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Article #82

SUMMARY     Nasal obstruction may contribute to sleep apnea. Several pathologica conditions giving rise to nasal obstruction often require surgical treatment: septal deformities, nasal polyps, choanal atresia (congenitally failed development of the opening from one of the nasal cavities into the nasal pharynx), inferior turbanate hypertrophy, and sinusitis.     The subjects were 50 adults with OSA who underwent surgery for nasal obstruction in the 12 months between 7/1/97 and 6/30/98. They included 41 men and 9 women, aged 20 to 71 years, of whom 16 had mild, 14 moderate, and 20 severe OSA. Their average Body Mass Index was increased (35). CPAP titration was also performed on 22 of these patients, included 13 of those with severe OSA.     Causes of nasal obstruction included septal deviation and/or inferior turbinate hypertrophy. Patients with sinusitis or other chronic diseases were excluded from the study. All had submucous resection of the septum with or without submucous resection of the bilateral inferior turbinates. They received polysomnography before surgery and at least six months after surgery.     After surgery, all but one patient reported improved nasal breathing, though only 34% noticed a decrease in snoring. Before surgery, 47 had complained of decreased energy; after surgery, 39 noticed improved energy. BMI did not change after surgery.     In contrast, the Respiratory Distress Index increased (though nonsignificantly) from 32/hr before surgery to 40/hr after surgery. The category of OSA severity did not change; however, patients with mild OSA prior to surgery showed a significant increase in RDI after surgery (from 9/hr to 19/hr). At the same time, CPAP pressures, applicable mostly to those with severe OSA, decreased significantly after surgery, from 9 to 7 cm H2O.     The authors considered their study an advance over prior reports in that it included results of polysomnography both before and after surgery. Their results showed improvement mainly on subjective self-report measures of improved nasal breathing, decreased snoring, and increased energy after surgery. The only objective polysomnographic finding indicative improvement was that of reduced CPAP pressures after surgery in the group of more severely ill OSA patients. Other PSG results suggested worsening of OSA, especially in those with milder illness.     The authors suggested some explanations for these negative findings in terms of the deeper sleep experienced after surgery resulting in greater muscle relaxation and therefore greater airway collapse. Also, repeated testing might have resulted in progressively deeper sleep. Although they acknowledged that "CPAP is the recommended treatment for OSA," they also asserted that "most patients do not comply with the CPAP treatment," leading to the necessity of surgical intervention. They noted that decreased CPAP pressures after surgery might make CPAP more tolerable.

Since the authors, writing from a surgical perspective, have portrayed their data, basically adverse to their treatment, in a fairly open, honest way, it is difficult to add my own criticisms. Nevertheless, I must do so.     The fact that only subjective reports supported effectiveness of the surgical procedures, and that only several weeks after surgery, suggests to me that the positive results may reflect effects of suggestion (placebo effects) and the implicit demand to report good results to treaters. Where objective evidence from polysomnography fails to support such subjective findings, suspicion increases.     Although I believe I understand their hypothesis that deepened sleep after surgery results in increases of RDI, I find this hard to believe, all the more since they present no evidence that sleep had in fact deepened (such as percentage of slow wave sleep).     Their admission that CPAP is the recommended treatment for OSA but that "most" patients don't comply with CPAP, includes a falsehood. It is a minority, though a major one, that fails to comply. Moreover, surgeons typically accept all too readily complaints about CPAP from patients, and one suspects that where nonsurgical sleep specialists would work hard to lessen adverse effects and sustain compliance, surgeons may simply advise surgery at the least complaint, in effect supporting the problem of CPAP noncompliance.     Of special concern here is the authors' finding that some OSA patients actually showed worsened OSA after surgery, a problem that comes up repeatedly, with varied explanations, the more convincing ones couched in terms of multiple sites of obstruction. Nevertheless, I must accept that obstructed nasal breathing is a problem in and of itself, for which surgery may well be indicated, regardless of the poorly-supported therapeutic effects on concurrent OSA.

"Everyone who is born holds dual citizenship, in the kingdom of the well and in the kingdom of the sick... Illness is the night-side of life, a more onerous citizenship." Susan Sontag

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