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Characteristics of obstructive sleep apnea syndrome in patients with partial laryngectomy

Abstract Objectives The impacts of partial laryngectomy on sleep‐disordered breathing were rarely investigated and reported in a limited number of patients. The aim of this study was to assess the prevalence of obstructive sleep apnea‐hypopnea syndrome (OSAHS) in patients with partial laryngectomy. Study design Case series. Methods All patients undergoing partial laryngectomy by open approach (frontolateral vertical partial laryngectomy and supracricoid horizontal partial laryngectomy) for squamous cell carcinoma of the larynx between January 2006 and December 2019 were enrolled. Listed patients were contacted via telephone to propose participating in the study and plan a sleep study: self‐assessments of sleep quality using the Pittsburgh Sleep Quality Index (PSQI) following a home sleep recording using respiratory polygraphy. Daytime sleepiness was also self‐assessed by using the Epworth sleepiness scale. Results Twenty patients with sleep record were included to the analyses. There were 11/20 patients (55%) diagnosed with moderate to severe OSASH. No relationship between OSAHS severity and age as well as body mass index (BMI) was observed. The Epworth sleepiness score was not necessarily high in patients with moderate/severe OSASH. Type of partial laryngectomy did not influence apnea‐hypopnea index (AHI) results. There was no difference in terms of age, BMI, gender, type of partial laryngectomy, and the presence of adjuvant radiotherapy between two groups AHI < 15/h and AHI ≥ 15/h. Conclusion A sleep study screening for OSAHS should be considered in patients with partial laryngectomy in order to improve their sleep quality and quality of life even though they did not exhibit daily sleepiness and obesity.


| INTRODUCTION
Sleep disorder is one of the main complaints of cancer patients. Most studies have focused on insomnia and cancer-related fatigue. 1 However, few studies focused on obstructive sleep apnea-hypopnea syndrome (OSAHS) in a small number of patients with head and neck cancer, especially in some after treatment. Head and neck tumors may cause anatomic abnormalities of the upper airway. Treatments including surgery and radiation may further engender airway narrowing and architectural modifications. Moreover, these therapies induced neurosensory dysfunction affecting feedback from the upper airway to the pharyngeal dilatators. 2 Thus, patients with head and neck cancer of the laryngopharynx are at significant risk of OSAHS. 2 Faiz et al, in a series of 56 patients with head and neck cancers, showed a significant sleep-related breathing disorder was noted in 93% of patients, and 84% met clinical criteria for OSAHS. 1 Other compounding causes for sleep disturbance which is specific to head and neck cancers include pain, depression, nicotine and alcohol use, and xerostomia. 3 Poor impact on sleep due to xerostomia, occurring after radiation therapy, is a common complaint of patients with head and neck cancer. Xerostomia can lead the excessive consumption of liquids resulting in nocturia, frequent arousals, and difficulty in returning to sleep after awakening. Similarly, post-therapeutic swallowing disorders can also result in frequent arousals due to salivary stasis during sleep. Disfiguring surgery and functional loss of upper aerodigestive tract (eating, speaking, and swallowing) may also predispose those patients to depression.
Thus, the features of OSAHS in patients with head and neck cancers may be untypical. Since OSAHS without treatment is at risk of high overall mortality, it is recommended conducting a sleep study for patients with unexplained daytime sleepiness. 4 However, for asymptomatic individuals or some with unrecognized symptoms, especially in ones with head and neck cancers, current screening tools cannot be reliable. Thus, seeking anatomical abnormalities of upper airway, which may be predictive factors for OSAHS, should be considered.
So, identifying OSAHS in these patients are able to decrease their overall symptom burden. 1 The larynx that forms the junction between the upper and lower airways contributes also to OSAHS physiopathology. 2 However, the impacts of partial laryngectomy on sleep-disordered breathing are rarely investigated and reported in a small number of patients. [5][6][7] Laryngeal function preservation surgery modifies the anatomical structure of the pharynx and larynx which may affect the mechanoreceptor pathway and laryngeal sensitivity leading to the occurrence or aggravation of OSAHS. 2   were any technique problems raised during the recording (loss of sensor, defect in the power supply to the polygraph), a new sleep recording was planned. All involved patients gave their informed consent prior to study inclusion. This study was approved by the institutional review board of University Hospital of Nancy, France.

| STATISTICAL ANALYSIS
All statistical analyses were performed with SAS version 9.1 (SAS Institute, Inc., Cary, North Carolina). Descriptive statistics for quantitative variables were expressed as mean ± SD and as percentages for qualitative variables. The normality of continuous variables was tested with the Shapiro-Wilk test. Characteristics between groups were compared using the χ 2 for categorical variables and the Wilcoxon-Mann-Whitney test for continuous variables (due to the lack of conditions to perform the parametric tests). A two-tailed value of P < .05 was considered statistically significant.

| RESULTS
A total of 67 patients underwent a partial laryngectomy with open approach from 2006 to 2019 in our tertiary hospital. Eight patients were dead, 11 (16.4%) were lost to follow-up, 48 (71.6%) were regularly followed up until the studied period. Among these 48 patients, 19 were unreachable despite of phoning at least three times, 9 refused to participate in the study (5 for distance from home to hospital, 2 for "good" self-qualified sleep, and 2 for other medical problems), and 9 had a sleep record before the onset of the study. So, 20 patients with sleep record were included to analyses.  OSAHS severity was divided into two groups (AHI < 15/h not requiring any treatments and AHI ≥ 15/h requiring specific treatments). There were no statistically significant differences between two groups in terms of age, BMI, gender, type of partial laryngectomy, and the presence of adjuvant radiotherapy (Table 3).  Other particularity of OSAHS in these patients is a low score of ESS. Our findings are similar of data published by Ouyang et al. 7 However, the high PSQI in these ones indicates poor sleepers. Thus, ESS is not a reliable tool to recommend performing sleep record in patients with partial laryngectomy. The low score of the ESS reported by these patients may be explained that they are accustomed to this chronic condition since fatigue is often overlooked or considered "normal"

T A B L E 1 Characteristics of patients
and acceptable 13

| CONCLUSION
Sleep study, especially OSAHS screening, needs regarding in patients with partial laryngectomy to improve their sleep quality and quality of life even though they did not exhibit daily sleepiness and obesity.