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ORIGINAL ARTICLE
Year : 2021  |  Volume : 19  |  Issue : 2  |  Page : 83-87

Study of obstructive sleep apnea parameters in patients of nasal polyposis using peripheral arterial tonometry


Department of Otorhinolaryngology and Head and Neck Cancer Surgery, Sir Ganga Ram Hospital, Delhi, India

Date of Submission06-Jan-2021
Date of Decision30-Jan-2021
Date of Acceptance10-Feb-2021
Date of Web Publication15-Apr-2021

Correspondence Address:
Dr. Rajat Basak
Department of Otorhinolaryngology and Head and Neck Cancer Surgery, Sir Ganga Ram Hospital, Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_2_21

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  Abstract 


Background: Obstructive sleep apnea (OSA) syndrome is characterized by partial or complete cessation of airflow and oxygen desaturation during sleep owing to upper airway collapse. This study assesses the OSA parameters in nasal polyposis patients before and after functional endoscopic sinus surgery (FESS) with the help of peripheral arterial tonometry (PAT) device. Methodology: This was a prospective study done in the months of April 2015 to June 2016. Patients with bilateral nasal polyps with Lund Mackay Scoring marking equal to and more than two of both sides. Thirty patients willing to undergo PAT sleep study before and after FESS were recruited. The sleep parameters thus obtained in the pre- and postoperative period were analyzed. Results: Out of 30 patients, 22 patients were male and eight patients were female. The mean age was 43.17 with standard deviation of 10.06 years. The mean body mass index was 29.12 with a standard deviation of 5.76. All patients underwent FESS. The PAT study was done before and after surgery. Snoring grading and Epworth Sleepiness Scale scoring improved in the majority of patients after surgery. The mean respiratory disturbance index (RDI) in the preoperative period was 32.7 which decreased to 11.34 in the postoperative period. The mean apnea hypopnea index (AHI) in the preoperative period was 22.85 which decreased to 6.34 in the postoperative period. The mean oxygen desaturation index (ODI) in the preoperative period was 16.8 which decreased to 4.4 after surgery. Significant correlation (P < 0.001) was found between pre- and postoperative RDI, AHI, ODI, and oxygen desaturation events. Conclusion: The OSA parameters before and after endoscopic sinus surgery in nasal polyposis patients got improved. The PAT device, which is the newest novel plethysmograph, proved to be a reliable device for the assessment of sleep apnea parameters in nasal polyposis in the pre- or postoperative period.

Keywords: Apnea hypopnea index, functional endoscopic sinus surgery, obstructive sleep apnea, oxygen desaturation index, peripheral arterial tonometry device, peripheral arterial tonometry, respiratory disturbance index, sinus polyposis


How to cite this article:
Basak R, Rai D, Munjal M. Study of obstructive sleep apnea parameters in patients of nasal polyposis using peripheral arterial tonometry. Curr Med Issues 2021;19:83-7

How to cite this URL:
Basak R, Rai D, Munjal M. Study of obstructive sleep apnea parameters in patients of nasal polyposis using peripheral arterial tonometry. Curr Med Issues [serial online] 2021 [cited 2021 May 13];19:83-7. Available from: https://www.cmijournal.org/text.asp?2021/19/2/83/313817




  Introduction Top


Obstructive sleep apnea (OSA) syndrome is characterized by partial or complete collapse of the upper airway during sleep.[1],[2] OSA is characterized by snoring, fatigue, witnessed breath holds, gasping, choking, excessive day time sleepiness, episodes of fragmented sleep, reduced alertness, mood changes, and nocturia.[1],[2] It also has been associated with several comorbidities, including cardiovascular disease, arrhythmia, stroke, obesity, metabolic syndrome, hypertension, insulin resistance, cerebrovascular accidents, increased risk of craniofacial abnormality, and road traffic accidents. Obesity is the most common risk factor associated with OSA.[2],[3] The prevalence of OSA in morbidly obese population has been reported to be 70%. Increased neck circumference, increased waist hip ratio, and central trunk obesity have also been associated with increased risk of OSA. OSA has also been associated with reactive oxygen species, serum proinflammatory markers such as tumor necrosis factor-alfa, interleukin (IL)-1B, and IL-6.14. These markers are also responsible for daytime sleepiness.[2],[3],[4] OSA patients experience repeated episodes of hypoxemia and hypercarbia. This results in the episodes of increased sympathetic tone, circulating catecholamines, endothelial dysfunction, and vascular remodeling. This leads to an arterial noncompliance and secondary hypertension and reported in more than 70% of patients.[2],[3],[4]

Due to anatomical abnormality, defects in the neuromuscular tone or a combination of both, the upper airway collapses and the inspiratory flow is compromised. Patients with OSA are unable to provide a greater neuromuscular strength to overcome this airway obstruction compared to non OSA patients. This concept is supported by studies which show that electrical stimulation of the genioglossus muscle can correct the airway obstruction. The cause of the abnormal motor activation of the pharyngeal muscle is inherent or acquired or due to postobstructive microarousal.[4] There are various causes of dynamic and fixed nasal obstructions such as engorgement of blood vessels in middle and inferior turbinate, deviated nasal septum, congenital and acquired upper airway malformations, nasal polyps, and chronic inflammation.[3],[4],[5]

Nasal polyps are fleshy swellings arising from the mucosal linings of nose and paranasal sinuses (PNS). They have grape-like appearance with a body and a stalk. They originate in the upper part of the nose around the openings of the PNS.[6],[7] They grow within the nasal cavity and within the sinuses from the middle and superior meatus resulting in nasal blockage and cessation of airflow to the olfactory region with a prevalence rate of 2%. These are mainly situated in the middle meatus and originate from the mucous membrane of the outlets (ostia, clefts, and recesses) from the PNS.[6],[7] In these patient's endoscopic sinus surgery relieves snoring and sleep disturbances to a greater extent. Several studies done in the West showed improved OSA parameters before and after endoscopic sinus surgery in nasal polyposis.[8],[9],[10] This study was done to assess the ODA parameters in nasal polyposis patients before and after functional endoscopic sinus surgery (FESS) with the help of peripheral arterial tonometry (PAT) device.


  Methodology Top


This prospective study was conducted at Sir Ganga Ram Hospital, New Delhi, India, in the Department of Otorhinolaryngology and Head and Neck Surgery. The study included patients from February 2015 to June 2016 with the symptoms of OSA due to nasal polyp.

Inclusion criteria

  1. Age: Above 18 years with the symptoms of nasal obstruction due to nasal polyp
  2. Bilateral Nasal polyps with Lund Mackay Score equal to and more than 2 of both sides
  3. Symptoms of OSA
  4. Epworth Sleepiness Scale (ESS) scoring equal to and more than 12.


Exclusion criteria

  1. Peripheral vasculopathy and neuropathy
  2. Nonsinus cardiac arrhythmia
  3. Severe lung disease
  4. Use of alfa adrenergic blocker
  5. Presence of any serious medical illness
  6. Micrognathia, cleft palate, and palatopharyngeal insufficiency
  7. Facial developmental anomaly
  8. Freidman Tongue Position III and IV
  9. Tonsillar hypertrophy III and IV
  10. Gross deviated nasal septum.


Patient recruitment

Relevant history of OSA symptoms along with a history of systemic disorder was taken. ESS scoring was noted. Patients with ESS equal to and more than 12 were recruited. Computed tomography scan of PNS in coronal, sagittal, and axial sections without contrast was done. Patients with nasal polyps affecting beyond the middle meatus corresponding to Score 2 of Lund Mackay System in both the nostrils were recruited. Patient information sheet was given to each of them. Informed consent form was obtained for undergoing sleep study before and after FESS. Prior to surgery, all patients underwent sleep study with PAT device overnight. After 3 months from surgery, PAT study was done again. The statistical data thus collected preoperatively and 3 months postoperatively were analyzed.

The following parameters were assessed by the PAT device: Respiratory Distress Index (RDI), Apnea hypopnea index (AHI), oxygen desaturation index (ODI), oxygen desaturation events, pulse rate, total sleep time, valid sleep time, rapid eye movement (REM) percentage of total sleep, non-REM percentage of total sleep, wake percentage of total sleep, and percentage of sleep with snoring.

Apnea–Hypopnea Index

OSA was further subdivided into varying degrees of severity depending on the AHI as follows: mild - AHI 5–14/h, moderate: AHI - 15–30/h, and severe - AHI >30/h. Respiratory Distress Index (RDI) was calculated as the number of apneas and hypopneas divided by the number of hours of sleep. ODI was determined as the number of times per hour of sleep that the blood's oxygen level drops by 3% or more from baseline.

Statistical methods

Statistical testing was conducted with the Statistical Package for the Social Sciences (SPSS) software version 17.0, Armonk, NY, USA continuous variables were presented as mean, standard deviation (SD) or median if the data were unevenly distributed. Categorical variables were expressed as the frequencies and percentages. The comparison of normally distributed continuous variables from pre- to postoperative change was done using the paired t-test. Nominal categorical data between the groups were compared using Mc nemar test and association was checked using the Chi-squared test. Nonnormal distribution continuous variables were compared using Wilcoxon Rank-sum test. For all statistical tests, a P < 0.05 was taken to indicate a statistically significant difference.

Ethical considerations

The study was approved by the Institutional Review Board (IRB Min. No. EC/02/15/782 dated 17/02/2015) and patient confidentiality was maintained by using unique identifiers and by password protected data entry software with restricted uses.


  Results Top


Among 30 patients, 22 (73.3%) were male. The mean age was 43.17 years (SD: 10.06). The median weight was 77.5 kg. The median body mass index (BMI) was 23.23 kg/m2, and the mean BMI was 29.12 kg/m2 (SD: 5.76 kg/m2). Among the 30 patients, six (26.7%) patients had BMI in the normal range, 10 (33.3%) patients were overweight, 6 (20%) patients were in the Obese Class I group, 5 (16.7%) patients were in the Obese Class II group, and 1 (3.3%) patient were in the Obese Class III group. These details are shown in [Table 1].
Table 1: Baseline characteristics

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In the preoperative period, 12 (40%) of patients had Snoring Grading III and 18 (60%) of patients had Snoring Grade IV. In the postoperative period, three (10%) patients had Snoring Grading III, 16 (53.3%) patients had Snoring Grade II, and 11 (36.7%) patients had Snoring Grade I. Preoperative and postoperative distribution of other sleep parameters in the pre- and postoperative period and their correlation are given in [Table 2] and [Table 3]. The mean oxygen desaturation events in the preoperative period were 107.6 with a SD: 62.54. The mean oxygen desaturation events in the postoperative period were 29.67 (SD: 26.65). Distribution of sleep parameters in the pre- and post-operative period and their correlation are given in [Table 4].
Table 2: Preoperative parameters of obstructive sleep apnea

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Table 3: Postoperative changes in obstructive sleep apnea parameters

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Table 4: Distribution of sleep parameters in the pre- and postoperative period and their correlation

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Sleep percentage with snoring

The mean sleep % with snoring in the preoperative period was 89.94 (SD: 18.56). The mean sleep % with snoring in the postoperative period was 77.93 (SD: 24.21). The P value between pre- and post-operative sleep percentage with snoring was 0.01 that was statistically significant.

Wake percentage

The wake percentage in the preoperative period was 21.35 (SD: 7.16). The maximum and minimum wake percentage is 42.5 and 12.3, respectively, in the preoperative period. The wake percentage in the postoperative period was 15.47 (SD: 5.24). The maximum and minimum wake percentage is 27.9 and 7.12, respectively, in the postoperative period.


  Discussion Top


OSA is caused by recurrent obstruction of the upper airway during sleep, preventing airflow into the lungs and resulting in repeated falls in oxygen saturation.[2],[3] OSA is diagnosed when the number of hypopnea and the apnea is equal to and more than 5/h.[2],[3],[4] BMI is a good indicator of obesity and the normal range of BMI is 18.5–24.99 kg/m2. In our study of 30 patients, only eight patients (26.7%) had normal BMI. Ten (33.3%) patients were overweight. Six patients belonged to obese Class I, five patients belonged to obese Class II, and one patient belonged to obese Class III. Thus, in this study, it was shown that obesity was an important risk factor of OSA, which is consistent with other studied done in the past.[11]

Out of 30 patients, 12 (40%) patients had snoring Grading III and 18 (60%) patients had snoring grading IV. After surgery, 10% patients had snoring Grading III, 53.3% patients had snoring Grade II, and 36.7% patients had snoring Grade I. After surgery, none of the patients had snoring Grading IV, the number of patients having snoring Grading III has been decreased from 40% to 10%. ESS is a reliable score to detect the propensity for daytime sleepiness. It consists of several different situations in which a person has chance to doze and a patient with OSA has more chance to doze.[12],[13],[14] Before surgery, the number of patients having ESS in the range between 10 and 12 was 6 and more than 12 was 24. This meant that 20% of patients had tendency for moderate and 80% of patients had tendency for severe day time sleepiness. After surgery, only one patient had a tendency for severe daytime sleepiness. The tendency of daytime sleepiness changed from severe to minimal category after surgery indicating that the removal of cause of nasal obstruction decreased the OSA symptom. This states that ESS is a good criterion for detecting and monitoring the symptoms of OSA. Before surgery, the number of patients having mild, moderate, and severe RDI was 1, 10, and 19, respectively. After surgery, the number of patients having severe RDI was 3 and those having moderate and mild RDI were 11 and 10, respectively. The mean AHI in the preoperative period decreased from 22.85 to 6.34 in the postoperative period which is a good clinical outcome. The number of patients having mild, moderate, and severe ODI were 10, 14, and 6, respectively. In the postoperative period, the number of patients having mild, moderate, and severe ODI were 11, 3, and 0, respectively. The maximum ODI decreased from 46.5 to 11.4 after surgery. This means that the removal of the cause improved the number of sleep disturbances and increased the quality of sleep. The number of apnea and hypopnea decreased significantly in the postoperative period. The newest device, the PAT detects the number of arousals with the help of two parameters: increase in sympathetic activity and increase in heart rate. The parameters showing the number of disturbances in the sleep are respiratory distress index (RDI), AHI and ODI. In the postoperative period, a decrease in the parameters was found. Significant correlation was found between pre and postoperative AHI, RDI and ODI which is a good clinical outcome.


  Conclusion Top


This prospective study showed snoring grading, ESS scoring improved in majority of patients after FESS. The mean RDI, ODI, and AHI in the preoperative period decreased significantly in the postoperative period indicating that the OSA parameters before and after endoscopic sinus surgery in nasal polyposis patients got improved.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Research quality and ethics statement

The authors of this manuscript declare that this scientific work complies with reporting quality, formatting, and reproducibility guidelines set forth by the EQUATOR Network. The authors also attest that this clinical investigation was determined to require Institutional Review Board/Ethics Committee review, and the corresponding protocol/approval number is IRB Min. No. EC/02/15/782 dated 17/02/2015). We also certify that we have not plagiarized the contents in this submission and have done a Plagiarism Check.



 
  References Top

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Johns MW. Sleepiness in different situations measured by the Epworth Sleepiness Scale. Sleep 1994;17:703-10.  Back to cited text no. 13
    
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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