Sinonasal Characteristics in Patients with Obstructive Sleep Apnea Compared to Healthy Controls

Background. The difference in nasal obstruction between OSA patients and healthy individuals is not adequately documented. Our aim was to describe the sinonasal quality of life and nasal function in OSA patients and healthy controls using the sinonasal outcome test-20 (SNOT-20), nasal obstruction visual analog scale (NO-VAS), and peak nasal inspiratory flow (PNIF). Methodology and Principal. Ninety-three OSA patients and 92 controls were included in a case-control study from 2010 to 2015. Results. Mean SNOT-20 score in the OSA group was 1.69 (SD 0.84) compared to 0.55 (SD 0.69) in controls (p<0.001, 95% CI [0.9, 1.4]). The mean NO-VAS score was 41.3 (SD 12.8) and 14.7 (SD 14.4) in the OSA group and controls, respectively, (p<0.001, 95% CI [22.7, 30.6]). PNIF measured 105 litres/minute in the OSA group and 117 litres/minute in controls (p<0.01, 95% CI [−21.8, −3.71]). There was a positive correlation between subjective nasal obstruction and change in PNIF after decongestion in the control group alone. Conclusions. OSA patients have a reduced sinonasal QoL and lower peak nasal inspiratory flow compared to controls. Treatment of nasal obstruction in OSA patients should be made a priority along with treatment of the ailment itself

The Influence of the Nasal Airway in Obstructive Sleep Apnea

Norsk sammendrag - Patogenesen til obstruktivt søvnapne syndrom (OSA) ser ut til å være multifaktoriell men de anatomiske og nevroregulatoriske mekanismene som er involvert i sammenfall av de øvre luftveier under søvn er ikke tilstrekkelig definert. Den viktigste passasjen for luft fra omgivelsene til pharynx går via nesekaviteten, og dens rolle i utviklingen av søvnapne syndromet er ikke forstått, selv om dens betydning har vært gjenstand for debatt over flere tiår. Nesekaviteten er et komplekst anatomisk område med en enda mer kompleks fysiologi. I tillegg til de rent fysiologiske responsene som normal neseventilasjon fører med seg, vil nesens hulrom og dynamiske slimhinne påvirke både hastigheten til luftstrømmen og luftveistrykket før luften når bløtdelene i halsen. I dette området vil det oppstå en gjensidig interaksjon mellom luftstrømmen og veggene i luftveiene som innen strømningsfysikk kalles” Fluid Structure Interaction”. Gjennom sannsynligvis multiple reguleringsmekanismer vil denne prosessen etterhvert lede til de sammenfall av luftveiene som karakteriserer OSA. Når man undersøker og behandler pasienter med OSA opplever man ofte tilbakevendende klager på nesetetthet i pasientgruppen. Kontinuerlig overtrykksbehandling der man benytter et relativt lavt positivt luftveistrykk via en nesemaske eller hel ansiktsmaske (CPAP) er førstevalget ved behandling av sykdommen. Bruk av slik maske krever en funksjonell nesekavitet for å ha adekvat effekt. Når dette ikke er tilfelle, kan OSA pasienter bli tilbudt behandling av nesetettheten, enten medisinsk, kirurgisk eller en kombinasjon av begge. Nesekirurgi kan være en effektiv måte å behandle nesetetthet på og ved korrekt utførte prosedyrer ser man en reduksjon av resistansen i nesekaviteten. Dette har stor betydning fordi OSA pasientene tolererer maskebruken bedre og behandlingseffekten øker. Hos enkelte pasienter kan man i tillegg se at intranasale endringer etter kirurgi er assosiert med endringer i både de subjektive OSA symptomene og i mindre grad med endringer i de objektive OSA parametrene. Dette leder oss til å anta at hos enkelte kan nesekirurgi alene endre visse predisponerende faktorer som er nødvendig for sykdomsutviklingen. I denne Phd tesen undersøkes effekten av å kombinere to spesifikke intranasale kirurgiske prosedyrer hos OSA pasienter, forskjeller i objektive mål av nesekavitetens volum, minste tverrsnittsareal, luftstrøm i nesen samt nese- og bihulerelatert livskvalitet mellom OSA pasienter og friske kontroller. Tesen er del av et samarbeid mellom det medisinske fakultet og fakultet for ingeniørvitenskap ved NTNU samt Sintef industri, og springer ut fra et pågående interdisiplinært samarbeidsprosjekt kalt "Modelling of Obstructive Sleep Apnea by Fluid-Structure Interaction in the Upper Airways". I dette prosjektet undersøkes biomekaniske egenskaper i bløtvevet samt de strømningsfysiske egenskapene i de øvre luftveier hos OSA pasienter. Som et foreløpig resultat av dette samarbeidet inneholder denne tesen også en beskrivelse av en computerbasert matematisk modell (Finite element modell – FE modell) der biomekaniske egenskaper i den bløte gane hos seks OSA pasienter som får utført intranasal kirurgi undersøkes. Hovedkonklusjonen i denne tesen er at OSA pasienter har mindre tverrsnittsareal og volum især i fremre til midtre del av nesekaviteten og luftstrømmen som når bløtvevet i pharynx vil i det minste til en viss grad påvirkes av endringer i dette området. OSA pasienter har redusert evne til forsert inspirasjon av luftstrømmen gjennom nesekaviteten samt redusert nese- og bihulerelatert livskvalitet. Disse forholdene bør vurderes i utredningen og gjenspeiles i behandlingen av pasientene. Artikkel 1 er en retrospektiv observasjonsstudie av 59 pasienter med verifisert OSA diagnose og nasalstenose som enten fikk utført septumplastikk alene (n=33) eller septumplastikk kombinert med volumreduserende kirurgi av nedre nesemuslinger (n=26). Vi fant en signifikant reduksjon i AHI i gruppen som fikk kombinert kirurgi hvilket antyder en tilleggseffekt av volumreduserende kirurgi i nesekaviteten hos OSA pasienter. I artikkel 2 sammenlignes nesekavitetens geometri og funksjon mellom 93 OSA pasienter og 92 friske kontroll individer som ble inkludert over en seks års periode. Minste tverrsnittsareal og nesekavitetens volum ble målt, i tillegg til høyeste forserte inspiratoriske luftstrøm (PNIF) i begge grupper. Vi fant et lavere tverrsnittsareal, lavere nesevolum og lavere PNIF blant OSA pasienter sammenlignet med kontrollene. Artikkel 3 bygger på artikkel 2 og her utvides undersøkelsene med pasientrelaterte utfall. Artikkelen beskriver sinonasal livskvalitet, symptomer og inspiratorisk funksjon hos 93 OSA pasienter og 92 kontroll individer ved bruk av en visuell analog skala for nesetetthet (NO-VAS) og en sinonasal utfallstest (SNOT-20) samt PNIF. Den pasient rapporterte nesetettheten var økt i OSA gruppen, og sinonasal livskvalitet var redusert hos OSA pasienter sammenlignet med kontrollene. En positiv korrelasjon mellom endring i PNIF og subjektiv nesetetthet ble observert i kontrollgruppen alene. Artikkel 4 er et resultat av samarbeidet med institutt for konstruksjonsteknikk ved NTNU og beskriver biomekaniske egenskaper i velopharynx hos seks OSA pasienter med nesetetthet som gjennomgår intranasal kirurgi. Tilgjengelig kommersielt software (Mimics, Abaqus) ble benyttet til å simulere effekten av forskyvning av den bløte gane, lukningstrykket i velopharynx og deformasjonen i bløtvevet. Med denne computerbaserte FE modelleringen kunne vi postulere en korrelasjon mellom anatomien i den bløte gane, OSA parametre og simulert lukningstrykk, samt en lineær korrelasjon mellom deformasjon av den bløte gane og simulert lukningstrykk. Vi fant ingen korrelasjon mellom simulert lukningstrykk og OSA parametre før eller etter intranasal kirurgi. Metoden kan være av betydning i persontilpasset OSA kirurgi, samt i den postoperative evalueringen av resultatene etter luftveiskirurgi i denne pasientgruppen

An observational cohort study of the effects of septoplasty with or without inferior turbinate reduction in patients with obstructive sleep apnea.

Background The objective of this observational study was to evaluate the outcomes of intranasal surgery in patients with obstructive sleep apnea (OSA) in a single institution in Norway. Methods Fifty-nine patients with OSA and clinically significant nasal obstruction underwent either septoplasty alone or septoplasty with concomitant volume reduction of the turbinates from August 2008 until the end of December 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 surgical procedures on sleep related parameters. Results There was a significant reduction in the apnea-hypopnea index (AHI) only in the group that had septoplasty with turbinate reduction (17.4, (SD 14.4) – 11.7, (SD 8.2), p <0.01), and this effect was significantly better than in the group treated with septoplasty alone. Other objective parameters remained unchanged. Subjective assessments obtained with a postoperative questionnaire showed an equally positive effect on diurnal sleepiness and nasal obstruction in both groups, and a better effect on sleep quality in the combined treatment group. Conclusion The effect of nasal surgery on obstructive sleep apnea seemed to be greater when there were indications for combined surgery of the inferior turbinates and the nasal septum, compared to when there were indications for septoplasty alone

Sinonasal Characteristics in Patients with Obstructive Sleep Apnea Compared to Healthy Controls

Background. The difference in nasal obstruction between OSA patients and healthy individuals is not adequately documented. Our aim was to describe the sinonasal quality of life and nasal function in OSA patients and healthy controls using the sinonasal outcome test-20 (SNOT-20), nasal obstruction visual analog scale (NO-VAS), and peak nasal inspiratory flow (PNIF). Methodology and Principal. Ninety-three OSA patients and 92 controls were included in a case-control study from 2010 to 2015. Results. Mean SNOT-20 score in the OSA group was 1.69 (SD 0.84) compared to 0.55 (SD 0.69) in controls (p <0.001, 95% CI [0.9, 1.4]). The mean NO-VAS score was 41.3 (SD 12.8) and 14.7 (SD 14.4) in the OSA group and controls, respectively, (p < 0.001, 95% CI [22.7, 30.6]). PNIF measured 105 litres/minute in the OSA group and 117 litres/minute in controls (p < 0.01, 95% CI [−21.8, −3.71]). There was a positive correlation between subjective nasal obstruction and change in PNIF after decongestion in the control group alone. Conclusions. OSA patients have a reduced sinonasal QoL and lower peak nasal inspiratory flow compared to controls. Treatment of nasal obstruction in OSA patients should be made a priority along with treatment of the ailment itself

Palatal implant surgery effectiveness in treatment of obstructive sleep apnea: a numerical method with 3D patient-specific geometries

Obstructive sleep apnea (OSA) affects a large percentage of the population and is increasingly recognized as a major global health problem. One surgical procedure for OSA is to implant polyethylene (PET) material into the soft palate, but its efficacy remains to be discussed. In this study, we provide input to this topic based on numerical simulations. Three 3 dimensional (3D) soft palate finite element models including mouth-close and mouth-open cases were created based on three patient-specific computed tomography (CT) images. A simplified material modeling approach with the Neo-Hookean material model was applied, and nonlinear geometry was accounted for. Young’s modulus for the implant material was obtained from uniaxial tests, and the PET implant pillars were inserted to the 3D soft palate model. With the finite element model, we designed different surgical schemes and investigated their efficacy with respect to avoiding the soft palate collapse. Several pillar schemes were tested, including different placement directions, different placement positions, different settings for the radius and the array parameters of the implant pillars, and different Young’s moduli for the pillars. Based on our simulation results, the longitudinal-direction implant surgery improved the stiffness of the soft palate to a small degree, and implanting in the transverse direction was evaluated to be a good choice for improving the existing surgical scheme. In addition, the Young’s modulus of the polyethylene material implants has an influence on the reinforcement efficacy of the soft palate.acceptedVersion© 2017. This is the authors’ accepted and refereed manuscript to the article. This manuscript version is made available under the CC-BY-NC-ND 4.0 license http://creativecommons.org/licenses/by-nc-nd/4.0

A pilot study of scoring individual sleep apnea events using non-contact radar technology, pulse oximetry and machine learning (Somnofy®)

The gold standard for assessing sleep apnea, polysomnography, is resource intensive and inconvenient. Thus, several simpler alternatives have been proposed. However, validations of these alternatives have focused primarily on estimating the apnea-hypopnea index (apnea events per hour of sleep), which means information, clearly important from a physiological point of view such as apnea type, apnea duration, and temporal distribution of events, is lost. The purpose of the present study was to investigate if this information could also be provided with the combination of radar technology and pulse oximetry by classifying sleep apnea events on a second-by-second basis. Fourteen patients referred to home sleep apnea testing by their medical doctor were enrolled in the study (6 controls and 8 patients with sleep apnea; 4 mild, 2 moderate, and 2 severe) and monitored by Somnofy (radar-based sleep monitor) in parallel with respiratory polygraphy. A neural network was trained on data from Somnofy and pulse oximetry against the polygraphy scorings using leave-one-subject-out cross-validation. Cohen’s kappa for second-by-second classifications of no event/event was 0.81, or almost perfect agreement. For classifying no event/hypopnea/apnea and no event/hypopnea/obstructive apnea/central apnea/mixed apnea, Cohen’s kappa was 0.43 (moderate agreement) and 0.36 (fair agreement), respectively. The Bland-Altman 95% limits of agreement for the respiratory event index (apnea events per hour of recording) were -8.25 and 7.47, and all participants were correctly classified in terms of sleep apnea severity. Furthermore, the results showed that the combination of radar and pulse oximetry could be more accurate than the two technologies separately. Overall, the results indicate that radar technology and pulse oximetry could reliably provide information on a second-by-second basis for no event/event which could be valuable for management of sleep apnea. To be clinically useful, a larger study is necessary to validate the algorithm on a general population

Quality of life and symptoms before and after nasal septoplasty compared with healthy individuals

Abstract Background The goal of this study is to compare quality of life (Qol) and symptoms in 91 patients with a deviated nasal septum preoperatively and postoperatively with a control group of 93 healthy individuals. Methods All patients reported Qol on Sino-Nasal-Outcome-Test-20 (SNOT-20) and symptoms on visual analogue scale (VAS) preoperatively and 6 months after surgery and the results were compared with the controls. Results Mean SNOT-20 score improved from 1.8(SD0.9) preoperatively to 0.9(SD0.8) postoperatively (p < 0.000) but did not reach the same level as the controls 0.4(SD0.5). Septum surgery leads to a significant symptom improvement for all symptoms investigated (p < 0.000) on VAS. The patients reached the same level as the healthy controls in 6 of 11 symptoms (headache, facial pain, sneezing, trouble with rhinosinusitis, cough and snoring) but the patients group had significantly more trouble with nasal blockage (VAS 29 vs 9), change in sense of smell (VAS 12 vs5), nasal discharge (VAS 22 vs 11), oral breathing (VAS 23 vs 13) and reduced general health (VAS 12 vs 5) also postoperatively (p < 0.01). Sub analyses showed that allergic patients reported a VAS score of 36 (SD30) for nasal blockage and 17 (SD22) for facial pressure postoperatively versus 23(SD22) and 6(SD13) in non-allergic patients (p < 0.03 and p < 0.01). Patients with obstructive sleep apnea syndrome (OSAS) reported more trouble with snoring on VAS postoperatively than other patients, 42(SD28) versus 20(SD23) (p < 0.002). Conclusion Septoplasty leads to a highly significant improvement in Qol and symptoms. The patients do not reach the same level of Qol as healthy controls. All symptoms are reported as mild on VAS postoperatively. Allergic patients tend to report more nasal blockage and facial pressure postoperatively than other patients and a focus on medical treatment should be kept also postoperatively. Patients with obstructive sleep apnea report more trouble with snoring postoperatively and alterative treatment options for snoring may be considered in these patients