Regarding the sleep apnea severity assessment, polysomnography (PSG) was performed in 17 studies,[19–21,24–37] watch-PAT in 1 study. The most commonly used subjective assessment is ESS, which is performed in 16 studies.[20–22,24–30,32–37]
The age of participants ranged from 20 to 70 years, with an average age of 44 years. The overall proportion of male patients was 90.5%, ranged 63.0% to 100%. Reported baseline BMI, but only 8 studies (44.4%) reported postoperative BMI. The detailed data are shown in Table 2.
Five studies were not included in the ESS score analysis since they did not obtain detailed post- or preoperative mean ± SD of ESS scores.[20,21,28,33,35] Thus, ESS scores were only analyzed in the other 11 studies.[22,24–27,29,30,32,34,36,37]
Although different interventions aimed at multiple airway levels have been applied for airway collapse, isolated nasal surgery is rarely considered for the specific management of OSA. However, the reported effects were inconsistent. The present study showed that AHI could be significantly improved postoperatively by isolated nasal surgery. Our analysis used a subgroup analysis, the index before and after the operation according to the reliability of the group, and once again combined to get the same positive results, which provided a more validated result.
We attributed the varying conclusions with previous studies to: we included more recent studies accessing sleep apnea severity with a similar criterion; we adopted a more reliable analyzing measurement, which subgrouped and analyzed the collected data. As a measure of surgical intervention, nasal surgery first opens middle nasal meatus and sinuses, therefore helping in draining of nasal and sinus cavity secretion and maintaining their normal physiological function; second decreased upper airway resistance reduces episodes of mouth breathing, negative pressure of the nasopharynx and improves the collapsibility of the oropharyngeal cavity. It is reported that nasal surgeries improved the compliances of continues positive pressure therapy.[38,39] In addition, improvement of psychological symptoms, such as depression as well as daytime sleepiness, were reported even without substantial AHI change.[30,32–34,36,37] Because of the subjective clinical effect on patients, correcting nasal obstruction is still considered an important measure of treating OSA. But the long-term improvement of both objective and subjective indexes needs to be confirmed by a more long-term observational experiment.
The present study compared the difference between post- and preoperative values to evaluate the treatment effect. We did not perform the sensitivity analysis by removing each study to investigate its effect on the summarized effect and heterogeneity. This is because while collecting and organizing data we performed imputation of SD of change in some studies, and we subgrouped and analyzed the included studies basing on whether they provided original individual data or SD of change or we estimated SD of change. Then the subgroups were combined and analyzed. In the meta-analysis of AHI, the result of subgroup 1 is −4.17(−7.62, −0.73), subgroup 2: −4.19(−7.51, −0.88), overall: −4.15(−6.48, −1.82), which indicated consistence of the 2 subgroups with the correlation coefficient 0.667. In the meta-analysis of ESS, similar results were obtained by aforementioned 2 meta-analyses.
In previous studies, researchers regarded increased NR as a contributor in inducing and aggravating OSA, and made conclusions that nasal surgery could decrease NR significantly and improve other sleep indices such as oxygen saturation nadir, arousal index, sleep efficiency, and sleep architecture. However, AHI did not show significant change, with some studies even reporting aggravated AHI postoperatively. A possible explanation is that AHI along, as an indicator of how respiratory events occur, is not sufficient to describe the immigration of sleep stage, or decreases in ventilation (ie, length of the events or the fraction of events that are hypopneas).[41,42] Some other studies reported opposite conclusion that nasal surgery can significantly improve AHI,[20,22] which may result from the different phenotypes of the patients. Multiple risk factors are reported to contribute to sleep apnea, such as abnormal anatomy of upper airway, unstable breathing control, compromised upper airway muscle activation, and low arousal threshold. These individual key factors could affect nasal surgery efficacy. Moreover, the efficiency of unilevel upper airway surgery may eliminate overtime, which might be a reason for the discrepancy of the surgical outcomes.
In addition, most of the studies were followed up for a short time, which may have a particular effect on the outcome.
. Mullington JM, Haack M, Toth M, et al. Cardiovascular, inflammatory, and metabolic consequences of sleep deprivation. Prog Cardiovasc Dis 2009;51:294–302.
. Lal C, Strange C, Bachman D. Neurocognitive impairment in obstructive sleep apnea
. Chest 2012;141:1601–10.
. Ferris BG Jr, Mead J, Opie LH. Partitioning of respiratory flow resistance in man. J Appl Physiol 1964;19:653–8.
. Carpenter JG. Mental aberration attending hypertrophic rhinitis, with sub-acute otitis media: read in the section of laryngology and otology, at the forty-third annual meeting of the american medical association, held at Detroit, MI, June, 1892. J Am Med Assoc 1892;XIX:539–42.
. Welis WAMD. Some nervous and mental manifestations occurring in connection with nasal disease. Am J Med Sci 1898;116:677–91.
. Kohler M, Bloch KE, Stradling JR. The role of the nose in the pathogenesis of obstructive sleep apnoea and snoring. Eur Respir J 2007;30:1208–15.
. Boudewyns AN, Van de Heyning PH, De Backer WA. Site of upper airway obstruction in obstructive apnoea and influence of sleep stage. Eur Respir J 1997;10:2566–72.
. Exar EN, Collop NA. The upper airway resistance syndrome. Chest 1999;115:1127–39.
. Deegan PC, McNicholas WT. Predictive value of clinical features for the obstructive sleep apnoea syndrome. Eur Respir J 1996;9:117–24.
. Young T, Finn L, Kim H. Nasal obstruction as a risk factor for sleep-disordered breathing. The University of Wisconsin Sleep and Respiratory Research Group. J Allergy Clin Immunol 1997;99:S757–762.
. Friedman M, Maley A, Kelley K, et al. Impact of nasal obstruction on obstructive sleep apnea
. Otolaryngol Head Neck Surg 2011;144:1000–4.
. Badr MS. Pathophysiology of upper airway obstruction during sleep. Clin Chest Med 1998;19:21–32.
. Silvoniemi P, Suonpaa J, Sipila J, et al. Sleep disorders in patients with severe nasal obstruction due to septal deviation. Acta Otolaryngol Suppl 1997;529:199–201.
. Jenkinson C, Stradling J, Petersen S. Comparison of three measures of quality of life outcome in the evaluation of continuous positive airways pressure therapy for sleep apnoea. J Sleep Res 1997;6:199–204.
. Strohl KP, Redline S. Recognition of obstructive sleep apnea
. Am J Respir Crit Care Med 1996;154(2 Pt 1):279–89.
. Han D, Zhang L. Nasal cavity ventilation expansion techniques. Acta Otolaryngol 2011;131:1244–8.
. Ishii L, Roxbury C, Godoy A, et al. Does nasal surgery
improve OSA in patients with nasal obstruction and OSA? A meta-analysis
. Otolaryngol Head Neck Surg 2015;153:326–33.
. Li HY, Wang PC, Chen YP, et al. Critical appraisal and meta-analysis
of nasal surgery
for obstructive sleep apnea
. Am J Rhinol Allergy 2011;25:45–9.
. Xiao Y, Han D, Zang H, et al. The effectiveness of nasal surgery
on psychological symptoms in patients with obstructive sleep apnea
and nasal obstruction. Acta Otolaryngol 2016;136:626–32.
. Shuaib SW, Undavia S, Lin J, et al. Can functional septorhinoplasty independently treat obstructive sleep apnea
? Plastic Reconstr Surg 2015;135:1554–65.
. Yalamanchali S, Cipta S, Waxman J, et al. Effects of endoscopic sinus surgery and nasal surgery
in patients with obstructive sleep apnea
. Otolaryngol Head Neck Surg 2014;151:171–5.
. 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.
. Higgins JPT, Green S. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011.
. Moxness MH, Nordgard S. An observational cohort study of the effects of septoplasty with or without inferior turbinate reduction in patients with obstructive sleep apnea
. BMC Ear Nose Throat Disord 2014;14:11.
. Victores AJ, Takashima M. Effects of nasal surgery
on the upper airway: a drug-induced sleep endoscopy study. Laryngoscope 2012;122:2606–10.
. Sufioglu 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;269:487–94.
. 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;25:338–41.
. Bican A, Kahraman A, Bora I, et al. What is the efficacy of nasal surgery
in patients with obstructive sleep apnea
syndrome? J Craniofac Surg 2010;21:1801–6.
. Tosun F, Kemikli K, Yetkin S, et al. Impact of endoscopic sinus surgery on sleep quality in patients with chronic nasal obstruction due to nasal polyposis. J Craniofac Surg 2009;20:446–9.
. Li HY, Lee LA, Wang PC, et al. Can nasal surgery
improve obstructive sleep apnea
: subjective or objective? Am J Rhinol Allergy 2009;23:e51–5.
. Kim ST, Choi JH, Jeon HG, et al. Polysomnographic effects of nasal surgery
for snoring and obstructive sleep apnea
. Acta Otolaryngol 2009;124:297–300.
. 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;22:59–63.
. Li HY, Lin Y, Chen NH, et al. Improvement in quality of life after nasal surgery
alone for patients with obstructive sleep apnea
and nasal obstruction. Arch Otolaryngol Head Neck Surg 2008;134:429–33.
. Koutsourelakis I, Georgoulopoulos G, Perraki E, et al. Randomised trial of nasal surgery
for fixed nasal obstruction in obstructive sleep apnoea. Eur Respir J 2008;31:110–7.
. Virkkula P, Bachour A, Hytönen M, et al. Snoring is not relieved by nasal surgery
despite improvement in nasal resistance. Chest 2006;129:81–7.
. Nakata S, Noda A, Yagi H, et al. Nasal resistance for determinant factor of nasal surgery
in CPAP failure patients with obstructive sleep apnea
syndrome. Rhinology 2005;43:296–9.
. Verse T, Maurer JT, Pirsig W. Effect of nasal surgery
on sleep-related breathing disorders. Laryngoscope 2002;112:64–8.
. Friedman M, Tanyeri H, Lim JW, et al. Effect of improved nasal breathing on obstructive sleep apnea
. Otolaryngol Head Neck Surg 2000;122:71–4.
. 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;38:279–86.
. Fairbanks DN. Effect of nasal surgery
on snoring. Southern Med J 1985;78:268–70.
. Olsen KD, Kern EB, Westbrook PR. Sleep and breathing disturbance secondary to nasal obstruction. Otolaryngol Head Neck Surg 1981;89:804–10.
. Ohki M, Usui N, Kanazawa H, et al. Relationship between oral breathing and nasal obstruction in patients with obstructive sleep apnea
. Acta Otolaryngol Suppl 1996;523:228–30.