

Nasal surgery (septomeatoplasty) significantly improved subjective snoring in the snore outcome survey (SOS), visual analogue scale, and total nasal resistance.1 This study revealed that 86% of patients showed improved SOS scores, with an average improvement of 46%.1 The sleep partners of 12% of the patients stated complete cessation of snoring.1 Thus, nasal surgery alone improved snoring in the majority (86%) of the patients but stopped snoring in only 12% of them. Patients with small tonsil sizes (grade I/II) had better outcomes of nasal surgery in terms of snoring.1 This could be attributable to the fact that large tonsils reduced the oropharyngeal lumen, which increased air speed, facilitating soft palate oscillation.

5.4. Nasal surgery for better quality of life

Nasal surgery reduced daytime sleepiness, as assessed by Epworth sleepiness scale (ESS), and improved quality of life (QOL), as evaluated by the 36-Item Short Form Health Survey (SF-36).44 Remarkable improvements were observed in ESS scores (by 27.3%), generic SF-36 role-emotional (by 30.4%), and role-physical (by 20.7%) QOL subscales.44 Correction of an obstructed nasal airway significantly improved disease-specific and generic QOL in adult patients with OSA with nasal obstruction.

5.5. Nasal surgery for OSA

A previous study reported nonsignificant changes in AHI and other polysomnographic parameters after nasal surgery. Despite improved subjective QOL, nasal surgery did not improve adverse sleep respiratory events.2 Another literature review and meta-analysis revealed that the weighted mean AHI measured through polysomnography in nine studies decreased from 35.2 ± 22.6 to 33.5 ± 23.8 events/hour after nasal surgery (overall p = 0.69), and the pooled success rate of nasal surgery in treating OSA was only 16.7%; the results demonstrated that the efficacy of nasal surgery in treating OSA was limited.5 Patients with lower BMI, less daytime sleepiness, and lower tongue position had a higher success rate than the others (50% vs 3%; p < 0.001).2 Therefore, nasal surgery for OSA was suggested for patients with a lower BMI, less daytime sleepiness, and lower tongue position for considerable reduction of AHI.

5.6. Nasal surgery in multilevel airway surgery for OSA: Simultaneous or staged?

One study compared simultaneous and staged type of nasal/palatal operation.45 The results indicated that the incidences of surgical complications (safety) and postoperative RDI (efficacy) were indistinguishable between the two groups, whereas lower total hospitalization expenses were incurred in the simultaneous surgery group than in the staged surgery group.45 The data suggested that surgical outcomes in the simultaneous surgery group were equivalent to those in the staged surgery group in terms of safety and efficacy. However, simultaneous surgery was more cost-effective in terms of medical expenses.

5.7. Nasal surgery improves CPAP compliance

Among patients treated with CPAP therapy, nasal surgery caused a significant reduction in therapeutic pressure, with a mean difference of −2.66 cm of water pressure.46 In addition, the self-reported CPAP adherence rates also significantly improved in the surgical group.47 Kempfle et al48 modeled the cost-effectiveness of the surgical group versus the nonsurgical group in patients undergoing CPAP and concluded that nasal surgery was a cost-effective strategy for improving CPAP compliance in patients with OSA with nasal obstruction.

6. MINI-INVASIVE SEPTOTURBINOPLASTY

Mini-invasive septoturbinoplasty (MIST) involves a Killian incision with removal of the deviated septum, which is the same as conventional surgery. A 1-cm wide portion of the dorsal and caudal septal segment, also named L-strut, must be preserved to support the nasal dorsum and tip. MIST is different to conventional septoturbinoplasty in (1) For deviated maxilla crests, we shave the lateral bony surface for preservation of a triangular hump in the nasal floor to reduce active bleeding from damage of great palatine artery (Fig. 3).8 (2) We prefer out-fracture instead of excision of the inferior turbinate to preserve nasal mucosa and avoid empty nose syndrome.8,49 (3) Trans-septal sutures and incision drainage avoid septal hematoma and sustained nasal packing. MIST can be performed using two approaches: (1) endoscopy or surgical loupe can be implemented for providing a clear surgical view during the dissection of the perpendicular plate and vomer bone from the septal mucosa to minimize the risk of septal perforation and (2) crossing suture technique can be combined with MIST to correct causal septal deviations.50 In summary, MIST can significantly widen the nasal passage, improve the sensation of nasal congestion, preserve nasal function, and reduce the risk of empty nose syndrome.

F3
Fig. 3:
Illustration of the procedure of mini-invasive septoturbinoplasty. (1) Correction of deviated septum; (2) the pyramidal shape of the maxillary crest is preserved to avoid greater palatine artery bleeding; (3) out-fracture of inferior turbinate combined with submucosal cauterization; and (4) trans-septal sutures can prevent septal bleeding and hematoma.

7. DOME SURGERY AND NASAL PATENCY

DOME is used to treat patients with OSA with a narrow palate and nasal floor. Abnormal skeletal framework such as a high arched palate and transverse maxillary deficiency can also cause disturbances in nasal breathing and worsen sleep apnea. DOME includes limited LeFort I osteotomy for maxilla separation and implantation of the expander screw (Fig. 4).34 The expander device starts to take effect 5–7 days after surgery and creates an expansion rate of 0.25 mm/d. The expander is kept in place for 9–11 months. In general, DOME can lead to an 8- to 12-mm widening of the transverse maxillary diameter.34 A gap between the maxillary central incisors appears during the treatment course. Thus, orthodontic procedures are essential for correction of the malpositioned teeth. DOME contributes to nasal floor expansion, especially at the level of internal nasal valve, which is the major source of nasal resistance.51 The procedure significantly relieves nasal obstruction, reduces AHI, and improves the amount of rapid eye movement sleep.34 For patients with OSA with nasal obstruction and a narrow maxilla, DOME is an effective and safe treatment option with minimal adverse effects.

F4
Fig. 4:
Distraction osteogenesis maxillary expansion (DOME) improves nasal patency. DOME is a surgical procedure for patients with high arched and narrow palates (asterisk). After DOME surgery, the nasal floor widens and the space between the tongue and the palate increases (arrows).

8. NASAL IRRIGATION IMPROVES NASAL BREATHING

Nasal irrigation typically uses isotonic (0.9%) or hypertonic saline (generally 2%-3%) to rinse and wash the nasal passage. This technique can filter and flush out dust, allergens, and mucus, which restores mucociliary clearance function.52 Postoperative nasal irrigation is helpful in removing crusts and reducing nasal secretion and postsurgical edema.53 Allergic rhinitis (AR) frequently results in turbinate swelling, watery rhinorrhea, and nasal congestion. Patients with chronic rhinosinusitis (CRS) often develop a thick nasal mucopus and experience postnasal drip, a foul smell, and nasal obstruction. Both diseases may cause impaired nasal breathing, night cough, and sleep disturbance. A recent study developed an innovative herbal irrigation using Glycyrrhiza glabra, which belongs to a family of licorice and has a sweet taste and favorable smell, to treat AR.54 Turbinate congestion, postnasal discharge, and nasal patency were significantly improved after 1 month of herbal irrigation therapy. Moreover, the herbal solution possesses a fragrant smell and a sweet taste in contrast to the salty and bitter taste of the saline solution, which improves patient motivation for receiving treatment. For patients with AR or CRS undergoing surgery, regular nasal irrigation is recommended for optimizing and maintaining the surgical outcomes.

9. CONCLUSIONS

Nasal surgery is an indispensable armamentarium of the holistic care for OSA. In addition to relieving nasal obstruction, nasal surgery is effective in reducing snoring intensity, improving daytime spirit, and enhancing general QOL. Although it leads to significant reduction in RDI, its effect on AHI remains controversial. A combination of nasal surgery and multilevel pharyngeal surgery may result in more favorable surgical outcomes. For patients treated with CPAP therapy, nasal surgery can significantly reduce the therapeutic pressure and enhance CPAP compliance. Thus, multimodality treatment and holistic care for OSA should involve nasal surgery for optimizing treatment outcomes.

Acknowledgements

The study was financially supported by grants from the Ministry of Science and Technology, Taiwan. (MOST 109-2314-B-182A-054-) and Chang Gung Memorial Hospital, Taoyuan, Taiwan. (CMRPG6J0331, CMRPG6K0301). This manuscript was edited by Wallace Academic Editing. The authors wish to thank Ko-Hung Hsu for the illustrations.

Author Contributions: Dr Ming-Shao Tsai and Dr Hung-Chin Chen contributed equally to this work.

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Keywords:

Nasal surgery; Nose; Patency; Sleep apnea; Snoring

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