RESEARCH ARTICLE

An observational cohort su

There is growing interest in the field of sleep-related dis- have been performed in several forms over the last 3 de-

Moxness and Nordgrd BMC Ear, Nose and Throat Disorders 2014, 14:11http://www.biomedcentral.com/1472-6815/14/11performed are often quite randomly chosen. To ourTechnology (NTNU), Trondheim, NorwayFull list of author information is available at the end of the articleorders (SRD) and in obstructive sleep apnea (OSA) par-ticularly. This is due to the impact of SRD on globalhealth, and a result of more profound insight into the ef-fects of sleep deprivation, and the biomechanical andphysiological changes that occur during the developmentof upper airway collapse during sleep [1]. The traditionalway of understanding the collapsing airway includes boththeories of neuromuscular regulation [2] and theories of

cades [4]. To date, tracheotomy is the only surgical pro-cedure with definite and lasting success, but it is regardedas a method with unwanted side effects. Multiple level sur-gery has gained support, as well as maxillomandibular sur-gery, but these are also major procedures and the sameconcerns regarding morbidity apply for these. The effect oflimited and less extensive surgery of the upper airways stillneeds evaluation regarding selection of procedure andresults. Nasal surgery has been performed extensively inthese patients, often with good effect on quality of life(QOL) measures [5,6]. Still, there is no conclusive evidenceof clinical effect, and the different nasal procedures

* Correspondence: stale.nordgard@ntnu.no2The department of Otorhinolaryngology, Head and Neck Surgery, St OlavUniversity Hospital, Trondheim, Norway3The Institute of Neuroscience, The Norwegian University of Science andBackgroundAbstract

Background: The objective of this observational study was to evaluate the outcomes of intranasal surgery inpatients with obstructive sleep apnea (OSA) in a single institution in Norway.

Methods: Fifty-nine patients with OSA and clinically significant nasal obstruction underwent either septoplastyalone or septoplasty with concomitant volume reduction of the turbinates from August 2008 until the end ofDecember 2010. Subjects were scheduled for sleep polygraphy before and 3 months after treatment.In this observational single-centre cohort study we evaluated and compared the effect of these two specific surgicalprocedures on sleep related parameters.

Results: There was a significant reduction in the apnea-hypopnea index (AHI) only in the group that hadseptoplasty with turbinate reduction (17.4, (SD 14.4) 11.7, (SD 8.2), p

Moxness and Nordgrd BMC Ear, Nose and Throat Disorders 2014, 14:11 Page 2 of 5http://www.biomedcentral.com/1472-6815/14/11knowledge, there are no other clinical studies that com-pare the results of different nasal procedures for nasalobstruction in patients with OSA. We have evaluatedand compared the results of two specific surgical proce-dures in the nasal cavity, septoplasty alone and septo-plasty with simultaneous turbinate volume reduction.

MethodsThis study was an observational single-centre cohortstudy. It was approved by the national regional ethicscommittee and was registered in Clincaltrials.gov.(NCT01282125). Between August 2008 and December2010, 78 patients with OSA were treated surgically fornasal obstruction in Aleris Hospital in Trondheim,Norway. Fifty-nine of these had been treated with septo-plasty alone or septoplasty combined with volume re-ductive surgery of the turbinates. Group 1 (n = 33)consisted of patients who had undergone septoplastyalone, and group 2 (n = 26) of patients treated with com-bined septoplasty and volume reductive surgery. Theremaining patients underwent rhinoseptoplasties (n = 8),functional endoscopic sinus surgery (n = 4) and turbinateresection (n = 7) as single procedures, but the groupswere too small to be subanalyzed. All patients in the twoanalyzed groups underwent traditional cartilage preserv-ing septoplasty under general anesthesia. The volume re-ductive surgery comprised radiofrequency tissue ablation(n = 10) (BM 780-II, Sutter Medizintechnik Gmbh), lat-eral fracture of the lower turbinate (n = 15), and surgicalreduction of concha bullosa (n = 1).The patients were referred to the sleep clinic for sus-

pected OSA from either primary care physicians or ENTspecialists within a specific geographical area. All pa-tients underwent a nocturnal sleep evaluation with anEmbletta Portable Diagnostic System (ResMed, SanDiego, California, USA) or a Reggie polygraph (Camtech,Oslo, Norway) and a clinical examination. There wereno prior history of nasal surgery or prolonged use ofnasal steroids. None of the patients were diagnosed withchronic rhinosinusitis or enlarged adenoids. Patientswith confirmed OSA and clinically significant nasal ob-struction due to a septal deviation with or withouthypertrophy of turbinates were offered intranasal surgeryas a first line of treatment. The decision to supplementseptoplasty with volume reductive surgery in selectedpatients was based on the clinical evaluation, and notsupported by objective measurements. If there were acoherence between the patients complaints of nasalblockage on both sides, and there was obvious swellingof the inferior turbinates that was relieved after decon-gestion with tetracain/adrenalin over 5-10 minutes inthe office, one would recommend that turbinate reduc-

tion should be performed at the time of the septal sur-gery. Only patients with apnea-hypopnea index (AHI) >5and BMI 3-7 were defined as moderate, and scores >7-10 were considered good [7]. The primary outcomewas alterations in the AHI, oxygen desaturation index(ODI), body mass index (BMI) and Epworth SleepinessScale (ESS) in the two groups. The secondary outcomewas to evaluate the effect of surgery on sleep quality andnasal obstruction reported in the questionnaire. SPSS19.0 was used for the statistical evaluations. Preoperativeand postoperative values were evaluated using the Wil-coxon matched-pairs test in continuous variables with-out normal distribution (ODI, ESS). Variables withnormal distribution (BMI, AHI) were evaluated usingthe paired t-test. The values for AHI were transformedusing natural logarithm in order to create a normal dis-tribution. An independent t-test was used to comparethe changes of the objective measures and VAS aftersurgery between group 1 and 2. Differences with p

gender or BMI. We looked at changes in the objectiveparameters before and after surgery in three ways: theoverall changes in both groups pooled together, changeswithin each group, and the changes in the mean differ-ence between the groups (Table 1). Overall, in bothgroups together, there was no significant reduction inmean AHI after surgery: 18.1 (13.7) - 16.6 (12.9), (95%CI -1.84, 4.83), p = 0.365, mean ODI: 14.2 (12.3) 12.4(10.7), (95% CI -1.16, 4.75), p = 0.229 or mean BMI: 28.1(3.2) 28.3 (3.0), (95% CI 0.673, 0.285), p = 0.422.The reduction in mean ESS, however, was highly statis-tically significant: 10.7 (3.7) 8.9 (3.8), (CI 1.00,2.61), p

erd

Moxness and Nordgrd BMC Ear, Nose and Throat Disorders 2014, 14:11 Page 4 of 5http://www.biomedcentral.com/1472-6815/14/11Figure 1 The self-reported improvement of sleep quality after surgThe values for septoplasty in blue (left) and the values for septoplasty anstudies represent no exception [9,10,12,14,15]. If wehad presented the results pooled as a single studygroup, without a comparison of the two different surgi-cal approaches, we would have missed the statisticallysignificant improvement in patients with combined sur-gical treatment. Assessments of the overall effect ofnasal surgery on OSA predict that 16.7% will have a re-duction in AHI [10] that meets the criteria by Sher[8,9]. In this observational study, we singled out twodifferent intranasal surgical procedures for comparisonand found that there were statistical differences in theoutcome of AHI between septoplasty alone and septo-plasty combined with volume reductive surgery in OSApatients. Using the same Sher criteria, we found a neartwofold increase in treatment success in the combinedsurgery group compared with the septoplasty group.This difference did not reach statistical significance butit is possible that it would do so in a larger study groupas the difference in AHI reduction was significant. Onemight anticipate that the better effect on OSA might bedue to a larger effect on nasal obstruction in patients inneed of combined surgery. It is also possible that theadditional inferior turbinate hypertrophy affected thelaminar airflow and pharyngeal walls negatively to ahigher degree, and hence this group achieved a betterresult after surgery. Li et al [13] found that patients witha low Friedman tongue position had better results fromy. The improvement (VAS sleep) described as mild, moderate or good.volumereduction of the inferior turbinates in green (right).nasal surgery and Morinaga et al reported less effect inpatients with a narrow retroglossal space and highMallampati score. It may indicate that the increased con-tribution of pharyngeal structures to OSA will worsen thefinal results as the percentage of the nasal obstruction isdiminished. On the other hand, it may also indicate thatthe effect of surgery was better for patients with concomi-tant increased volume of the turbinates and septal devi-ation because the total contribution of the nasalobstruction to OSA development may have been greaterthan in patients with septal deviation alone.In this observational study, there are some limitations

that should be taken into consideration. The number ofpatients in group 2 is low and could represent a statis-tical uncertainty. There is a higher night-to-night sleeppolygraph variation regarding AHI in mild or moderatesleep apnea than in severe apnea that may influencethe results on an individual basis [16]. This might sug-gest that a follow-up study should be performed in pa-tients for whom there is a discrepancy betweensubjective and objective results. Furthermore, there is alack of objective measuring of nasal obstruction in anoutpatient setting that would otherwise help the sur-geon in deciding which type of surgery to perform. Ourstudy is an observational cohort study, and the patientswere therefore not randomized to specific treatmentgroups. As a result, we cannot conclude that combined

Neck Surgery, St Olav University Hospital, Trondheim, Norway. 3The Instituteof Neuroscience, The Norwegian University of Science and Technology

Moxness and Nordgrd BMC Ear, Nose and Throat Disorders 2014, 14:11 Page 5 of 5http://www.biomedcentral.com/1472-6815/14/11surgery is better than septoplasty alone in all patientswith clinical indications for septal surgery. There mayalso be possible side effects of supplementing volumereductive surgery in all OSA patients with septal de-formities, and this approach should be avoided. How-ever, the results for OSA in our material seemed to bebetter when both turbinate hypertrophy and septal de-viation were treated. Even though combined surgerydoes not imply a cure for the majority of the patients,there was a reduction of symptoms, verified by thequestionnaire, which indicates that 80% perceived animprovement in their quality of sleep after the com-bined surgery. This study then supports the view thatan effect on daytime sleepiness is observed more oftenthan on obstructive apnea and hence that nasal surgeryalone is best suited for patients with mild or moderateobstructive sleep apnea. As long as we do not have anysingle treatment that provides a cure for OSA and notall patients with mild and moderate OSA will accept ortolerate CPAP or oral devices, there will be a place fortargeted surgical treatments that improve QOL in thesepatients.

ConclusionIn this observational cohort study, the effect on AHIwas significantly better when indication for septoplastycombined with surgery of the inferior turbinates waspresent, compared to septoplasty alone. The overall ef-fect in both groups pooled together showed no signifi-cant effect on reduction of the objective parameters buta significant reduction in the subjective ESS score. Thisimplies that intranasal surgery has a good effect on thesubjective quality of sleep in OSA patients, and thatthere might be an added effect on AHI in selected pa-tients with both septal deviation and hypertrophy of theinferior turbinates. Future randomized and prospectivestudies that can identify responders to nasal surgery aswell as what type of intranasal surgery needed.

Competing interestsThe authors declare that they have no competing interests, neitherfinancially nor non-financially.

Authors contributionsMM performed the surgery, collected the sleep related perameters, analyseddata and contributed in writing the manuscript. SN contributed to design,analysed and interpreted data, contributed in writing the manuscript, andreviewed the final version. Both authors read and approved the finalmanuscript.

AcknowledgementsPart of the work was funded by Unimed Innovation AS, St Olav UniversityHospital, Trondheim, Norway and Center for Endoscopic Nasal and Sinussurgery, Aleris Hospital Trondheim, Norway.The authors want to thank Margaret Forbes as language editor.Author details1Center for Endoscopic Nasal and Sinus surgery, Aleris Hospital Trondheim,Trondheim, Norway. 2The department of Otorhinolaryngology, Head and(NTNU), Trondheim, Norway. 4Post: Department of Neuroscience, NTNU, TheMedical Faculty, N-7489 Trondheim, Norway.

Received: 17 March 2014 Accepted: 13 October 2014Published: 21 October 2014

References1. Mullington JM, Haack M, Toth M, Serrador J, Meier-Ewert H: Cardiovascular,

inflammatory and metabolic consequences of sleep deprivation.Prog Cardiovasc Dis 2009, 51(4):294302.

2. Longobardo GS, Evangelisti CJ, Cherniack NS: Analysis of the interplaybetween neurochemical control of respiration and upper airwaymechanics producing upper airway obstruction during sleep in humans.Exp Physiol 2008, 93(2):271287.

3. Van Hirtum A, Pelorson X, Lagre PY: In vitro validation of some flowassumptions for the prediction of the pressure distribution duringobstructive sleep apnea. Med Biol Eng Comput 2005, 43(1):162171.

4. Powell NB: Contemporary surgery for obstructive sleep apnea syndrome.Clin Exp Otorhinolaryngol 2009, 2(3):107114.

5. Li H, Lin Y, Chen N, Lee L, Fang T, Wang P: Improvement in quality of life afternasal surgery alone for patients with obstructive sleep apnea and nasalobstruction. Arch Otolaryngol Head and Neck Surg 2008, 134(4):429433.

6. Georgolas C: The role of the nose in snoring and obstructive sleepapnoea: an update. Eur Arch Otorhinolaryngol 2011, 268(9):13651373.

7. Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, Cohen N, Cervin A,Douglas R, Gevaert P, Georgalas C, Goossens H, Harvey R, Hellings P, Hopkins C,Jones N, Joos G, Kalogjera L, Kern B, Kowalski M, Price D, Riechelmann H,Schlosser R, Senior B, Thomas M, Toskala E, Voegels R, Wang de Y, Wormald PJ:EPOS 2012: European postion paper on rhinosinusitis and nasal polyps2012. A summary for otorhinolaryngologists. Rhinology 2012, 50(1):112.

8. Sher AE, Schechtman KB, Piccirillo JF: The efficacy of surgical modificationsof the upper airway in adults with obstructive sleep apnea syndrome.Sleep 1996, 19(2):156177.

9. Verse T, Maurer JT, Pirsig W: Effect of nasal surgery on sleep-relatedbreathing disorders. Laryngoscope 2002, 112(1):6468.

10. Koutserelakis I, Georgoulopoulos G, Perraki E, Vagiakis E, Roussos C,Zakynthinos SG: Randomised trial of nasal surgery for fixed nasalobstruction in obstructive sleep apnea. Eur Respir J 2008, 31(1):110117.

11. Li HY, Wang PC, Chen YP, Lee LA, Fang TJ, Lin HC: Critical appraisal andmeta-analysis of nasal surgery for obstructive sleep apnea. Am J RhinolAllergy 2011, 25(1):4549.

12. Kim ST, Choi JH, Jeon HG, Cha HE, Kim DY, Chung YS: Polysomnographiceffects of nasal surgery for snoring and obstructive sleep apnea.Acta Otolaryngol 2004, 124:297300.

13. Li HY, Lee LA, Wang PC, Fang TJ, Chen NH: Can nasal surgery improveobstructive sleep apnea: Subjective or objective? Am J Rhinol Allergy 2009,23:e51e55.

14. 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, 122:7174.

15. Morinaga M, Nakata S, Yasuma F, Noda A, Yagi H, Tagaya M, Suqiura M,Teranishi M, Nakashima T: Pharyngeal morphology: A determinant ofsuccessful nasal surgery for sleep apnea. Laryngoscope 2009, 119:10111016.

16. Rollheim J, Tvinnereim M, Sitek J, Osnes T: Repeatibility of sites of sleep-induced upper airway obstruction. A 2-night study based on recordings ofairway pressure and flow. Eur Arch Otorhinolaryngol 2001, 258(5):259264.

doi:10.1186/1472-6815-14-11Cite this article as: Moxness and Nordgrd: An observational cohortstudy of the effects of septoplasty with or without inferior turbinatereduction in patients with obstructive sleep apnea. BMC Ear, Nose andThroat Disorders 2014 14:11.

AbstractBackgroundMethodsResultsConclusion

BackgroundMethodsResultsDiscussionConclusionCompeting interestsAuthors contributionsAcknowledgementsAuthor detailsReferences

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