Comparative study between single-stage multilevel surgery and staged surgery for management of snoring and/or obstructive sleep apnea

Abstract
Background
When the nasal obstruction is identified in cases of snoring and/or OSA with suspected oropharyngeal and nasal obstruction, the combination of nasal and palate surgeries is suggested to be conducted in either a single-staged or multi-staged manner. This study aimed to assess the efficacy and safety of combined nasal-palatopharyngeal surgery in a staged versus a single-stage multilevel procedure.

Methods
Prospective randomized comparative study included 60 patients with combined nasal and retropalatal obstruction, > 18 years old, BMI < 40, with snoring and/or mild to moderate OSA (AHI ˂ 30) and ASA < 3. Patients were randomly allocated into three groups (every 20 patients); groups 1 and 2 patients underwent a staged procedure, where group 1 had a nasal surgery as a first step for management of nasal obstruction, followed by a BRP after 3 months and vice versa for group 2 patients, while group 3 patients had a single-stage combined nasal surgery and (BRP). Preoperative and 6 months post-operative SOS, SBPS, ESS scores, and polysomnography data (AHI, ODI) were recorded. Post-operative complications, pain (VAS), and duration of hospital stay were monitored.

Results
Post-operative improvement in SOS, SBPS, EES, AHI, and ODI were similar after a staged or a single-stage multilevel procedure with no significant intergroup differences. Total operative time for single-stage multilevel surgery (80 ± 25 min) was significantly shorter than that for the staged procedure (135 ± 30 min). Post-operative complications were temporary and not severe in both surgical procedures and included wound infection (11.67%) and nasal bleeding (11.67%), which were resolved immediately by firm pressure and nasal packing and suture extrusion (5%). However, it didn't appear to alter anatomical and functional outcomes. Post-operative pain by VAS was significantly higher after a single-stage multilevel procedure (5.8 ± 1.4) compared to (2.8 ± 0.6 and 3.7 ± 0.7, respectively) in groups 1 and 2 that underwent a staged surgery.

Conclusion
Combined nasal surgery and BRP, either staged or single-stage multilevel procedure in the treatment of snoring and/or mild and moderate OSA with nasal obstruction, provide similar successful improvement in subjective and objective findings. A single-stage procedure was safer because of a significantly shorter total operative time, and repeated hospitalization and need for anesthesia were avoided.