CLINICAL NOTE

Impact of Endoscopic Sinus Surgery on Sleep Quality

in Patients With Chronic Nasal Obstruction
Due to Nasal Polyposis
Fuat Tosun, MD,* Kismet Kemikli, MD,* Sinan Yetkin, MD,Þ Fuat Ozgen, MD,Þ
Abdullah Durmaz, MD,* and Mustafa Gerek, MD*

resistance caused by nasal obstruction results in greater pressure

Objective: The aim of this study was to investigate the effect of gradient in the upper airway. Snoring, obstructive sleep apnea, and
endoscopic sinus surgery on sleep quality in a patient group who has other sleep-related breathing disorders occur in response to pressure
chronic nasal obstruction resulting from nasal polyposis. gradient and turbulent airflow. Nasal polyposis is a common cause
Methods: Twenty-seven patients with nasal polyposis, filling at of nasal obstruction, and snoring is a usual symptom in these
least 50% of each nasal passage, were enrolled in the study. patients.1 Patients with nasal polyposis have higher ratios of sleep
Assessment of nasal patency was determined by nasal endoscopy disturbances.2
and acoustic rhinometry. All patients underwent endoscopic sinus Improvement of sleep-related breathing disorders after nasal
surgery with polypectomy. Sleep quality was evaluated, using visual surgeries has been reported in several studies.3Y6 However, etiologic
factors of nasal obstruction in these studies are heterogeneous,
analog scale, Epworth sleepiness scale, and polysomnography
including nasal septum deviation, inferior turbinate hypertrophy,
before and 3 months after the surgery. nasal vault deformities, and nasal polyposis. As a result, it is
Results: Nasal resistance decreased significantly after the surgery impossible to standardize the ratio of nasal obstruction and is
(P G 0.01). Snoring scores were significantly improved postopera- difficult to assess precisely the impact of nasal surgery on sleep
tively (P G 0.01) and completely disappeared in 9 of 27 patients. A quality. In the current study, we aimed to evaluate the impact of
significant improvement occurred in mean daytime sleepiness scores endoscopic sinus surgery with polypectomy on sleep-related
in the postoperative period (4.14) as compared with the preoperative breathing disorders objectively in a patient group who has nasal
values (9.44; P G 0.01). There was no significant difference between obstruction resulting from nasal polyposis.
preoperative (6.85) and postoperative (5.53) mean values of apnea-
hypopnea index (P = 0.55). MATERIALS AND METHODS
Conclusions: Endoscopic sinus surgery with polypectomy signifi- This study was conducted at our tertiary referral hospital
cantly improves sleep quality, including snoring and daytime between 2005 and 2007. Patients who had the complaint of chronic
nasal obstruction caused by nasal polyposis and met the inclusion
sleepiness in patients with chronic nasal obstruction due to nasal
criteria mentioned later were randomly selected for the study. All
polyposis. However, it has a limited benefit on apnea-hypopnea patients were informed about the procedure, and they gave a written
index scores. consent form for going examination in the rhinology laboratory and
Key Words: Snoring, obstructive sleep apnea, nasal obstruction, sleep research center. Our institutional review board approved the
study. The study was carried out according to the principles of
endoscopy, surgery
Declaration of Helsinki. At first, the nasal passages were examined
(J Craniofac Surg 2009;20: 446Y449) by conventional anterior rhinoscopy and nasal endoscopy. The
patients who had chronic nasal obstruction for more than 6 months
and had at least 50% of obstruction of each nasal passage due to
nasal polyposis on endoscopic examination were included in the
N asal breathing is the physiological route of respiration. It is also
important to maintain the respiratory rhythm during sleep. The
closed jaw stabilizes the upper respiratory airway. During sleep, oral
study. Medical history for sleep-related breathing disorders was
taken. Patients with maxillofacial deformity, central sleep apnea, and
other primary sleep disorders (insomnia, periodic limb movement,
breathing is unstable because of altered mechanical situation. restless legs, parasomnias, and narcolepsy), systemic diseases
Negative intrathoracic pressure during inspiration generates a associated with sleep apnea, had body mass indexes of more than
negative pressure gradient across the upper airway. Increased nasal 27.3 kg/m2 in women and 27.8 kg/m2 in men, and those who were
put into Mallampati classifications 3 and 4 were excluded from
From the Departments of *Otorhinolaryngology Head and Neck Surgery, the study. Severity of snoring was determined by visual analog
and †Psychiatry, Gulhane Military Medical School, Ankara, Turkey. scale (VAS), graded 0 to 10 preoperatively. Nasal patency was mea-
Received October 11, 2008. sured with Eccovision Acoustic Rhinometer (Hood Laboratories,
Accepted for publication December 7, 2008. Pembroke, MA). Cross-sectional area 2 (CSA2), total nasal volume,
Address correspondence and reprint requests to Fuat Tosun, MD, Department
and nasal resistance were recorded to determine the severity of nasal
of Otorhinolaryngology Head and Neck Surgery, Gulhane Military
Medical Academy, Etlik 06018, Ankara, Turkey; E-mail: fuattosun@ obstruction objectively.
yahoo.com All patients underwent a 1-night sleep study at a sleep research
Copyright * 2009 by Mutaz B. Habal, MD center. Sleep parameters were recorded on a 32-channel polygraph
ISSN: 1049-2275 (Somno Star Alpha Series 4, Sensor Media Corporation, Yorba
DOI: 10.1097/SCS.0b013e31819b97ef Linda, CA). In the sleep studies, standard recording parameters,

446 The Journal of Craniofacial Surgery & Volume 20, Number 2, March 2009

Copyright @ 2009 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery & Volume 20, Number 2, March 2009 Impact of Endoscopic Sinus Surgery

including electroencephalogram (C3, C4, O1, and O2), electroocu- Mean VAS score for snoring improved significantly after the
logram, submental electromyogram, and electrocardiogram, were surgery (preoperatively, 6.40 and postoperatively, 1.77; P G 0.01).
used. Oronasal airflow, respiratory effort, finger pulse oximetry, and All of the 27 patients were snorers preoperatively. Snoring com-
the tibialis muscle activity were measured for screening sleep-related pletely disappeared in 9 patients (33%), and satisfactory improve-
breathing disorders. Excessive daytime sleepiness was measured ment was told by 18 patients (67%) in the postoperative period.
using the Epworth sleepiness scale (ESS). All patients underwent Mean value of excessive daytime sleepiness, measured by ESS,
endoscopic sinus surgery for the removal of nasal polyps and for the decreased significantly (P G 0.01) in the postoperative period (pre-
treatment of chronic sinusitis. All of the preoperative examinations operatively, 9.44 and postoperatively, 4.14). A number of patients
and the measurements including VAS scoring for snoring, ESS having ESS scores more than 10 were 14 before the surgery and was
scoring, nasal endoscopy, acoustic rhinometry, and polysomnogra- 1 postoperatively. Mean apnea-hypopnea index (AHI) score did not
phy were repeated 3 months after the surgery. change significantly in the postoperative period (5.53) as compared
SPSS version 15.0 for Windows (SPSS, Inc, Chicago, IL) was with the preoperative mean value (6.68; P = 0.55). Apnea-hypopnea
used for statistical analysis. Statistical significance of the findings index scores decreased in 11 patients, increased 11 patients, and did
was evaluated using the paired Student’s t-test for parametric data not change in 5 patients in the postoperative period, and there was no
and Wilcoxon signed-rank test for nonparametric data. A P = 0.05 significant difference between these 3 groups of patients by means of
was considered statistically significant. patients’ ages (P = 0.105; range, 27Y70 y and mean, 47.6364 y for
the first group; range, 20Y53 y and mean, 38.6364 y for the second
RESULTS group; and range, 21Y50 y and mean, 31.6000 y for the third group).
Twenty-seven patients, 22 men and 5 women, aged between There were no significant differences between preoperative and
20 and 70 years (mean [SD], 40.37 [14. 48] y) were included in the postoperative mean values of peripheral oxygen saturation, number
study. Body mass indexes of the patients were between 22.04 and of arousals, percentage of sleep stages, and rapid eye movement
26.80 kg/m2 (23.87 [1.31] kg/m2). Ratios of nasal obstruction due (REM) stage (Table 2).
to nasal polyposis were 50%:75% in 20 patients and 75%:100% in
7 patients in the right nasal passage, and 50%:75% in 8 patients DISCUSSION
and 75%:100% in 19 patients in the left nasal passage on diagnostic Nasal obstruction is widely mentioned among the risk factors
endoscopy. Patients’data were summarized on Tables 1 and 2. Mean of sleep-related breathing disorders. In a study of Udaka et al,7
total nasal volume increased significantly (P G 0.01) in the including 3442 subjects, the patients with chronic nasal obstruction
postoperative period (preoperatively, 4:01 cm3 and postoperatively, reported significantly higher ESS scores and lower quality of life
8.33cm3 in the right side; preoperatively, 4.42 cm3 and postoper- scores than control ones, and habitual snoring had an additive
atively, 9.66 cm3 in the left side). Mean nasal resistance decreased influence on these changes. Koutsourelakis et al8 found that AHI
from 24.02 to 1.99 cm H2O Lj1 minj1 in the right and from 23.85 scores inversely related with the change of nasal breathing. Serrano
to 1.75 cm H2O Lj1 minj1 in the left nasal passage in the post- et al2 reported that 50% of patients with nasal polyposis had snoring,
operative period (P G 0.01). and these patients also had a 2-fold higher risk ratio of sleep

TABLE 1. Preoperative Data of the Patients

Preoperative Measurements
No. Patients Minimum Maximum Mean SD
CSA2-right 27 0.070 1.830 0.608 0.517
CSA2-left 27 0.090 2.490 0.913 0.718
Nasal resistance-right 27 1.150 141.00 24.023 32.685
Nasal resistance-left 27 0.840 184.00 23.851 45.142
Total nasal volume-right 27 0.00 8.800 4.018 2.321
Total nasal volume-left 27 0.00 9.190 4.427 2.068
Apnea index 27 0.00 37.100 5.782 10.00
Apnea-hypopnea index 27 0.00 45.900 6.685 11.782
Sleep latency 27 0.00 76.500 13.644 16.077
Sleep stage 0, % 27 1.700 40.900 12.385 10.431
Sleep stage 1, % 27 0.00 14.300 3.211 3.080
Sleep stage 2, % 27 35.00 72.900 58.226 9.068
Sleep stage 3, % 27 0.00 19.00 6.341 4.358
Sleep stage 4, % 27 0.00 24.00 9.059 8.066
REM, % 27 1.100 19.00 10.804 4.997
ESS-score 27 9.444 4.079
Snoring score (VAS) 27 6.407 2.390
Minimum O2 saturation 15 73.00 91.00 83.133 6.653
Mean O2 saturation 15 82.00 97.00 91.400 4.837
Arousals 11 4.00 21.00 11.955 5.032

* 2009 Mutaz B. Habal, MD 447

Copyright @ 2009 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Tosun et al The Journal of Craniofacial Surgery & Volume 20, Number 2, March 2009

TABLE 2. Postoperative Data of the Patients

Comparison With
Postoperative Measurements Preoperative Values
No. Patients Minimum Maximum Mean SD z t P
CSA2-right 27 0.830 4.290 2.307 0.820 4.286 G0.01*
CSA2-left 27 1.180 8.290 3.369 1.854 4.257 G0.01*
Nasal resistance -right 27 0.600 5.930 1.991 1.381 3.914 G0.01*
Nasal resistance-left 27 0.400 3.500 1.763 0.842 4.229 G0.01*
Total nasal volume-right 27 4.900 13.400 8.338 2.366 4.286 G0.01*
Total nasal volume-left 27 5.140 26.700 9.667 4.098 4.286 G0.01*
Apnea index 27 0.00 48.700 4.986 10.641 0.671 0.502
Apnea-hypopnea index 27 0.00 49.400 5.533 10.807 0.586 0.558
Sleep latency 27 0.500 66.00 16.167 20.385 0.188 0.851
Sleep stage 0, % 27 1.00 67.600 13.611 15.063 0.063 0.949
Sleep stage 1, % 27 0.00 13.00 2.830 2.632 0.024 0.981
Sleep stage 2, % 27 21.500 73.400 57.922 11.801 0.00 1.000
Sleep stage 3, % 27 0.00 12.00 4.789 2.889 1.959 0.061
Sleep stage 4, % 27 0.00 34.800 7.904 8.513 1.050 0.294
REM, % 27 2.700 27.00 12.907 5.760 1.842 0.077
ESS-score 27 4.148 3.159 6.265 G0.01*
Snoring score (VAS) 27 1.778 1.847 8.846 G0.01*
Minimum O2 saturation 15 70.00 96.00 85.300 9.707 0.449 0.677
Mean O2 saturation 15 86.00 99.00 93.700 3.831 0.179 0.867
Arousals 11 0.00 30.00 13.667 8.467 1.309 0.321
*Statistically significant.

disturbance as compared with controls. Because the nasal route is significant improvement in sleep quality. On the other hand, the effect
preferred for respiration during wakefulness and sleepiness in of nasal surgery on AHI scores is modest. One of the most optimistic
healthy adults, it is plausible to suggest that correction of nasal results belongs to Kim et al,3 reporting that mean AHI score
obstruction may relieve sleep-related breathing disorders. Like- decreased from 39 to 29 in 21 patients who underwent septal surgery
wise, several authors report that nasal surgery produces improve- with or without inferior turbinectomy. In a worldwide literature
ment of symptoms in patients with snoring and obstructive sleep review study, Verse et al13 pointed out that success rate of nasal
apnea.3,5,9 However, in these studies, nasal pathologies causing surgery, performed for the treatment of obstructive sleep apnea,
obstruction are different, such as the deviation of the nasal septum, seems to be less than 20%. Friedman et al6 reported no significant
the nasal vault deformities, or the inferior turbinate hypertrophies, change of respiratory disturbance index after improvement of the
so it is difficult to make precise comparison between the increment nasal airway with nasal surgery in 50 patients. Postoperative mean
of nasal patency after nasal surgery and the improvement of sleep- AHI did not change significantly as compared with preoperative
related breathing disorders. values in our 27 patients with nasal polyposis (P = 0.55). Surgical
On the contrary, several studies reported no improvement of improvement of nasal airway alone cannot improve AHI scores
sleep-related breathing disorders after nasal surgeries.10,11 More- significantly, but it relieves some of the symptoms of obstructive
over, Verse et al12 reported that AHI and excessive daytime sleepiness sleep apnea and may be used as a contributor to the other surgical
increased and relative duration of REM sleep decreased after intervention for the treatment of these patients.
endoscopic sinus surgery in 2 patients with nasal polyposis. The Correction of chronic nasal obstruction decreases negative
findings of these studies indicate that argument about the effect of pressure in the nasopharynx during sleep and relieves snoring by
nasal surgery on sleep quality has never ended yet. In the current preventing vibration of the uvula and the soft palate. The nasal
study, a homogenous group of patients having nasal obstruction due passage is the natural route of respiration, and patency of nasal
to only nasal polyposis, filling at least 50% of the nasal passages, airway allows a comfortable sleep. On the other hand, abnormalities
were selected for the study. Three months after the surgery, im- of every part of the upper respiratory tract, including the nasal
provement of nasal breathing was confirmed by patients’description, passages, the nasopharynx, the oropharynx, the hypopharynx, and
nasal endoscopy, and acoustic rhinometry. A significant relief was the larynx, may contribute to sleep disturbances. Nasal obstruction is
achieved in snoring (P G 0.01). Snoring completely disappeared in one of the etiologic factors mentioned previously. As a result, nasal
33% of the patients, and a satisfactory improvement was told by 67% surgery only can be a component of other treatment methods of
of the patients. A significant improvement was also obtained in ESS obstructive sleep apnea, but it alone is not sufficient to improve AHI
scores (P G 0.01). The similar relief in snoring and daytime scores significantly.
sleepiness was also reported by several authors after septoplasty Series et al14 pointed out that only the patients with normal
or turbinate surgery.3Y6,9 In considering these findings, it is possible cephalometric measurements benefitted from the nasal surgery for
to say that surgical correction of nasal obstruction provides a the treatment of obstructive sleep apnea, and they recommended

448 * 2009 Mutaz B. Habal, MD

Copyright @ 2009 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery & Volume 20, Number 2, March 2009 Impact of Endoscopic Sinus Surgery

cephalometric evaluation, including posterior airway space and the 5. Elsherif I, Hussein SN. The effect of nasal surgery on snoring.
mandibular plane to the hyoid bone distance preoperatively. In a Am J Rhinol 1998;12:77Y79
similar study consisting of 20 patients with nasal obstruction and 6. Friedman M, Tanyeri H, Lim JW, et al. Effect of improved nasal
obstructive sleep apnea, normal AHI values were achieved after breathing on obstructive sleep apnea. Otolaryngol Head Neck Surg
nasal surgery in patients with only normal cephalometric measure- 2000;122:71Y74
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daytime sleepiness and decreased quality of life even in the absence
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improvement of nasal airway helps the use of nasal continuous hospital. Ann Saudi Med 2002;22:158Y162
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* 2009 Mutaz B. Habal, MD 449

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