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Table 1.  Patient Characteristics by OSA Severity Defined by the Apnea-Hypopnea Indexa
Patient Characteristics by OSA Severity Defined by the Apnea-Hypopnea Indexa
Table 2.  Incidence of Complications
Incidence of Complications
Table 3.  Potential Risk Factors in Those With and Without Complicationsa
Potential Risk Factors in Those With and Without Complicationsa
Table 4.  Logistic Regression Analysis of Postoperative Complications Given Any Complication as the Dependent Variablea
Logistic Regression Analysis of Postoperative Complications Given Any Complication as the Dependent Variablea
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Original Investigation
March 2017

Association Between Severity of Obstructive Sleep Apnea and Number and Sites of Upper Airway Operations With Surgery Complications

Author Affiliations
  • 1Department of Otorhinolaryngology–Head and Neck Surgery, International Islamic University Malaysia, Jalan Hospital, Kuantan, Pahang, Malaysia
  • 2Department of Community Medicine, International Islamic University Malaysia, Jalan Hospital, Kuantan, Pahang, Malaysia
  • 3Department of Anaesthesiology, International Islamic University Malaysia, Jalan Hospital, Kuantan, Pahang, Malaysia
JAMA Otolaryngol Head Neck Surg. 2017;143(3):239-246. doi:10.1001/jamaoto.2016.3268
Key Points

Question  In upper airway surgery for obstructive sleep apnea (OSA), would the severity of OSA or multilevel surgery be associated with a higher rate of short-term operative complications?

Findings  In a cohort study of 95 adults, the rate of complications was 51%. No significant association was found between OSA severity based on the apnea-hypopnea index and the number of concurrent operations with complications.

Meaning  In patients with OSA undergoing upper airway surgery, the severity of OSA as assessed by the apnea-hypopnea index and concurrent multilevel surgery performed were not associated with a higher rate of operative complications.

Abstract

Importance  In patients with obstructive sleep apnea (OSA), operative risks depend on the severity of the underlying OSA and the invasiveness of the surgical procedure.

Objective  To investigate the nature of the associations between the severity of OSA and the number and anatomical sites of upper airway operations with operative complications.

Design, Setting, and Participants  This retrospective study included adult patients diagnosed with OSA (apnea-hypopnea index [AHI], >5) who underwent upper airway surgery at a single tertiary referral hospital between October 1, 2008, and October 1, 2015.

Interventions  All patients underwent single or combination surgery on the nose, palatopharyngeal (tonsils, adenoids, and soft palate), and tongue base as a treatment of OSA.

Main Outcomes and Measures  Pulmonary, surgical, and cardiovascular complications within the first 30 postoperative days were analyzed according to OSA severity and types of upper airway surgery. Logistic regression was used to assess the multivariable association of OSA, age, sex, body mass index, medical comorbidities, and types of upper airway surgery with short-term operative complications.

Results  The study included 95 patients (87 males [91.6%]; 83 were Malay [87.4%]; mean [SD] age, 37.7 [1.6] years) with complete data and follow-up who underwent upper airway surgery to treat OSA. Patients with more severe OSA had greater body mass index (Cohen d, 0.27; 95% CI, −0.28 to 0.82), longer surgical time (Cohen d, 1.57; 95% CI, 0.95-2.15), and older age (Cohen d, 3.06; 95% CI, 2.29-3.77). At least 1 operative complication occurred in 48 of 95 patients (51%). In a multivariable model, the overall complication rate was increased with age and body mass index. Complication rates were not associated with AHI severity, type of procedure performed, and whether the surgery was single or combination surgery. Lowest oxygen desaturation (odds ratio, 1.03; 95% CI, 0.96-1.45; P = .04) and longest apnea duration (odds ratio, 1.03; 95% CI, 0.99-1.08; P = .02) were polysomnographic variables that predict the short-term operative complications.

Conclusions and Relevance  In patients with OSA undergoing upper airway surgery, the severity of OSA as assessed by AHI, and the sites and numbers of concurrent operations performed were not associated with the rate of short-term operative complications.

Introduction

Patients with obstructive sleep apnea (OSA) have an increased risk of postoperative complications.1-4 Guidelines from the American Society of Anesthesiologists recommend that, for patients with OSA, the operative risk depends on the severity of the underlying OSA and the invasiveness of the surgical procedure.5,6 These guidelines, which are based primarily on expert opinion, rated airway surgery as the type of surgery with the highest risk of potential operative complications. Although it may be intuitive to suggest that patients with more severe OSA are at higher risk of operative complications, the literature supporting this claim is conflicting. Several studies7-9 found significant correlation between operative complications and apnea severity, whereas others10-12 found the opposite.

Surgical procedures for OSA often involve multiple, concurrent surgery at different sites of the upper airway.13,14 However, most of the data of operative complications in patients undergoing upper airway surgery for OSA mainly focused on a single-site operation, such as uvulopalatopharyngoplasty (UPPP) or tonsillectomy.7,9-12 To our knowledge, only a limited number of previous studies8,10 have attempted to stratify the risks of complications from concurrent, multilevel surgery for OSA diagnosed by strict criteria and yielded differing results.

The aim of this retrospective study was to investigate the nature of the associations between the severity of OSA and the number and anatomical sites of upper airway operations with operative complications. The primary hypothesis was that, in patients undergoing upper airway surgery for OSA, the severity of OSA would be associated with a higher rate of operative complications. The secondary hypothesis was that the sites and number of operations performed would influence the rate of operative complications.

Methods

Data were collected by systematic review of patient medical records supplemented by 1-to-1 personal interview with the patients. Inclusion criteria were OSA diagnosis by polysomnography (apnea-hypopnea index [AHI], >5), age older than 18 years, and single or combination surgery on the upper airway as treatment of OSA with the patient under general anesthesia at a tertiary care hospital in Malaysia between October 1, 2008, and October 1, 2015. The study was performed at Hospital Tg Ampuan Afzan, Kuantan, Pahang, and the International Islamic University Malaysia. Only data from patients who gave written informed consent for the use of their medical records for research purposes were included in the study. All data were deidentified. Exclusion criteria were patients with syndromes associated with craniofacial abnormalities, oxygen-dependent cardiopulmonary patients, and patients with a history of congenital cardiac disease or cardiac surgery. The study obtained ethical clearance from the ethical committee board of International Islamic University Malaysia and approval by the clinical research committee of Hospital Tg Ampuan Afzan, Kuantan, Malaysia.

The diagnosis of OSA was confirmed preoperatively using a 22-channel Sapphire Crystal polysomnogram (CleveMed Inc). All polysomnography was performed as a technologist-attended overnight study at a single center. The technical specifications, scoring of polysomnographic data, and diagnosis of OSA were made according to the American Academy of Sleep Medicine (AASM) guidelines.15,16

Procedure, Instrumentation, and Monitoring

In the study patients, upper airway operations to treat OSA were single or combination surgery on the nasal, palatopharyngeal, and tongue base area. The classifications of the types of surgery used in the study are as follows. Nasal surgery included septoplasty, turbinoplasty, nasal polypectomy, and turbinate reduction surgery. Palatopharyngeal surgery included UPPP, uvulopalatal flap procedure, modified cautery-assisted palatal stiffening operation, laser-assisted uvulopalatoplasty, radiofrequency stiffening of the soft palate, tonsillectomy, adenoidectomy, and lateral pharyngoplasty. Tongue base surgery was radiofrequency or coblator tongue base reduction surgery. The patients with OSA in our hospital usually had a routine trial of continuous positive airway pressure (CPAP) treatment after the diagnosis by polysomnography. Indications for surgery in our patients were definite anatomical upper airway obstruction and failed or intolerable CPAP treatment, following the AASM guideline.15

Potential candidates were identified from the operating theater electronic database. Verbal informed consent was obtained by telephone conversation, and the patients were arranged for an interview session, after which written consent was obtained. Data were collected mainly through medical record review, complemented by the patients’ self-reporting during the interview session. The data extracted included patient characteristic information; comorbid medical condition; preoperative, intraoperative, and postoperative surgical and anesthetic variables; preoperative polysomnographic results; and operative complications. The complications were pulmonary, cardiovascular, or surgery related. Pulmonary complications were defined as clinically important and clearly documented in the records, such as aspiration, atelectasis, suspected or definite respiratory infections, airway intervention by means of CPAP or bilevel positive airway pressure (BiPAP) in those who never used it preoperatively, pulmonary edema, postoperative tracheal reintubation or tracheostomy, oxygen desaturation of 85% or less in the postoperative period, bronchospasm, and respiratory arrest. Cardiovascular complications included myocardial infarction, thromboembolic events, arrhythmias, persistent hypertension requiring medical intervention, and stroke. Surgical complications within the first 30 days of operation were bleeding, surgical site infections, wound breakdown, readmission to the operating theater for further surgical procedure, and hospital readmission for any reasons related to the surgery after initial discharge from the ward.

Comorbid conditions included history of diagnosis and current treatment for hypertension, type 1 diabetes, cardiovascular disease (coronary artery disease, heart failure, atrial fibrillation, ventricular ectopy), pulmonary disease (asthma, chronic obstructive pulmonary disease, bronchitis, or pulmonary hypertension), hypothyroidism, and kidney disease (blood creatinine concentrations above the age-adjusted norm).

After postanesthesia recovery in the operating theater, patients were transferred to the intensive care unit with strict 1-on-1 nursing care or to an acute care section of a general ward, where they were under 24-hour continuous oximetry monitoring. The decision for the transfer was made by the attending anesthesiologist (A.H.M.). It is a standard practice in our center to apply CPAP or BiPAP postoperatively in the postanesthesia care unit in patients who were using these devices preoperatively.

Statistical Analysis

Analysis was performed using SPSS statistical software for Windows, version 19 (IBM Inc). Using the estimated incidence of overall complications of surgery in patients with OSA at 30% with a 10% margin of error,3,4,7,17,18 the sample size was calculated using a single proportion formula in Power Analysis and Sample Size, 11th edition (NCSS Statistical Software), software. The estimated minimum sample size was 92.

The severity of OSA was quantified into mild, moderate, and severe using AHI according to the AASM criteria.15,19 Patient and procedural characteristics were presented according to the OSA severity. Data were calculated in mean (SD) for continuous variables and frequency (percentage) for categorical variables. Data characteristics were compared across the OSA severity using analysis of variance or the Kruskal-Wallis test for continuous variables and the χ2 or Fisher exact test for categorical variables.

The prevalence and types of complications were described. Patients were then categorized into complication and noncomplication groups and compared for each potential risk factor. The unpaired, 1-tailed t test or Mann-Whitney test and χ2 or Fisher exact test were performed to analyze data with respect to the presence or absence of a specific risk factor for complications.

Logistic regression was used to analyze the multivariable association of potential confounding factors with operative complications. In all cases, P < .05 was considered statistically significant.

Results

Within the study period, 135 patients underwent upper airway surgery as a treatment for OSA. Seventeen patients were lost to follow-up and were excluded from the study. Another 23 patients were excluded because the information compiled in the database was incomplete, such as absent results of preoperative sleep study and incomplete documentation of the intraoperative and postoperative findings. The characteristics of the 95 patients are presented in Table 1. Within this cohort, the mean (SD) age was 37.7 (1.6) years, which was a relatively younger population undergoing OSA surgery; 87 patients (92%) were male; and 83 (87%) were Malay. The young age of the patients reflects the more aggressive approach in treating younger patients with severe OSA in our population.20 Patients with more severe OSA were observed to have greater body mass index (BMI) (Cohen d, 0.27; 95% CI, −0.28 to 0.82), longer surgical time (Cohen d, 1.57; 95% CI, 0.95-2.15), and older age (Cohen d, 3.06; 95% CI, 2.29-3.77).

Thirty-eight patients (40%) were prescribed CPAP before surgery, of whom 8 patients had central apnea components in their preoperative polysomnographic results. In these patients, no correlation was seen between the amount of positive pressure they required preoperatively or the central apnea components in their polysomnographic results with operative complications. Forty-eight of 95 patients (51%) developed at least 1 operative complication. The complication rates are presented according to the time of occurrence (ie, intraoperative, immediately postoperative [from the recovery room period until within 24 hours of surgery], and within 2-30 postoperative days). For analysis purposes, an overall dichotomous variable was created for patients who experienced any operative complication, and a dichotomous variable was created for each complication category to identify patients with more than 1 complication in each category (Table 2). Because some patients experienced multiple complications, the overall rate of complications is less than the sum of the individual complication subcategory. The most common complications were respiratory, and most complications occurred during the intraoperative period. Overall, respiratory and cardiovascular complications occurred early, whereas surgical complications happened after day 1 of surgery.

The patients underwent the following procedures. Five patients (5%) underwent nasal surgery only, 33 (35%) underwent palatopharyngeal surgery only, 4 (4%) underwent tongue base surgery only, and 53 (56%) underwent a combination of at least 2 operations simultaneously. We categorized patients into complication and noncomplication groups and compared these groups to determine factors that contributed to operative complications (Table 3). Complication is affected by age (Cohen d, 2.78; 95% CI, 2.19-3.32) and BMI (Cohen d, 3.2; 95% CI, 2.57-3.78). The presence of comorbid disease generally increases the rate of complication, but this finding was not statistically significant (P = .07). Within the polysomnographic factors, lowest oxygen desaturation (Lsat) (Cohen d, 5.5; 95% CI, 4.58-6.33) and longest apnea duration (Cohen d, 4.0; 95% CI, 3.27-4.66) were significantly associated with complications but not AHI. Complication rates were not affected by the sites of surgery and whether a single operation or concurrent multilevel operations were performed.

Logistic regression was used to analyze the multivariable association of OSA variables, age, BMI, smoking, and type of surgery with postoperative complications. Analyses were performed given any complication as the dependent variable (Table 4). Analyses were also performed separately for pulmonary, surgical, and cardiovascular complications alone. Increased BMI and age were associated with increased likelihood of all categories of complications. Within the polysomnographic variables, Lsat and longest apnea duration were associated with significantly higher odds of complications. However, OSA severity category (mild, moderate, or severe) and AHI were not associated with higher odds of operative complications. Similarly, multilevel operations were not associated with increased complication rates compared with a single operation.

Discussion

Among the multiple comorbidities associated with upper airway surgery that may increase perioperative complications, OSA may attract particular attention because it poses further risk of airway obstruction and yet is not intensely looked for during preoperative assessments. To our knowledge, this study represents one of the comprehensive reports examining the effect of OSA diagnosed by strict criteria on the rate of perioperative complications in multiple concurrent upper airway surgery sites. The main finding is that, among patients undergoing upper airway surgery as a treatment for OSA, we did not find an independent association between severity of OSA as determined by the AHI with short-term operative complications. Within the polysomnographic variables, only Lsat and longest apnea duration predict the operative complications. No association was found between the number and levels of concurrent upper airway surgery performed and frequency of operative complications.

Limitations

It is challenging to study risks of surgical complications in OSA cases because of the wide variations of the definitions used for complications among studies and the low incidence of life-threatening complications, which requires a large sample size to analyze with significance. In addition, previous studies2,8 that used clinical symptoms of OSA as their selection criteria without performing polysomnography for standard diagnosis may have included other forms of sleep-disordered breathing (SDB), such as upper airway resistance syndrome, which may affect the true interpretation of the results. The criteria for diagnosis of upper airway resistance syndrome is still controversial,2,8 and increasingly more physicians recognize upper airway resistance syndrome as a clinical syndrome that has differential features from OSA.21

With these limitations in mind, it is not surprising that past studies7-12 designed to assess OSA as a risk factor for operative complications for airway and nonairway operations have published contrasting results. We hypothesized that, if the diagnosis of OSA is an independent risk for operative complications, there should be a significant association between the severity of OSA and the rate of complications. As expected in our patients, age, BMI, and smoking increase the risk of complications in upper airway surgery. Nonetheless, univariate and multivariable analyses revealed no association between preoperative AHI severity and complication rates. Because sleep laboratories differ in their criteria for detecting episodes of apnea and hypopnea, many experts believe that the sleep laboratory’s assessment (none, mild, moderate, or severe) should take precedence over the actual AHI (the number of episodes of SDB per hour) in measuring the severity of OSA for research purposes.5,6 Even with the use of mild, moderate, and severe category grading, no significant association was found between OSA severity and the complication rates found in our data. Thus, either OSA is not an independent risk factor for operative complications or the preoperative recognition, and hence the subsequent preoperative medical management, mitigates this risk. Studies3,22,23 have found that the rate of surgical complications was reduced in patients with OSA preoperatively treated with CPAP. Large studies17,24 also found that, regardless of OSA severity, a planned elective surgery in patients with preoperatively diagnosed and managed OSA did not result in increased risk of perioperative complications. For example, in a study published in 2003, Sabers and colleagues24 found that preoperative diagnosis of OSA was not a risk factor for surgical complications among patients undergoing outpatient surgical procedures. Similarly, a more recent and comprehensive study17 examining the effect of OSA on the rate of complications of bariatric surgery discovered no association between the severity of OSA as assessed preoperatively and perioperative complications.

Increasing evidence shows that the incidence of operative complications is greater in unrecognized OSA than in known OSA.1,25 Recently, a matched cohort study26 found that, although the presence of OSA increased the rate of complications by 2-fold, it is the patients with unrecognized OSA who were twice as likely to experience complications than those whose conditions were diagnosed and managed accordingly before surgery. Alarmingly, the prevalence of OSA was estimated to increase more than 4-fold from 1993 until recently.27,28 In our study population, SDB is reported to affect 46 of 317 children (14.5%) aged 7 to 15 years and 549 of 1611 adults (34.1%) older than 30 years.29,30 It was estimated that more than 80% of patients have undiagnosed OSA,27 and unrecognized OSA is prevalent among adult surgical patients.31,32 This finding may lead to a significantly increased risk of perioperative complications.32

We found that, rather than the AHI, Lsat (odds ratio, 1.03; 95% CI, 0.96-1.45; P = .04) and longest apnea duration (odds ratio, 1.03; 95% CI, 0.99-1.08; P = .02) were the polysomnographic variables that predict the perioperative complications. Many past studies2,3,8,9 on upper airway surgery for OSA reported that it is the preoperative Lsat or longest apnea duration that consistently linked with operative complications rather than the AHI severity. These studies2,3,8,9 might have indicated that, in the patients with polysomnography-confirmed OSA undergoing surgery, these variables are more important and significant than AHI in determining the rate of complication.

The current series includes 95 patients who underwent surgery for the treatment of OSA. There were no deaths in our series, but 48 of 95 patients developed at least 1 operative complication. This figure is high compared with many previous studies.8-10,33 We think this occurred partly because we have lowered the definition of complications to include even a slight deterrent from the normal variables (eg, temporary oxygen desaturation, CPAP or BiPAP intervention, and atelectasis are sometimes not included as respiratory complications in studies). Furthermore, compared with previous studies,2,8,9,26 most of our patients had severe OSA (54 of 95 [57%]) (Table 1). Similar to many other OSA surgery series,2,8,9,26 pulmonary complications were the most common and consistently reported complications of our cohort. The risk of respiratory complications after upper airway surgery is enhanced in patients with OSA because of the underlying anatomical and physiologic abnormality associated with the disease. Anesthetic and analgesic agents used during the perioperative period can decrease upper airway muscle tone and depress ventilatory responses, particularly during the early postoperative period.34 In particular, opioid anesthesia adversely affects SDB and leads to suggestions that it should be avoided in OSA surgery.5,34,35 These heightened concerns have prompted physicians to recommend routine postoperative intensive care unit stays in patients with comorbid factors and those undergoing multiple procedures.36-38 In our study, however, we did not find any significant association between the types of analgesics used and the rates of operative complications. The choices of anesthesia, analgesics, and intensive care unit use in our cohort are at the discretion of the attending anesthetists; thus, it is beyond the power of the study to give a meaningful conclusion on this point.

Our data did not reveal that concurrent, multilevel surgery sites increased the complication risks. Mickelson and Hakim,10 in their series of 344 UPPP surgery cases, noted a higher rate of complications in patients who underwent nasal procedures along with UPPP compared with UPPP alone. A more recent study39 that directly compared the complications rate in simultaneous nasal and pharyngeal surgery (group 1) or pharyngeal surgery alone (group 2) to treat OSA found that performing concurrent nasal and oropharyngeal surgery for OSA was safe when compared with oropharyngeal surgery alone. The authors even suggested that, with careful selection criteria, group 1 surgery can even be performed in the ambulatory setting.39 Many other past series found that complication rates were also not associated with types of procedures performed and whether the surgery was a single or combination surgery.8,15,40 However, the choice of surgical approach was predetermined and not randomized in our study; therefore, not all differences in complication rates can be attributed to operative approach alone. Multiple upper airway site operations for OSA can be performed in combination or in a multistep manner, with data indicating that surgical outcomes in a simultaneous surgery group were equivalent to those in a staged surgery group.41

The limitations of this negative finding must be acknowledged. First, all our patients had OSA diagnosed by polysomnography before the operation, so most of these patients received intensive treatment and monitoring intraoperatively and postoperatively. The intensity of the monitoring and intervention may have increased with the severity of OSA. It is likely that any substantial complication, such as respiratory depression, would have been diagnosed quickly and treated in these intensively monitored settings. Thus, this negative association between OSA severity and operative complication cannot be applied to patients with unrecognized or untreated OSA. Second, the result also cannot determine whether OSA per se increases perioperative risk because most of the patients in this series had OSA, and no patients without OSA were included as controls. Third, our study is retrospective; the nature of the study may predispose the study to recall bias, with data on relevant history and complications not collected. A large number of potential candidates (19%) were excluded because of communication and documentation loss, which could have affected the results of the study. Fourth, operations were performed by 3 different surgeons (Z.A.A., K.A., W.I.L.). Although the principal author (Z.A.A.) was present in the operating theater during all of the operations, this factor could still lead to technical bias. Fifth, to avoid confounding based on differences in polysomnographic techniques, we studied only patients who underwent polysomnography at a single institution, a potential source of selection bias.

Conclusions

In patients with OSA undergoing upper airway surgery, the severity of OSA as assessed by AHI and the sites and numbers of concurrent operations performed were not associated with the rate of short-term operative complications. Both Lsat and longest apnea duration more consistently predicted the operative complications in our study.

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Article Information

Corresponding Author: Zamzil Amin Asha’ari, MMed (ORL-HNS), Department of Otorhinolaryngology–Head and Neck Surgery, International Islamic University Malaysia, Jalan Hospital, 25100 Kuantan, Pahang, Malaysia (zamzilamin@yahoo.com).

Accepted for Publication: September 21, 2016.

Published Online: November 23, 2016. doi:10.1001/jamaoto.2016.3268

Author Contributions: Drs Asha’ari and Ab Rahman had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: Asha'ari, Ab Rahman, Mohamed.

Drafting of the manuscript: Asha'ari, Leman.

Critical revision of the manuscript for important intellectual content: Asha'ari, Ab Rahman, Mohamed, Abdullah.

Statistical analysis: Asha'ari, Ab Rahman.

Administrative, technical, or material support: Asha'ari, Abdullah, Leman.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Funding/Support: The study was supported by grant EBW B 13-022-0907 from the International Islamic University Malaysia (principal investigator, Dr Asha’ari).

Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and the decision to submit the manuscript for publication.

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