Do you want to learn about how nose surgery affects snoring and sleep apnea?

We know that information on the topic can be challenging to find and we would like to help.

This blog post was written by an ear, nose and throat surgeon who has seen and treated thousands of patients with nasal obstruction and snoring or sleep apnea.

As part of the background for this blog post, we also searched the internet for frequently asked questions and answered them.

The goal of the blog post is to educate you on and also to provide information as well as provide helpful illustrations.

Deviated nose in a woman. Note that the nasal bones (top part of the nose) and the cartilage (lower half of the nose) are deviated. The shape is like a reverse-c shape. CamachoMD.com
Deviated nose in a woman. Note that the nasal bones (top part of the nose) and the cartilage (lower half of the nose) are deviated. The shape is like a reverse-c shape.

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Summary for nasal surgery for snoring and obstructive sleep apnea:

Nasal obstruction or congestion is a common problem.

In patients with snoring or obstructive sleep apnea, nasal congestion often co-exists.

Snoring and sleep apnea patients with nasal obstruction who fail management with medications may undergo nose surgery to help treat it.

Two main surgeries for treating nasal obstruction include rhinoplasty and septoplasty surgeries.

In general, although the breathing may improve, the nose does not usually cause obstructive sleep apnea. So, sleep apnea might not improve.

However, because nose surgeries can reduce pressures on CPAP machines, patients tend to tolerate CPAP better after nose surgery.

What are the components of the nose and how do they relate to snoring and obstructive sleep apnea?

The outer nose is made up of cartilage, bone and soft tissues.

The inner portions of the nose are made up of the nasal septum (cartilage and bone), the turbinates (superior, middle and inferior which are made up of soft tissue and bone), and sinus tissue.

When a patient has a crowded nose, the velocity of the air increases.

A landmark study evaluating airway resistance during breathing found that 54% of the airway resistance occurs in the nose when humans breathe in (inspiration). [1]

Straight septum in a woman. The septum and turbinates can be seen. CamachoMD.com
Straight septum in a woman. The septum and turbinates can be seen.
Straight nasal septum in a woman. CamachoMD.com
Straight nasal septum in a woman.

What are the nasal disorders that narrow the nose?

The disorders that can narrow the nose include:

  • A deviated outer nose (such as from trauma),
  • A deviated nasal septum,
  • Large inferior turbinates,
  • Nasal polyps,
  • Nasal masses (growths, tumors), and
  • Large adenoids.
Deviated nose in a woman. Note that the nasal bones (top part of the nose) and the cartilage (lower half of the nose) are deviated. The shape is like a reverse-c shape. CamachoMD.com
Deviated nose in a woman. Note that the nasal bones (top part of the nose) and the cartilage (lower half of the nose) are deviated. The shape is like a reverse-c shape.
Deviated nasal septum in a woman. CamachoMD.com
Deviated nasal septum in a woman.

What is snoring and obstructive sleep apnea?

Some people snore when they sleep. Snoring is due to the vibration of the soft tissues of the throat.

The most common causes of snoring are the soft palate and the uvula.

Snoring is less commonly caused by the tongue, the tonsils, the epiglottis or the supraglottis.

Upper airway obstruction at the level of the soft palate. Note that since the airflow is blocked, the oxygen cannot get into the airway and carbon dioxide cannot leave. The light blue arrow points to the obstructed palate. CamachoMD.com
Upper airway obstruction at the level of the soft palate. Note that since the airflow is blocked, the oxygen cannot get into the airway and carbon dioxide cannot leave. The light blue arrow points to the obstructed palate.

Obstructive sleep apnea is when the airway becomes blocked during sleep.

If the airway is partially obstructed for 10 seconds, it is called a hypopnea.

If the airway is 90% obstructed or more for 10 seconds, then it is called an apnea.  

In some patients, the brain may wake up with even small amounts of airflow limitation, this is known as a respiratory effort related arousal (RERA).

How does Poiseuille’s law relate to the nose and sleep disordered breathing?

Poiseuille’s law states that the airflow that goes through a tube (the nasal cavity) is directly proportional to square of the cross sectional area of the tube and is directly proportional to the fourth power of the radius of the tube.[2]

Although the nose is not a tube, and the upper airway is not a tube, Poiseuille’s law in the theoretical sense would show that a 10% increase in the cross sectional area of the nasal cavity would lead to an airflow increase of 21%.[3]

Does having nasal obstruction cause airflow speed to change in the nose?

Yes.

Nasal obstruction is due to the narrowing of the inside of the nose.

When the space inside the nose becomes narrower, the velocity of the air as it goes through the nose increases.

An analogous way to think about this is if you have a garden hose and you turn on the water and let it run with the whole diameter of the hose, then it comes out at a slow velocity.

However, when you put your finger over the opening of the hose (narrowing the diameter of the opening), then the water comes out much faster.

So, what happens when the nose is narrowed, is that the velocity is faster and this can contribute to snoring (more vibration of the tissues in the throat while sleeping).

Upper airway that is open with normal breathing. Note that the oxygen goes into the airway and the carbon dioxide leaves the airway. CamachoMD.com
Upper airway that is open with normal breathing. Note that the oxygen goes into the airway and the carbon dioxide leaves the airway.

How does a narrowing of the nose cause snoring or obstructive sleep apnea?

Because the nose does not move in the majority of people, it is not the nose itself that causes the snoring or sleep apnea, rather it is the soft tissues in the floor of the nose, behind the nose or below the nose that cause snoring or sleep apnea.

However, if a patient has a blocked nose, then one of two things will happen during sleep.

The first thing that can happen is that the patient could keep breathing through their nose and the velocity of the air is increased and this causes the soft tissue to vibrate and this creates a snoring sound.

The second thing that can happen is that the patient could be so obstructed in their nasal breathing that they open their mouths to breathe.

When people breathe through their mouths during sleep, there is an increased tendency to snore. 

It is actually quite rare for a person to snore only during nasal breathing.[4]

Does a person who does not snore or have obstructive sleep apnea develop the disorders if their nose becomes obstructed?

Interestingly, yes.

Two studies evaluated healthy people who did not snore or have obstructive sleep apnea.

The researchers plugged the noses of the patients to see what would happen.

The healthy patients ended up developing obstructive sleep apnea.

In the first study, 8 patients’ breathing went from normal (about 1-2 obstructive events per hour on average) to abnormal (mild sleep apnea about 10 obstructive events per hour on average) when both sides of the nose were occluded.[5]

In the second study, 10 patients’ breathing went from normal (1.4 blockages per hour on average) to abnormal (mild sleep apnea with 8 blockages per hour on average) when both sides of the nose were occluded.[6]

Upper airway obstruction at the level of the soft palate and the tongue. Note that since the airflow is blocked, the oxygen cannot get into the airway and carbon dioxide cannot leave. The light blue arrow points to the obstructed palate and the obstructed tongue. CamachoMD.com
Upper airway obstruction at the level of the soft palate and the tongue. Note that since the airflow is blocked, the oxygen cannot get into the airway and carbon dioxide cannot leave. The light blue arrow points to the obstructed palate and the obstructed tongue.

Will a septoplasty or a rhinoplasty help or fix sleep apnea?

Because the nose does not move during sleep, generally speaking, it is unlikely that it will cure obstructive sleep apnea if it is moderate or severe.

There are times that a patient might have what is known as respiratory effort-related arousals and in that case, it is possible that there would be a reduction in those events and this could reduce the number of these events in some patients who have obstructive sleep apnea.[7]

The reason that the respiratory-effort related arousals may reduce after nasal surgery is because they are due to flow limitation that occurs during breathing, not due to significant obstruction of the airway.

Illustration of the nose of a woman viewed from the side. Cartilage and bone can be seen. CamachoMD.com
Illustration of the nose of a woman viewed from the side. Cartilage and bone can be seen.

Will nose surgery help improve sleepiness in patients with obstructive sleep apnea?

A review article found that there was a significant improvement in sleepiness using the Epworth sleepiness scale in patients who underwent nasal surgery and had obstructive sleep apnea.[7]

Will sinus surgery help or fix sleep apnea?

If the patient has large nasal polyps that are obstructing the airway, then it is possible that sinus surgery to remove the polyps can dramatically improve the nasal airway and allow air to flow much better.

However, like the nasal septum, it is rare for the patients to get cured after nasal surgery, including those who have nasal polyps.

Does nasal surgery reduce the pressures on CPAP machines?

A review article found that nasal surgery does reduce the pressures on the CPAP machine by 2-3 centimeters of water pressure.[8]

By reducing the pressures that effectively treat CPAP, the machines are more comfortable and more tolerable.

Does nasal surgery improve CPAP use?

Nasal surgery has been shown to improve CPAP use.

A research article found that 89% of patients in the literature who were not able to use CPAP before nasal surgery, were able to use CPAP after surgery. [8]

Government Disclaimer: The views expressed in this website are those of the author(s) and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

References:

1.            Ferris, B.G., Jr., J. Mead, and L.H. Opie, PARTITIONING OF RESPIRATORY FLOW RESISTANCE IN MAN. J Appl Physiol, 1964. 19: p. 653-8.

2.            Kimmelman, C.P., The problem of nasal obstruction. Otolaryngol Clin North Am, 1989. 22(2): p. 253-64.

3.            Powell, N.B., et al., Radiofrequency treatment of turbinate hypertrophy in subjects using continuous positive airway pressure: a randomized, double-blind, placebo-controlled clinical pilot trial. Laryngoscope, 2001. 111(10): p. 1783-90.

4.            Hsia, J.C., M. Camacho, and R. Capasso, Snoring exclusively during nasal breathing: a newly described respiratory pattern during sleep. Sleep Breath, 2014. 18(1): p. 159-64.

5.            Suratt, P.M., B.L. Turner, and S.C. Wilhoit, Effect of intranasal obstruction on breathing during sleep. Chest, 1986. 90(3): p. 324-9.

6.            Lavie, P., et al., The effects of partial and complete mechanical occlusion of the nasal passages on sleep structure and breathing in sleep. Acta Otolaryngol, 1983. 95(1-2): p. 161-6.

7.            Ishii, L., et al., Does Nasal Surgery Improve OSA in Patients with Nasal Obstruction and OSA? A Meta-analysis. Otolaryngol Head Neck Surg, 2015. 153(3): p. 326-33.

8.            Camacho, M., et al., The effect of nasal surgery on continuous positive airway pressure device use and therapeutic treatment pressures: a systematic review and meta-analysis. Sleep, 2015. 38(2): p. 279-86.