Nasal surgery is pivotal, not primary, in OSA surgery - a 25-year evidence based systematic review

To investigate the contribution of nasal surgery to multilevel OSA surgical success outcome.

Systematic review of MEDLINE, Google Scholar, Cochrane Library and Evidence Based Medicine Reviews to identify publications relevant to OSA, nasal resistance, pharyngeal volume/space, nasal surgery, multilevel surgery and its outcomes. All relevant studies published between January 2000 to December 2024 were included.

Twelve studies were included in this systematic review with 11 articles illustrating that nasal surgery was pivotal, and improved outcomes in multilevel OSA surgery, whilst nasal surgery alone for OSA did not significantly affect polysomnographic results. Five articles utilizing CBCT, 3D measurements of nasal and pharyngeal airway area/volume, computational fluid dynamics and nasal resistance demonstrated that reducing nasal resistance with nasal surgery increased the pharyngeal airway space and volume; whilst 6 articles established through clinical case studies that multilevel OSA surgery combined with nasal surgery yielded better AHI, LSAT and ESS outcomes than multilevel surgery without nasal surgery. The landmark article that reviewed 24 years of nasal surgery alone for OSA treatment, showed poor outcomes and minimal AHI change with nasal surgery alone.

As the upper airway is a continuous air conduit, reducing nasal resistance would reduce pharyngeal pressures leading to improvement of outcome parameters. Hence, including nose surgery in multilevel surgery improves surgical success.