Research has shown that there are important links between quality of life (QOL), sleep quality, and chronic rhinosinusitis. Studies suggest that more than 75% of patients with chronic rhinosinusitis have abnormal sleep quality, with worse sleep often being experienced in patients with more severe chronic rhinosinusitis. Higher levels of sleep dysfunction can also impact treatment decisions for patients with chronic rhinosinusitis, with their choices ranging from undergoing surgical therapy or continuing medical management.
“Sleep disorders and fatigue are both common among patients with chronic rhinosinusitis,” says Timothy L. Smith, MD, MPH. “These comorbidities are thought to be, in part, related to chronic inflammation in the sinuses. In some cases, they may be the result of chronic infections. It has been suspected that blockages in the nasal passages are the primary reason for decreased sleep quality in patients with chronic sinusitis, and that sleep quality will improve after the airway obstruction is treated.”
Patients with chronic rhinosinusitis and comorbid obstructive sleep apnea (OSA) have a lower QOL than others, according to clinical investigations. “Both chronic rhinosinusitis and OSA are known to have substantial adverse effects on sleep,” says Dr. Smith.
Taking a Closer Look
There is evidence suggesting that functional endoscopic sinus surgery (FESS) can result in lasting improvements in chronic rhinosinusitis-specific QOL among patients with medically refractory disease. It is unclear, however, if similar improvements can be achieved in patients with chronic rhinosinusitis and comorbid OSA after FESS.
For a study published in JAMA Otolaryngology—Head & Neck Surgery, Dr. Smith and colleagues sought to determine the impact of comorbid OSA on chronic rhinosinusitis disease-specific QOL and sleep dysfunction in patients with chronic rhinosinusitis following FESS. The investigators conducted a prospective analysis involving 405 adults over a 3-year period at multiple sites.
The study group used the Rhinosinusitis Disability Index (RSDI) survey, the 22-item Sinonasal Outcome Test (SNOT-22), and the Pittsburgh Sleep Quality Index (PSQI) to measure preoperative and postoperative outcomes, using OSA as the primary, independent risk factor. According to the results, 15% of participants had comorbid OSA, a prevalence that resembles that of the general United States population. Significant postoperative improvements after FESS were reported across all disease-specific QOL measures for participants with comorbid OSA and for those without the disease. Patients without OSA also reported greater improvements on sleep quality and had fewer sleep disturbances.
Participants without OSA reported significantly greater improvements in RSDI global scores, RSDI physical and functional subdomain scores, and SNOT-22 rhinologic symptom domain scores. The average postoperative scores significantly improved over time for all disease-specific QOL outcome measures in patients with only chronic rhinosinusitis and in those with chronic rhinosinusitis and OSA (Table). However, patients without OSA reported significant sleep quality score improvement from preoperative scores for the PSQI, but those with comorbid OSA did not report such improvements as measured by any aspect of the PSQI.
Analyzing the Implications
Considering the high prevalence of OSA and chronic rhinosinusitis as well as their detrimental effects on physical and neuropsychiatric function, Dr. Smith says understanding the contribution that OSA makes in chronic rhinosinusitis has important implications. OSA has been linked to many health consequences that are thought to result from sleep disruption, including depression, hypertension, congestive heart failure, arrhythmias, myocardial infarction, stroke, and death.
“Sinus surgery may lead to better improvements in QOL and sleep quality in patients with chronic rhinosinusitis by improving control of chronic inflammation rather than simply improving nasal obstructions,” Dr. Smith says. Findings of the study suggest that patients with chronic rhinosinusitis have a high prevalence of sleep dysfunction that significantly improves following FESS. In addition, people with OSA should be treated concurrently for both chronic rhinosinusitis and OSA to optimize sleep dysfunction and improve QOL.
Directing Future Research
According to Dr. Smith, more studies are needed to further elucidate the discordance and underlying mechanisms of sleep improvement between patients who have chronic rhinosinusitis with and without OSA using objective sleep measures. “Our study shows that sleep quality is diminished in patients with chronic rhinosinusitis with and without OSA, but the underlying etiology and pathophysiologic mechanism of this sleep dysfunction are still unknown,” he says.
Future investigations should also explore the connection between reducing nasal obstructions and objective measures of sleep function. “We don’t know enough about all of the health consequences that can emerge in patients with chronic rhinosinusitis and comorbid OSA,” says Dr. Smith. “This highlights the fact that more studies are needed to look into these associations.”
Alt JA, DeConde AS, Mace JC, Steele TO, Orlandi RR, Smith TL. Quality of life in patients with chronic rhinosinusitis and sleep dysfunction undergoing endoscopic sinus surgery: a pilot investigation of comorbid obstructive sleep apnea. JAMA Otolaryngol Head Neck Surg. 2015;141:873-881. Available at: http://archotol.jamanetwork.com/article.aspx?articleid=2436627.
Alt JA, Smith TL, Schlosser RJ, Mace JC, Soler ZM. Sleep and quality of life improvements after endoscopic sinus surgery in patients with chronic rhinosinusitis. Int Forum Allergy Rhinol. 2014;4:693-701.
Alt JA, Smith TL, Mace JC, Soler ZM. Sleep quality and disease severity in patients with chronic rhinosinusitis. Laryngoscope. 2013;123:2364-2370.
Smith TL, Litvack JR, Hwang PH, et al. Determinants of outcomes of sinus surgery: a multi-institutional prospective cohort study. Otolaryngol Head Neck Surg. 2010;142:55-63.