Resuming positive airway pressure (PAP) therapy immediately following endoscopic sinus surgery may not be associated with worse sinonasal outcomes.
In a prospective controlled study, investigators included 100 adults with chronic rhinosinusitis undergoing functional endoscopic sinus surgery at 4 US academic medical centers between 2019 and 2024, 49 of whom had obstructive sleep apnea (OSA) and resumed PAP therapy on postoperative day 0 or 1 and 51 of whom did not have OSA. Both primary and revision procedures were included, with surgical extent ranging from bilateral maxillary antrostomy and anterior ethmoidectomy to comprehensive sinus surgery.
The primary outcome was change in Lund-Kennedy endoscopic scores from baseline to postoperative visits at 5 to 12 days and 18 to 31 days. Secondary outcomes included sinonasal symptoms measured using the SNOT-22 test, sleep quality assessed with the Pittsburgh Sleep Quality Index (PSQI), epistaxis severity, bleeding requiring medical management, and PAP-related complications. Multivariable analyses adjusted for sex, asthma, aspirin-exacerbated respiratory disease, diabetes, surgery type, and nasal polyp status.
At the first postoperative visit, mean Lund-Kennedy scores increased by 0.5 points in the PAP group and decreased by 1.4 points among controls, indicating less improvement in the PAP group in the unadjusted analysis. Although this difference was statistically significant before adjustment, early PAP resumption was not independently associated with higher endoscopic scores after adjustment. At the second visit, scores decreased by 0.8 points in the PAP group and 2.1 points among controls, with no statistically significant difference between groups. Adjusted analyses similarly showed no statistically significant association between early PAP resumption and worse endoscopic outcomes at either visit.
Sinonasal symptoms improved in both groups. At the first postoperative visit, mean SNOT-22 scores decreased by 15 points among patients receiving PAP therapy and 14 points among controls. By the second visit, scores had decreased by about 20 and 26 points, respectively. Adjusted analyses found no statistically significant association between early PAP resumption and higher SNOT-22 scores at either assessment.
Mean PSQI scores decreased by 2.6 points in the PAP group and 1.5 points among controls at the first postoperative visit. At the second visit, the corresponding decreases were 3.6 and 4.3 points. Neither unadjusted nor adjusted analyses identified statistically significant differences between groups.
Mean epistaxis severity scores were 1.0 among patients receiving PAP therapy and 1.3 among controls. No patients in the PAP group required medical management for epistaxis compared with 1 patient in the control group. Adjusted analyses found no statistically significant association between early PAP resumption and greater bleeding severity or the need for medical intervention. No PAP-related complications were reported.
Diabetes was present in 14% of patients receiving PAP therapy vs. 2% of controls, whereas aspirin-exacerbated respiratory disease was reported in 14% of controls and 0% of the PAP group. Postoperative oral steroids were administered to 31% of patients receiving PAP therapy vs. 67% of controls. The differences could have influenced postoperative healing and symptom outcomes, although adjusted analyses did not identify worse outcomes associated with early PAP resumption.
The study had several limitations, including its nonrandomized design, incomplete data collection for selected variables, and baseline differences between groups. PAP adherence was self-reported rather than electronically verified, and patients without OSA were not formally screened for the condition. PAP adherence was higher than typically observed in clinical practice and that OSA severity was not evaluated. The relatively small sample limited the assessment of uncommon complications, while the exclusion of patients with skull base defects and those undergoing certain extensive procedures restricted generalizability.
The results could inform perioperative management and support reconsideration of prolonged delays in PAP resumption that have largely been driven by theoretical concerns.
"These findings address a common area of clinical uncertainty and support the safety of early PAP use following [functional endoscopic sinus surgery]," wrote lead study author Garret Choby, MD, of the University of Pittsburgh Medical Center, and colleagues.
Full disclosures of the study authors can be found in the study.