nasal septal perforation ( nsp ) is a rare disorder characterized by composite loss of mucosa and bone or cartilage that compose the nasal septum .
septal surgery , trauma , inflammatory diseases , and use of topical nasal sprays have been implicated in the etiology of nsp ( 2 , 3 ) .
although most of the patients with nsp are asymptomatic , complaints may occur , depending on the size and location of the perforation .
patients with posterior septal perforations are usually asymptomatic . anteriorly located small perforations may cause a whistling sound while breathing , and patients with larger anterior perforations complain of dry and blocked nose , crusting , foreign body sensation , and bleeding .
nasal septal perforations may also alter nasal airflow patterns and physiology . although a number of studies have evaluated the effect of nasal septal deviation and its surgical treatment on sleep - disordered breathing ( sdb ) ,
there is little data on sleep parameters and sdb in a cohort of patients with nasal septal deviation .
similarly , to the best of our knowledge , no studies in the english literature have investigated the effect of nsp and its treatment on polysomnographic parameters .
therefore , in this study we aimed to investigate polysomnographic sleep and respiratory parameters in patients with nsp as well as changes in those parameters after treatment of nsp . to the best of our knowledge ,
we conducted a clinical study at the otorhinolaryngology department of ankara numune training and research hospital .
all investigations were performed in accordance with the declaration of helsinki on biomedical studies involving human subjects , and informed consent was obtained from all participants before the study began .
the participants were selected from patients who presented with nsp and were admitted to the otorhinolaryngology clinic .
prior to the onset of the sleep study , the data were registered for each participant individually , including age , sex , height and weight ( to calculate body mass index [ bmi ] ) , medical history of comorbid diseases , previous surgeries , and complaints caused by nsp .
exclusion criteria included nasal problems other than septal perforation ( e.g. , nasal polyps , chronic rhinosinusitis , allergic rhinitis , and septal deviation ) , other sleep disorders ( e.g. , insomnia , hypersomnia , and sleep - related movement disorders ) , and neurologic and psychiatric disorders .
first , all patients had a detailed otorhinolaryngologic examination , and the location of nsp was determined by diagnostic nasal endoscopy .
the septal perforation width and length were measured in millimeters and septal perforation area was calculated as width  length . after detailed medical history - taking and physical examination , participants who were found to be appropriate to include in this study completed the epworth sleepiness scale ( ess ) questionnaire and underwent a full - night polysomnography ( psg ) study .
the ess is an 8-item questionnaire designed to capture an individual s propensity to fall asleep during commonly encountered situations , on a scale ranging from 0 to 3 .
the scores for the 8 questions are added together to obtain a single total score that can range from 0 to 24 . in adults ,
we used the alice 5 psg ( alice 5 diagnostic sleep system , philips respironics , philips healthcare , the netherlands ) device to record baseline and post - procedure psg .
all psgs were performed during at least 7 hours of spontaneous sleep , under the supervision of an experienced sleep technician in the sleep center of ankara numune education and research hospital .
the channels included in psg were 4-channel electroencephalography , 3-channel electromyography ( mentalis , and right and left tibialis anterior muscles ) , 2-channel electrooculography ( right and left eyes ) , 2-channel electrocardiography , nasal airflow , thoracic and abdominal respiratory movements , pulse oximetry , and body position . sleep and respiratory parameters were evaluated according to the american academy of sleep medicine ( aasm ) criteria , consisting of non - rapid eye movement ( nrem ) stages n1 , n2 , n3 , and rem stage during sleep .
stage 2 is identified by the presence of k - complexes or sleep spindles ( or both ) .
stage 3 ( n3 ) represents the deepest stages of sleep and is also described as slow - wave sleep
. rapid eye movement ( rem ) sleep is commonly described as paradoxical sleep and is characterized by a highly activated brain within a paralyzed body .
rem sleep is identified by the combination of 3 conditions : ( 1 ) the eeg returns to a relatively low - voltage , mixed - frequency pattern within cessation of sleep spindles , k - complexes , and high - amplitude slow waves ; ( 2 ) the chin emg falls to the lowest level of the recording ; and ( 3 ) the eog channels demonstrate the presence of rapid eye movements .
psg records were scored according to the guidelines american academy of sleep medicine manual for scoring of sleep and associated events , version 2.0 ( 2014 ) . following acquisition of baseline psg data ,
a silicone septal button was placed under local anesthesia to cover the perforation , and complete closure of the perforation was confirmed by endoscopic nasal examination .
a post - procedure psg was obtained at least 7 days after the insertion of the septal button .
psg parameters , including sleep efficiency , durations of stages 1 , 2 , and 3 and rem , total apnea hypopnea index ( ahi ) , rem ahi , non - rem ahi , and mean and lowest po2 saturation were compared between the baseline and post - procedure recordings .
baseline and post - procedure parameters related to sleep were also compared after dividing the patients into 2 groups , those with ahi < 5 and those with ahi 5 .
statistical analysis was performed using spss version 11.5 for windows ( spss , inc . ,
the paired samples t test was used for the variables with a normal distribution , and wilcoxon matched pair test was used for variables that were not normally distributed .
the independent samples t test was used for the variables with normal distribution in relation with the perforation size , and the mann - whitney u test was used for the variables that were not normally distributed .
normally distributed variables are presented as mean sd , whereas variables that were not normally distributed are shown as median [ interquartile range ( iqr ) ] .
the ess is an 8-item questionnaire designed to capture an individual s propensity to fall asleep during commonly encountered situations , on a scale ranging from 0 to 3 .
the scores for the 8 questions are added together to obtain a single total score that can range from 0 to 24 . in adults , an ess score 10 indicates increased daytime sleepiness .
we used the alice 5 psg ( alice 5 diagnostic sleep system , philips respironics , philips healthcare , the netherlands ) device to record baseline and post - procedure psg .
all psgs were performed during at least 7 hours of spontaneous sleep , under the supervision of an experienced sleep technician in the sleep center of ankara numune education and research hospital .
the channels included in psg were 4-channel electroencephalography , 3-channel electromyography ( mentalis , and right and left tibialis anterior muscles ) , 2-channel electrooculography ( right and left eyes ) , 2-channel electrocardiography , nasal airflow , thoracic and abdominal respiratory movements , pulse oximetry , and body position .
sleep and respiratory parameters were evaluated according to the american academy of sleep medicine ( aasm ) criteria , consisting of non - rapid eye movement ( nrem ) stages n1 , n2 , n3 , and rem stage during sleep .
stage 2 is identified by the presence of k - complexes or sleep spindles ( or both ) .
stage 3 ( n3 ) represents the deepest stages of sleep and is also described as slow - wave sleep
. rapid eye movement ( rem ) sleep is commonly described as paradoxical sleep and is characterized by a highly activated brain within a paralyzed body .
rem sleep is identified by the combination of 3 conditions : ( 1 ) the eeg returns to a relatively low - voltage , mixed - frequency pattern within cessation of sleep spindles , k - complexes , and high - amplitude slow waves ; ( 2 ) the chin emg falls to the lowest level of the recording ; and ( 3 ) the eog channels demonstrate the presence of rapid eye movements .
psg records were scored according to the guidelines american academy of sleep medicine manual for scoring of sleep and associated events , version 2.0 ( 2014 ) .
following acquisition of baseline psg data , a silicone septal button was placed under local anesthesia to cover the perforation , and complete closure of the perforation was confirmed by endoscopic nasal examination .
a post - procedure psg was obtained at least 7 days after the insertion of the septal button .
psg parameters , including sleep efficiency , durations of stages 1 , 2 , and 3 and rem , total apnea hypopnea index ( ahi ) , rem ahi , non - rem ahi , and mean and lowest po2 saturation were compared between the baseline and post - procedure recordings .
baseline and post - procedure parameters related to sleep were also compared after dividing the patients into 2 groups , those with ahi < 5 and those with ahi 5 .
statistical analysis was performed using spss version 11.5 for windows ( spss , inc . ,
the paired samples t test was used for the variables with a normal distribution , and wilcoxon matched pair test was used for variables that were not normally distributed .
the independent samples t test was used for the variables with normal distribution in relation with the perforation size , and the mann - whitney u test was used for the variables that were not normally distributed .
normally distributed variables are presented as mean sd , whereas variables that were not normally distributed are shown as median [ interquartile range ( iqr ) ] .
nineteen patients diagnosed with nsp between september 2013 and april 2014 were included in the study .
the mean age of the patients was 42.2613.20 years ( range , 2365 years ) . among the total of 19 patients , 15 ( 79% )
patients had septoplasty , 2 ( 11% ) had use of nasal sprays , 1 ( 5% ) had nasal trauma , and 1 ( 5% ) patient did not have any clear etiologic factors in the history .
the most common complaint was dry nose and crusting ( n=19 , 100% ) , followed by nasal blockage ( n=13 , 68% ) , whistling during respiration ( n=5 , 26% ) , and daytime sleepiness ( n=2 , 10% ) .
the mean body mass index ( bmi ) was 27 ( range , 21.4434.53 ) , and the mean ess score was 4 .
when baseline psg parameters were analyzed , it was seen that sleep efficiency and percentages of n1 , n2 , and n3 were within normal limits ; however , there was a small decrease in percentage of rem sleep ( 15.45.2,% total sleep time ) ( table 1 ) .
rem sleep accounts for about 2025% of the sleep time in normal adults ( 9 ) and in our cases , percentage of rem sleep was less than in normal adults .
baseline ahi was < 5 in 9 patients , 514 in 5 patients , and 15 in 5 patients .
median baseline ahi was 5.30 ( 14.40 ) , and there was only a small deviation from the normal limits . on the other hand ,
median supine ahi was 10.00 ( 42.10 ) , and there was a tendency for supine position - dependent sleep apnea in patients with nsp .
median ahi [ 5.30 ( 14.40 ) vs. 2.40 ( 14.50 ) ] , and median supine ahi [ 10.00 ( 42.10 ) vs. 6.60 ( 37.00 ) ] decreased after correction of the perforation , but the differences were not statistically significant .
other studied baseline psg parameters did not change significantly after treatment of nsp ( table 1 ) .
the median nsp size was 66.00 ( 86.00 ) mm2 ( range , 5402 mm ) .
ten ( 53% ) patients had perforations 66 mm , and 9 ( 47% ) patients had perforations > 66 mm .
we divided the patients into 2 groups : ones with a perforation size 66 mm , and the ones with a perforation > 66 mm .
none of the studied parameters showed significant differences between the groups ( p>0.05 for all ) .
however , the median baseline supine ahi was 10.10 ( 34.15 ) in the group with a perforation > 66 mm , and it was 8.55 ( 51.43 ) in the group with a perforation size 66 mm .
although median supine ahi decreased to 1.60 ( 28.30 ) after closure of the perforation in the group with a perforation > 66 mm , the difference was not statistically significant ( p=0.130 ) .
there were no significant changes in the 2 groups for other baseline and post- procedure parameters studied ( p>0.05 for all ) ( table 2 ) .
the patients were divided into 2 groups according to their ahi : ones with ahi < 5 , and ones with ahi 5 .
none of the parameters studied in the 2 groups showed significant changes after closure of the perforation ( table 3 ) .
factors relating to anxiety and stress are the most important concomitants of sleep complaints in the general population .
the nasal airway is quite rigid during sleep , and , in contrast to the oropharyngeal segment , it does not collapse .
a number of studies investigated the presence of nasal septal deviation and the impact of its surgical correction on sleep quality and respiratory parameters in patients with obstructive sleep apnea , showing that nasal surgery alone was not effective in restoring a normal sleep architecture or in treatment of obstructive sleep apnea [ 1114 ] .
however , sufiolu et al . reported that nasal surgery might lead to a reduction in continuous positive airway pressure ( cpap ) levels . on the other hand ,
sleep disorders in patients with nasal septal deviation were investigated in only a few studies .
increased airway resistance , unstable mouth breathing , and nasal reflexes may cause sdb or exacerbate those that already exist . the first study published on nasal airflow in nsp
was conducted by grtzenmacher et al . , and reported that there was not a correlation between nsp size and abnormal aerodynamics .
air temperature in patients with nsp was significantly lower than the controls with normal noses , due to air mixing in nsp .
the airflow passing through the perforation was turbulent and fast , and airflow speed was higher towards the rear end of the perforation .
in addition , blood flow was greater at the edges of the perforation . steady turbulent flow occurring at the sagittal plane caused prolonged and extensive mucosal contact , leading to mucosal irritation and dryness .
nsp may cause nasal obstruction and lead to sleep problems , similar to nasal septal deviation .
our study is the first one in the literature that studied polysomnographic sleep parameters in patients with nsp .
the results of this study indicate that rem sleep duration was shorter in patients with nsp , and it did not increase after treatment [ 15.45.2 vs. 16.44.2 ] .
rem sleep accounts for about 2025% of the sleep time in normal adults ( 9 ) and in our cases , percentage of rem sleep was less than in normal adults . in our study , in 5 patients ahi values were 15 .
therefore , in these patients , obstructive sleep apnea may cause lower rem percentages . in addition , both median ahi [ 5.30 ( 14.40 ) vs. 2.40 ( 14.50 ) ] , and median supine ahi [ 10.00 ( 42.10 ) vs. 6.60 ( 37.00 ) ] decreased after correction of the perforation .
there was a great reduction in median supine ahi in patients with a perforation size > 66 mm [ 10.10 ( 34.15 ) vs. 1.60 ( 28.30 ) ] .
second , we analyzed only objective parameters , and not the subjective ones after closure of the perforation .
third , we treated nsp with a prosthesis ( silicone nasal septal button ) , and not with surgery .
our preliminary results indicated that nsp did not cause any deterioration in objective sleep parameters as determined by psg , other than a decrease in rem sleep duration and an increase in supine ahi .
correction of nsp did not affect rem duration , but supine ahi decreased after treatment .
further studies performed on a larger patient cohort may shed light on the effects of nsp and its treatment on sleep .
 backgroundnasal septal perforation ( nsp ) may alter nasal airflow patterns and physiology . to the best of our knowledge , no studies in the english literature have investigated the effect of nsp and its treatment on polysomnographic parameters . in this study 
 , we aimed to investigate polysomnographic parameters in patients with nsp as well as changes in those parameters after treatment of nsp.material/methodsnineteen patients diagnosed with nsp were included in the study . 
 all patients had baseline and post - procedure polysomnographies ( psg ) after insertion of silicone septal button for closure of nsp.resultsboth median ahi [ 5.30 ( 14.40 ) vs. 2.40 ( 14.50 ) ] and median supine ahi [ 10.00 ( 42.10 ) vs. 6.60 ( 37.00 ) ] decreased after correction of the perforation . 
 there was a large reduction in median supine ahi in patients with a perforation size > 66 mm2 [ 10.10 ( 34.15 ) vs. 1.60 ( 28.30)].conclusionswe conclude that nsp did not cause any deterioration in objective sleep parameters as determined by psg , other than a decrease in rem sleep duration and an increase in supine ahi 
 . correction of nsp did not affect rem duration and supine ahi decreased after treatment . 