Can nasal surgery help CPAP therapy?

Written by David Volpi, M.D., P.C., F.A.C.S.

This month’s blog is for anyone who has obstructive sleep apnea (OSA) and is having trouble using—or refusing to use—a Continuous Positive Airway Pressure (CPAP) machine while sleeping.

CPAP machines help nighttime interrupted breathing by pumping a continuous flow of air into the nasal passages, keeping the airway open, and preventing or greatly reducing snoring and paused breathing. Still, many people are uncomfortable wearing the CPAP mask at night. Some feel claustrophobic or claim it causes dry mouth, nasal congestion and/or skin irritations.

There are two points I want to make about CPAP machines. One is: realize there are different types of masks and machines available, so take the time to choose one that’s right for you. Choose a small, quiet machine with a comfortable mask that fits you well. A heated humidifier attached to the CPAP machine can reduce throat dryness. Also, adjust titration so the CPAP pressure isn’t too high.

The second point I want to make, is that for some patients with nasal obstruction, a nasal surgery called septoplasty may help make CPAP therapy easier when combined with the above suggestions. An article in the January 2014 issue of The Laryngoscope  explains this first-of-its-kind study.

In response to the difficulty many OSA patients have using CPAP—what doctors call “problematic nonadherence”—three researchers wanted to find out if septoplasty, a surgery for nasal obstruction, would improve CPAP use and effectiveness.

For the study, head researchers Justin Poirier MD, Charles George MD, FRCPC, and Brian Rotenberg MD, MPH studied 18 patients over a six month period. Their average age was 52, 15 were males, and three were female. All the participants had been diagnosed with OSA, were prescribed nasal CPAP, yet were unable to tolerate CPAP treatment mostly due to nasal obstruction and a deviated septum.

The patients underwent septoplasty surgery with inferior turbinoplasty to improve breathing and sinus drainage. Following the surgery, data was collected regarding the patients’ CPAP usage per night. Patients were also asked to fill out the Nasal Obstruction Symptom Evaluation (NOSE) Scale questionnaire on how their post-surgery nasal obstruction felt.

The results of the study were encouraging. Before surgery, average patient CPAP usage was 0.5 hours per night. Pre-surgery NOSE Scale questionnaire data averaged 16.1 among the patients, with a maximum possible score of 20.

After surgery, the mean nightly CPAP usage was 3.9 hours per night (significant difference compared to preoperative data at P < .05). And the NOSE Scale score decreased to 5.4 (significant difference compared to preoperative data at P < .05).

In summary, the results show improved CPAP compliance rates following septoplasty surgery in OSA patients with documented nasal obstruction. That said, it’s important to keep in mind that septopasty surgery should be considered conservatively and for appropriate patients. Nasal surgery is not a cure-all for OSA, but along with CPAP and/or other therapies, could make a positive difference in easing OSA-related symptoms. Further, the results of this study offers some written proof of the effectiveness of septoplasty surgery for nasal obstruction and OSA treatment.

If you have been diagnosed with OSA, or are suffering from snoring and sleep issues, I urge you to get evaluated by a qualified ear, nose, and throat doctor. Some common symptoms of OSA include snoring, paused breathing during sleep and excessive sleepiness during the day. Increased blood pressure is another sign you may have sleep apnea.

Untreated OSA can result in poor sleep (for you and your partner), lack of focus, increased cardiovascular disease, and even death. So please get checked out. There are multiple options and minimally invasive techniques available today to treat OSA and other sleep disorders.

Read the full article entitled, “The effect of nasal surgery on nasal continuous positive airway pressure compliance” in the January 2014 issue of The Laryngoscope.

Sleep Better — Get Smart about Your Smartphone

By Dr. David O. Volpi, M.D.

Smartphones, iPads, and other personal electronic devices are great ways to communicate and entertain ourselves, but they may also be negatively impacting the quality and quantity of our sleep.

As personal electronic devices have become more ubiquitous, the bright-light emitting screens that allow the use of mobile devices in dimly lit rooms have become a more common reason for sleep disruption, whether users realize it or not.

Why is that? Melatonin is a hormone produced by the pineal gland at night and when it is dark. It is a “timer” that tells the body that it is nighttime, and time to go to sleep. Exposure to light at night, such as that in the brightly-lit screens of many personal mobile devices, can interfere with melatonin, the hormone that helps control our sleep and wake cycles.

But rest easier: New research from the Mayo Clinic in Scottsdale, AZ explains a way to reduce the impact of electronic devises on sleep cycles.

Lois Krahn, M.D., a psychiatrist and sleep expert at the Mayo Clinic and co-author of the study said, “In the old days, people would go to bed and read a book. More commonly, people go to bed and they have their tablet on which they read a book or newspaper or look at material. The problem is it's a lit device, and how problematic is the light source from the mobile device?"

That question prompted Dr. Krahn to wonder, is the light from screens always a negative factor for sleep?" To find out, Krahn and his colleagues experimented with two tablets and a smartphone in a dark room, using a meter on its most sensitive setting to measure the light the devices emitted at various settings when held various distances from a person's face.

They discovered that when the brightness settings were lowered and the devices were held just over a foot from a user's face, it reduced the risk that the light would be bright enough to suppress melatonin secretion and disrupt sleep.

Explains Krahn, “We found that only at the highest setting was the light over a conservative threshold that might affect melatonin levels. If it's at the mid setting or at a low setting, it's bright enough to use."

The new Mayo Clinic research, which was presented in June at SLEEP 2013, the 27th annual meeting of the Associated Professional Sleep Societies LLC, in Baltimore, Md., also suggests things you can do to help prevent screen light from interfering with melatonin and affecting sleep.

These tips include dimming the smartphone or tablet brightness settings and holding the device at least 14 inches from your face while using it.

Other general tips include moving the TV and computer out of the bedroom, or at the very least, do not watch TV or work on the computer to bedtime.

With so many electronic distractions in our lives, it's important to re-claim the bedroom for its intended purpose: rest, relaxation, and sleep.

Untreated Sleep Apnea: The Quiet Danger on the Road

By Dr. David O. Volpi

It is common knowledge that untreated sleep apnea can have dire health effects, but researchers in England found out that loss of sleep also increases a person’s risk of nodding asleep at the wheel, and getting in a car accident. That endangers not only the person suffering from the sleep disorder, but any person driving around them at any given time.

The study, which was organized by the European Respiratory Society and the European Sleep Research Society, and presented April 12, 2013 at the Sleep and Breathing Conference in Berlin, determined that people with untreated sleep apnea are more likely to fail a driving simulator test, and report nodding asleep while driving.

Let’s review: What is sleep apnea?

Sleep apnea is a breathing disorder that causes a person’s breathing during sleep to be paused and/or shallow. The pauses generally last 10 to 20 seconds, and in severe cases, can occur hundreds of times a night. With obstructive sleep apnea (OSA), the airway is blocked and/or collapses while sleeping. Air squeezing by the blockage can cause loud snoring and interrupted sleep.

As a result of the paused breathing and/or snoring, many sleep apnea sufferers are woken up throughout the night and spend more time in light sleep, rather than deep, restful REM (rapid eye movement) sleep. This chronic sleep deprivation results in daytime sleepiness, and can negatively affect job performance, mood, reflexes, concentration, and it can lead to hypertension, heart disease, and memory problems.

Testing and results of the study

To determine the effect of untreated sleep apnea on driving, the researchers conducted two separate studies. The first was a driving simulation test where 133 patients with untreated sleep apnea and 89 without sleep apnea were asked to “drive” 90 km—about 55 miles.

Various criteria was recorded, including the participants’ ability to complete the driving distance, their time spent in the middle lane, and any participation in an unprovoked crash or a “veer event” crash.

The results of the driving simulation test showed that:

• Patients with untreated sleep apnea were more likely to fail the driving simulation test—24 percent of the sleep apnea patients failed the test, compared to 12 percent of those without sleep apnea.
• In addition, many patients with untreated sleep apnea were unable to complete the test at all, had more unprovoked crashes, and were unable to follow the clear driving instructions given at the beginning of the simulation test.

In the second study, 118 people with untreated sleep apnea and 69 without sleep apnea completed a questionnaire about their driving behavior, and also took the 90 driving test on the simulator.
The results showed that:

• 35 percent of those with untreated sleep apnea admitted to nodding asleep while at the wheel, and 38 percent of this same group failed the driving simulation test.
• By comparison, only 11 percent of people without sleep apnea said they have nodded off while driving, and none of this group failed the simulator test.

Key differences in the reasons for failure

While some people in the control group (those without sleep apnea) also failed the driving simulator test, the researchers noted key differences in why they failed the test:

• 13 people with untreated sleep apnea did not finish the test because they fell asleep or veered completely off the road.
• 5 people with untreated sleep apnea failed because they spent more than 5 percent of the study outside the lane they had been instructed to stay in.

But in the control group, no one failed the simulation for either of these reasons. Again, no one in the “without sleep apnea” group failed the driving simulation due to falling asleep, veering completely off the road, or driving outside the lane.

Dan Smyth of Sleep Apnea Europe noted, "The dangers of untreated sleep apnea and driving are highlighted in both studies. These studies give weight to the need for provision of sufficient resources for early diagnosis and treatment.

While further investigation is needed to examine the reasons for failure of the simulator tests, I acknowledge the researchers for bringing light to this very dangerous side effect of untreated sleep apnea. of sleep apnea, where effective treatment ensures a return to acceptable risk levels for road users."

Are you at risk for sleep apnea?

So how do you know you may have obstructive sleep apnea? Some common symptoms include snoring, paused breathing during sleep and excessive sleepiness during the day. Increased blood pressure is another sign you may have sleep apnea.

While sleep apnea is more common in men, OSA increases in women after age 50. Being overweight may also increase a woman’s risk of having sleep apnea. Menopausal women are three and a half times more likely to get OSA, possible due to reduced amounts of progesterone.

If you experiencing one or more of the above sleep apnea symptoms on a regular basis, see a qualified sleep doctor to get diagnosed and treated properly. There are multiple options and minimally invasive techniques available today to treat your sleep disorder.