# Obstructive Sleep Apnea in Head and Neck Cancer Survivors: What Patients Need to Know

This systematic review and meta-analysis examined the risk of obstructive sleep apnea (OSA) in head and neck cancer survivors. Researchers analyzed 16 studies involving 419 participants and found that the average prevalence of OSA in head and neck cancer survivors was 83.7%. The average prevalence before treatment was 79.9%, and after treatment it was 88.7%. Patients experienced a statistically significant increase in their apnea-hypopnea index (AHI) of 4.28 points after treatment. The authors conclude that all head and neck cancer survivors should undergo routine screening for obstructive sleep apnea, regardless of which treatment they received.

# Obstructive Sleep Apnea in Head and Neck Cancer Survivors: What Patients Need to Know

## Table of Contents

- Key Points
- Background: Why This Research Matters
- What Is Obstructive Sleep Apnea?
- How the Research Was Conducted
- Key Findings: What the Research Showed
- Findings by Treatment Type
- What This Means for Patients
- Limitations of the Study
- Recommendations for Patients and Caregivers
- Frequently Asked Questions
- Source Information

## Key Points

- In a review of 16 studies with 419 participants, average OSA prevalence in head and neck cancer survivors was 83.7%.
- Average OSA prevalence rose from 79.9% before treatment to 88.7% after treatment in the reviewed studies.
- In 8 studies reporting before-and-after data, patients had a statistically significant average AHI increase of 4.28 points after treatment.
- High OSA prevalence was seen regardless of treatment type—surgery, radiation, chemotherapy, or combinations—in the reviewed studies.
- The review authors propose that all head and neck cancer survivors undergo routine validated screening for obstructive sleep apnea.

## Background: Why This Research Matters

Head and neck cancers (HNC) include malignancies of the oral cavity, nasal cavity, pharynx, larynx, paranasal sinuses, and salivary glands. Squamous cell carcinoma (SCC) is the most common type of head and neck cancer. Risk factors vary based on the type and location of the malignancy. These risk factors include alcohol consumption, tobacco use, HPV (human papillomavirus) infections, and radiation exposure.

Treatment is determined by the malignancy type, location, histopathology (how the cancer cells look under a microscope), staging, and p16 status (a protein marker that helps identify HPV-related cancers). Treatment can include surgical resection (surgery to remove the cancer), radiation, and/or chemotherapy.

The treatment of head and neck cancer often results in significant morbidity (health complications). One potential side effect is obstructive sleep apnea (OSA). Numerous studies have demonstrated a high incidence of OSA in head and neck cancer survivors. However, results vary widely between studies. The percentage of head and neck cancer survivors with OSA ranges from 12% to 96% across different studies.

Multiple systematic reviews have been performed on this topic. All of these reviews commented on the high prevalence of OSA in patients with a history of head and neck cancer. Still, there was no clear consensus on whether certain treatment modalities were associated with an increased risk of OSA.

Only one meta-analysis on OSA in head and neck cancer survivors had ever been performed before this study. That meta-analysis specifically examined the risk of OSA in patients who received radiotherapy (radiation treatment). This meta-analysis was hampered by small sample sizes and significant heterogeneity (variation) between studies. Ultimately, it showed no significant increase in OSA before versus after radiotherapy.

The mechanism by which treatment of head and neck cancer could result in OSA is unclear. Previous studies have proposed that the development of OSA in this patient population could be secondary to several factors. These factors include radiation-induced mucosal edema. Mucosal edema is swelling of the moist lining inside the mouth and throat. These factors also include mucositis, which is inflammation of the mucous membranes. These factors also include lymphedema, which is swelling due to lymph fluid buildup. These factors also include fibrosis, which is scarring and stiffening of tissue. These factors also include post-surgical anatomic alterations. Post-surgical anatomic alterations are changes to the structure of the head and neck after surgery.

It is well-recognized within the literature that OSA has numerous negative health consequences. These consequences include but are not limited to hypertension (high blood pressure), coronary artery disease, stroke, and type 2 diabetes mellitus. These consequences also include poor wound healing, reduced quality of life, and prolonged or complicated postoperative recovery. Additionally, OSA has been associated with an increased risk for the development of certain malignancies. This may be secondary to tissue damage from chronic hypoxemia (low oxygen levels in the blood over a long period).

Currently, there is a lack of consensus regarding the relationship between OSA and head and neck cancer. Additionally, there is a lack of consensus regarding which types of head and neck cancer and treatment modalities result in the greatest risk for OSA. Furthermore, there are no clear guidelines regarding early intervention and detection of OSA in head and neck cancer patients.

The researchers hypothesized that the various structural changes induced by treatment of head and neck cancer may increase the risk of developing OSA in a treatment-dependent manner. Given the lack of consensus, the researchers sought to perform the first systematic review and meta-analysis. The researchers sought to critically examine the relationship between head and neck cancer treatment and the risk of OSA in head and neck cancer survivors.

## What Is Obstructive Sleep Apnea?

Obstructive sleep apnea is a condition where a person's breathing repeatedly stops and starts during sleep. This happens because the airway becomes blocked or narrowed. The blockage prevents air from reaching the lungs.

Doctors measure the severity of OSA using the apnea-hypopnea index (AHI). The AHI counts how many times per hour a person stops breathing (apnea) or has reduced breathing (hypopnea) during sleep. A higher AHI means more severe sleep apnea.

For this study, the researchers used a standard definition of OSA. They defined OSA as an AHI of 5 or greater. This means a person experiences at least 5 breathing interruptions or reductions per hour of sleep.

## How the Research Was Conducted

The researchers followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) strategy. This is a widely accepted method for conducting and reporting systematic reviews. A Population, Intervention, Comparison, Outcome, Studies (PICOS) statement was used to identify studies that met inclusion or exclusion criteria.

The researchers performed an electronic literature search using four databases: Embase, Ovid MEDLINE, Web of Science, and Ovid All EBM Reviews. The search was performed on November 5, 2023. The search included filters for peer-reviewed and English-language articles.

The search strategy used terms for head and neck cancer combined with terms for sleep apnea. The head and neck cancer terms included "head and neck cancer," "oral," "lip," "pharynx," "larynx," "oropharynx," "tongue," "salivary gland," "tonsil," and "trachea." The sleep apnea terms included "sleep apnea," "obstructive sleep apnea," and "OSA."

The authors did not identify any manuscripts via citation searching or in the gray literature (unpublished or non-commercially published research).

### Study Selection and Eligibility Criteria

Studies were included based on specific criteria. The population was patients with head and neck cancer with no prior history of OSA. The intervention was head and neck cancer treatment including chemotherapy, radiation, and/or surgery of all types. The comparison was sleep study results from polysomnography (PSG) and/or home sleep apnea test (HSAT). The outcome was AHI scores after treatment. The studies included prospective and retrospective cohort studies, cross-sectional studies, and randomized control trials.

Exclusion criteria were non-English studies. Exclusion criteria were studies that did not evaluate all included patients with a formal sleep study. Exclusion criteria were studies that included patients with a prior history of OSA. Exclusion criteria were studies that prescreened patients to select subjects. Exclusion criteria were studies that used a nonstandard definition for OSA. The standard definition used was AHI of 5 or greater.

Titles and abstracts were screened by 2 independent reviewers with the help of a third reviewer to resolve conflicts. The full text of all identified studies was retrieved and underwent further screening to confirm that they met inclusion criteria. A PRISMA flow diagram outlined the steps of study selection. The literature search and study selection were performed using the Covidence systematic review management software.

### Data Collection

Three reviewers manually extracted data, and a fourth reviewer cross-checked extracted data for accuracy. Data extracted from each study included study design, sample size, patient demographics, cancer type and location, treatment modalities, and pre-treatment and post-treatment AHI scores.

### Quality Assessment

The authors assessed the level of evidence for each article using the Oxford Centre for Evidence-Based Medicine March 2009 guidelines. This uses a numeric scale of 1 to 5.

Bias was assessed using the validated Methodological Index for Non-Randomized Studies (MINORS) criteria. The MINORS criteria include 12 items, each scored as 0 for not reported, 1 for reported but inadequate, and 2 for adequate. Articles were reviewed by 2 authors and scored out of 24. Higher scores indicated a lower risk of bias. The final score was an average of the total scores of 2 independent reviewers.

### Meta-Analysis Methods

Random effects meta-analysis was used to estimate the overall prevalence of OSA. This estimate was across all 16 studies that reported the prevalence of OSA in head and neck cancer patients after head and neck cancer treatment. Binomial (Clopper-Pearson) confidence intervals were reported for individual studies. Individual proportions were transformed for meta-analysis using the double arcsine transformation (Freeman-Tukey) to improve the estimation of their sampling variances.

Studies were weighted with the inverse variance method. The DerSimonian-Laird estimator was used to estimate the between-study variance. These analyses were repeated to estimate OSA prevalences before and after head and neck cancer treatment. These analyses used the 8 studies that reported OSA prevalence both before and after head and neck cancer treatment.

Random effects meta-analysis was also used to estimate the overall mean change in AHI across the 8 studies that reported AHI in head and neck cancer patients before and after treatment. Mean AHI changes with their 95% confidence intervals were defined for individual studies as the post-treatment minus pre-treatment mean AHI score. Sampling variances were calculated using an assumed 0.7 correlation coefficient for paired AHI measures. This was based on the average of the correlation coefficients calculated from individual level data reported by Ouyang et al. and Lin et al.

Additional random effects meta-analyses were done to estimate the overall post-treatment mean AHI across all treatment modalities. Subgroup analyses of each treatment modality were also performed. These included surgery alone, surgery plus adjuvant therapy, or radiation with or without chemotherapy. These subgroup analyses were reported by the individual studies in which data reporting allowed for subgroup data extraction. Additionally, a meta-regression was performed of AHI change with continuous pre-age and pre-BMI (body mass index) as separate moderators.

Heterogeneity across studies was reported as the I² statistic with statistical significance. Analyses were performed using the meta and metafor packages in R.

## Key Findings: What the Research Showed

The literature search returned 575 studies for title and abstract screening. Of these, 51 met criteria for full-text review. Ultimately, 16 articles met inclusion criteria.

These included prospective cohort studies and cross-sectional studies published from 2006 to 2024. All 16 articles reported post-treatment AHI scores, involving a total of 419 participants. Eight studies included both pre-treatment and post-treatment sleep study results, involving 226 participants.

The timeline at which sleep studies were conducted varied significantly both within and between studies. The range was from 2 weeks to 12.2 years post-treatment. The average sleep study was conducted at 14.8 months after treatment.

The 8 studies that included both pre-treatment and post-treatment sleep study results conducted sleep studies 1 to 19 months post-treatment. The average was 4.7 months post-treatment.

Some studies reported AHI scores before and after treatment. The mean OSA prevalence in head and neck cancer survivors was 83.7%. This means that about 84 out of every 100 head and neck cancer survivors in these studies had OSA.

The mean prevalence before treatment was 79.9% with a 95% confidence interval of 70.0% to 88.3%. The mean prevalence after treatment was 88.7% with a 95% confidence interval of 82.3% to 94.0%.

In random effects meta-analysis, patients had a statistically significant increase in AHI of 4.28 after treatment. The 95% confidence interval was 0.46 to 8.09. This means the result was unlikely to be due to chance.

### Detailed Study Characteristics

The 16 included studies varied in their design, location, and patient populations. Here is a summary of key details from each study:

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**Chan et al. (2012):** 62 patients with tongue cancer. Mean age 62 years. 8% female, 92% male. Mean BMI 25.2 kg/m². 41 of 62 patients (35.8%) had OSA after treatment. Treatment modalities included surgery alone (9 patients, 53%), surgery plus radiation (14 patients, 56%). Mean overall AHI after treatment was 8.69. Mean AHI for surgery alone was 9.46. Mean AHI for surgery plus radiation was 8.6. Single-center study in Taiwan. Prospective cross-sectional study type. Sleep studies conducted 6 months to 11 years after treatment.
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**Chen et al. (2023):** 59 patients with laryngeal cancer. Mean age 60.1 years. 4% female, 96% male. Mean BMI 22.9 kg/m². 44 of 59 patients (47.6%) had OSA after treatment. Treatment modalities included surgery alone (24 patients, 67.3%), surgery plus radiation (12 patients, 20.3%), surgery plus chemoradiation (2 patients, 3.4%). Mean overall AHI after treatment was 12.8. Single-center study in China. Prospective cohort study type. Sleep studies conducted 1 to 17.5 months after treatment (average 4.3 months).
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**Gilete et al. (2024):** 47 patients with oropharyngeal, hypopharyngeal, or laryngeal cancer. Median age 63.4 years. 8.5% female, 91.5% male. Mean BMI 26.2 kg/m² before treatment, 23.6 kg/m² after treatment. 33 of 47 patients (70%) had OSA before treatment. 20 of 32 patients (62.5%) who were followed after treatment had OSA. 11 of 32 patients (34.4%) had OSA after treatment. Treatment modalities included chemoradiation (12 patients, 25.2%), surgery plus adjuvant therapy (11 patients, 74.8%). Mean overall AHI before treatment was 11.6. Mean overall AHI after treatment was 19.1. Mean AHI for chemoradiation before treatment was 11.8, after treatment 22.13. Mean AHI for surgery plus adjuvant therapy before treatment was 11.4, after treatment 15.6. Single-center study in Germany. Prospective cohort study type. Sleep studies conducted 2 to 11 months after treatment (average 5 months).
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**Gilete et al. (2013):** 15 patients with tongue cancer. Mean age 57 years. 67% female, 33% male. Mean BMI 24.1 kg/m². 8 of 15 patients (53.3%) had OSA after treatment. 2 of 15 patients (13.3%) had OSA before treatment. Treatment modalities included surgery alone (2 patients, 13.3%), surgery plus radiation (11 patients, 73.3%), chemoradiation (2 patients, 13.3%). Mean overall AHI after treatment was 8. Mean AHI for surgery alone was 4.58. Mean AHI for surgery plus radiation was 8.46. Mean AHI for chemoradiation was 8.5. Single-center study in Israel. Prospective cohort study type. Sleep studies conducted 2 to 6 years after treatment (average 4.9 years).
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**Huang et al. (2021):** 15 patients with oral cavity or oropharyngeal cancer. Mean age 56.2 years. 6.7% female, 93.3% male. Mean BMI 24.1 kg/m². 14 of 15 patients (93%) had OSA before treatment. 15 of 15 patients (100%) had OSA after treatment. Treatment modalities included surgery alone (2 patients, 13.3%), surgery plus radiation (11 patients, 73.3%), chemoradiation (2 patients, 13.3%). Mean overall AHI before treatment was 4.07. Mean overall AHI after treatment was 7.3. Mean AHI for surgery alone before treatment was 4.07, after treatment 7.3. Single-center study in Taiwan. Prospective cohort study type. Sleep studies conducted 0.5 to 19 months after treatment (average 5.1 months).
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**Huppertz et al. (2012):** 33 patients with oropharyngeal or laryngeal cancer. Mean age 64.4 years. 18% female, 82% male. Mean BMI 24.83 kg/m² before treatment, 22.82 kg/m² after treatment. 30 of 33 patients (90%) had OSA before treatment. 15 of 33 patients (45.4%) had OSA after treatment. 16 of 17 patients (94.1%) who were followed had OSA after treatment. Treatment modalities included surgery plus radiation (15 patients, 45.4%), surgery plus chemoradiation (6 patients, 18.2%), chemoradiation alone (12 patients, 36.4%). Mean overall AHI before treatment was 20.2. Mean overall AHI after treatment was 20.4. Single-center study in Germany. Prospective cohort study type. Sleep studies conducted 6 to 8.3 years after treatment (average 2.9 years).
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**Hutcheson et al. (2017):** 16 patients with laryngeal or oropharyngeal cancer. Median age 61.9 years. 18.8% female, 81.2% male. Median BMI 29.8 kg/m². 8 of 16 patients (50%) had OSA after treatment. 14 of 16 patients (87.5%) had OSA before treatment. Treatment modalities included chemoradiation (14 patients, 87.5%), radiation alone (2 patients, 12.5%). Mean overall AHI after treatment was 10.34. Single-center study in the United States. Prospective cohort study type. Sleep studies conducted 0.8 to 8.3 years after treatment (average 2.9 years).
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**Inoshita et al. (2022):** 21 patients with nasopharyngeal, oropharyngeal, hypopharyngeal, or laryngeal cancer. Mean age 64.9 years. 3.1% female, 96.9% male. Mean BMI 22.7 kg/m² before treatment, 20.2 kg/m² after treatment. 17 of 21 patients (81%) had OSA before treatment. 9 of 21 patients (42.9%) had OSA after treatment. 18 of 21 patients (85.7%) had OSA after treatment. Treatment modalities included radiation alone (9 patients, 42.9%), chemoradiation (7 patients, 33.3%), induction chemotherapy plus radiation (1 patient, 4.8%), chemoradiation plus adjuvant chemotherapy (1 patient, 4.8%). Mean overall AHI before treatment was 14.5. Mean overall AHI after treatment was 14.9. Single-center study in Japan. Prospective cohort study type. Sleep studies conducted before and after treatment.
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**Israel et al. (2006):** 22 patients with laryngeal cancer. Mean age 56.5 years. 9.1% female, 90.9% male. Mean BMI 23.6 kg/m². 19 of 22 patients (86.4%) had OSA after treatment. 22 of 22 patients (100%) had OSA after treatment. Treatment modality was surgery alone (22 patients, 100%). Mean overall AHI after treatment was 19.4. Single-center study in Brazil. Prospective cohort study type. Sleep studies conducted 4 months to 12.2 years after treatment (average 3.2 years).
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**Liao et al. (2022):** 32 patients with oral cavity or oropharyngeal cancer. Mean age 54.7 years. 100% male. Mean BMI 24.4 kg/m² before treatment, 22.9 kg/m² after treatment. 21 of 32 patients (65.3%) had OSA before treatment. 10 of 32 patients (34.5%) had OSA after treatment. 22 of 32 patients (59.7%) had OSA after treatment. Treatment modalities included surgery alone (17 patients, 53.1%), surgery plus radiation (4 patients, 12.5%), surgery plus chemoradiation (9 patients, 28.1%). Mean overall AHI before treatment was 23.3. Mean overall AHI after treatment was 34.6. Single-center study in Taiwan. Prospective cohort study type. Sleep studies conducted 6 months before and after treatment.
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**Lin et al. (2014):** 18 patients with nasopharyngeal cancer. Mean age 49.8 years. 16.7% female, 83.3% male. Mean BMI 24.7 kg/m² before treatment, 21.8 kg/m² after treatment. 13 of 18 patients (72.2%) had OSA before treatment. 14 of 18 patients (77.8%) had OSA after treatment. Treatment modality was radiation (18 patients, 100%). Mean overall AHI before treatment was 6.2. Mean overall AHI after treatment was 12.7. Single-center study in Taiwan. Prospective cohort study type. Sleep studies conducted 6 months after treatment.
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**Nguyen et al. (2021):** 20 patients with laryngeal cancer. Mean age 66 years. 25% female, 75% male. Mean BMI 26.82 kg/m². 19 of 20 patients (95%) had OSA after treatment. 10 of 20 patients (50%) had OSA after treatment. Treatment modalities included surgery alone (10 patients, 50%), surgery plus radiation (10 patients, 50%). Mean overall AHI after treatment was 24.6. Mean AHI for surgery alone was 27.9. Mean AHI for surgery plus radiation was 21.2. Single-center study in France. Prospective cohort study type. Sleep studies conducted after treatment.
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**Ouyang et al. (2019):** 40 patients with laryngeal cancer. Mean age 55.5 years. 7.5% female, 92.5% male. Mean BMI 23.33 kg/m² before treatment, 23.56 kg/m² after treatment. 23 of 40 patients (57.5%) had OSA before treatment. 40 of 40 patients (100%) had OSA before treatment. 33 of 40 patients (82.5%) had OSA after treatment. Treatment modality was surgery alone (40 patients, 100%). Mean overall AHI before treatment was 6.75. Mean overall AHI after treatment was 14.43. Single-center study in China. Prospective cohort study type. Sleep studies conducted 3 months before and after treatment.
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**Qian et al. (2010):** 24 patients with oral cavity or oropharyngeal cancer. Mean age 60 years. 33.3% female, 66.7% male. Mean BMI 27.6 kg/m² before treatment, 29.76 kg/m² after treatment. 23 of 24 patients (95.8%) had OSA after treatment. 3 of 24 patients (12.5%) had OSA after treatment. 3 of 24 patients (12.5%) had OSA after treatment. 6 of 24 patients (25%) had OSA after treatment. 12 of 24 patients (50%) had OSA after treatment. Treatment modalities included surgery alone (3 patients, 12.5%), radiation (3 patients, 12.5%), chemoradiation (6 patients, 25%), surgery plus chemoradiation (12 patients, 50%). Mean overall AHI after treatment was 23.4. Mean AHI for surgery alone was 16.7. Mean AHI for radiation was 24.7. Mean AHI for chemoradiation was 11.5. Mean AHI for surgery plus chemoradiation was 30.8. Single-center study in Canada. Prospective cohort study type. Sleep studies conducted 6 to 96 months after treatment (average 25.6 months).
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**Teixeira et al. (2013):** 14 patients with laryngeal cancer. Mean age 60 years. 33.3% female, 66.7% male. Mean BMI 27.6 kg/m² before treatment, 29.76 kg/m² after treatment. 13 of 14 patients (92.9%) had OSA after treatment. 14 of 14 patients (100%) had OSA after treatment. Treatment modality was surgery alone (14 patients, 100%). Mean overall AHI after treatment was 19.4. Single-center study in Brazil. Cross-sectional clinic study type. Sleep studies conducted 1 to 102 months after treatment (average 67.2 months).
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**Yoshihashi et al. (2023):** 15 patients with oral cavity or oropharyngeal cancer. Mean age 64.9 years. 7% female, 93% male. Mean BMI 25.7 kg/m². 12 of 15 patients (80%) had OSA before treatment. 15 of 15 patients (100%) had OSA before treatment. 12 of 15 patients (80%) had OSA after treatment. Treatment modality was surgery alone (15 patients, 100%). Mean overall AHI before treatment was 13. Mean overall AHI after treatment was 18.4. Single-center study in Japan. Prospective controlled study type. Sleep studies conducted 2 and 14 days after treatment (median).

## Findings by Treatment Type

The researchers performed subgroup analyses to examine whether specific treatment modalities were associated with different risks of OSA. The treatment modalities examined were surgery alone, surgery plus adjuvant therapy (additional treatment after surgery), and radiation with or without chemotherapy.

The study found a high prevalence of obstructive sleep apnea in head and neck cancer survivors independent of treatment modality. This means that no single treatment type stood out as being significantly more or less likely to cause OSA than others.

The meta-regression examined whether pre-treatment age or pre-treatment BMI affected the change in AHI. The results of this analysis were not detailed in the abstract.

## What This Means for Patients

This study has several important implications for patients who have been treated for head and neck cancer.

First, the findings confirm that obstructive sleep apnea is extremely common in head and neck cancer survivors. The overall prevalence was 83.7%. This means that about 84 out of every 100 head and neck cancer survivors in these studies had OSA. This is a much higher rate than in the general population.

Second, the study found that OSA prevalence increased after treatment. Before treatment, the average prevalence was 79.9%. After treatment, the average prevalence was 88.7%. This suggests that head and neck cancer treatment may worsen or contribute to the development of OSA.

Third, patients experienced a statistically significant increase in their AHI of 4.28 points after treatment. The AHI is a measure of how severe sleep apnea is. An increase of 4.28 points means that patients had more breathing interruptions per hour of sleep after treatment compared to before treatment.

Fourth, the increase in OSA was seen regardless of which treatment modality patients received. This means that surgery, radiation, chemotherapy, or combinations of these treatments all carried a similar risk.

The authors note that OSA has numerous negative health consequences. These include hypertension, coronary artery disease, stroke, type 2 diabetes mellitus, poor wound healing, reduced quality of life, and prolonged or complicated postoperative recovery. Additionally, OSA has been associated with an increased risk for the development of certain malignancies.

This means that identifying and treating OSA in head and neck cancer survivors is important not just for sleep quality but for overall health and recovery.

## Limitations of the Study

The researchers acknowledged several limitations to their study.

First, the studies included in the analysis varied significantly in their design and methodology. The timeline at which sleep studies were conducted ranged from 2 weeks to 12.2 years after treatment. This wide range makes it difficult to determine exactly when OSA develops after treatment.

Second, there was significant heterogeneity between studies. Heterogeneity means that the studies differed from each other in important ways. This can affect the reliability of the combined results.

Third, some studies reported AHI scores before and after treatment, while others reported only post-treatment scores. This limited the number of studies that could be included in the pre-treatment versus post-treatment analysis.

Fourth, the study included only English-language articles. This means that relevant research published in other languages may have been missed.

Fifth, the authors excluded studies that included patients with a prior history of OSA. This means the findings may not apply to patients who already had OSA before their cancer diagnosis.

Sixth, the authors excluded studies that prescreened patients to select subjects. This means the findings may not reflect what happens in routine clinical practice.

Seventh, the authors excluded studies that used a nonstandard definition for OSA. All included studies used an AHI of 5 or greater to define OSA. This is a standard definition, but some studies may use different thresholds.

## Recommendations for Patients and Caregivers

Based on the findings of this study, the authors propose that all head and neck cancer survivors undergo routine validated screening for obstructive sleep apnea.

Here are some practical steps patients and caregivers can take:

1.
**Ask your doctor about OSA screening.** If you have been treated for head and neck cancer, ask your healthcare provider whether you should be screened for obstructive sleep apnea. The study authors recommend routine screening for all head and neck cancer survivors.
1.
**Be aware of OSA symptoms.** Common symptoms of OSA include loud snoring, gasping for air during sleep, waking with a dry mouth, morning headache, difficulty staying asleep, excessive daytime sleepiness, irritability, and difficulty concentrating. If you experience any of these symptoms, tell your doctor.
1.
**Understand that OSA can occur regardless of treatment type.** The study found that OSA risk was high regardless of whether patients received surgery, radiation, chemotherapy, or a combination. This means that all head and neck cancer survivors should be vigilant about OSA symptoms.
1.
**Know that OSA can affect your overall health.** OSA is linked to high blood pressure, heart disease, stroke, diabetes, poor wound healing, and reduced quality of life. Treating OSA can help improve these outcomes.
1.
**Follow up with your healthcare team.** Regular follow-up appointments after head and neck cancer treatment are important. Use these appointments to discuss any sleep problems or symptoms you may be experiencing.
1.
**Consider a sleep study.** If your doctor recommends a sleep study, it can be done either in a sleep laboratory (polysomnography) or at home (home sleep apnea test). Both methods can help diagnose OSA.
1.
**Discuss treatment options if diagnosed with OSA.** Treatment options for OSA include continuous positive airway pressure (CPAP) therapy, oral appliances, positional therapy, and in some cases, surgery. Your doctor can help you choose the best option for your situation.

The authors conclude that there is a high prevalence of obstructive sleep apnea in head and neck cancer survivors independent of treatment modality. Therefore, they propose that all head and neck cancer survivors undergo routine validated screening for obstructive sleep apnea.

## Frequently Asked Questions

### What is obstructive sleep apnea (OSA)?

OSA is a condition where breathing repeatedly stops and starts during sleep because the airway becomes blocked or narrowed, preventing air from reaching the lungs. Severity is measured by the apnea-hypopnea index (AHI), which counts breathing interruptions or reductions per hour of sleep. A higher AHI means more severe sleep apnea. In the reviewed studies, OSA was defined as an AHI of 5 or greater.

### How common is OSA in head and neck cancer survivors?

In a review of 16 studies involving 419 participants, the average prevalence of OSA in head and neck cancer survivors was 83.7%. That means about 84 out of every 100 survivors in these studies had OSA. Before treatment, average prevalence was 79.9%; after treatment, it was 88.7%. This is much higher than in the general population, though individual study results varied widely.

### Does head and neck cancer treatment increase the risk of OSA?

In the 8 studies that reported AHI before and after treatment, patients had a statistically significant average increase in AHI of 4.28 points after treatment. Average OSA prevalence rose from 79.9% before treatment to 88.7% after. This suggests treatment may worsen or contribute to OSA, but the wide range of study timings makes it hard to say exactly when OSA develops.

### Does the type of treatment affect OSA risk?

The review found a high prevalence of OSA in head and neck cancer survivors regardless of treatment modality. Subgroup analyses examined surgery alone, surgery plus adjuvant therapy, and radiation with or without chemotherapy. No single treatment type stood out as significantly more or less likely to cause OSA than others. This means all survivors should be vigilant about OSA symptoms, whatever treatment they received.

### What are the symptoms of OSA I should watch for?

Common symptoms include loud snoring, gasping for air during sleep, waking with a dry mouth, morning headache, difficulty staying asleep, excessive daytime sleepiness, irritability, and difficulty concentrating. If you have been treated for head and neck cancer and experience any of these, tell your doctor. The review authors recommend routine validated screening for all head and neck cancer survivors.

### Why is it important to diagnose and treat OSA after head and neck cancer?

OSA is linked to high blood pressure, coronary artery disease, stroke, type 2 diabetes, poor wound healing, reduced quality of life, and prolonged or complicated postoperative recovery. It has also been associated with an increased risk of certain malignancies, possibly due to chronic low oxygen levels. Identifying and treating OSA can help improve these outcomes, not just sleep quality.

### I finished treatment for head and neck cancer and my doctor hasn't mentioned sleep apnea screening — when should I get a second opinion?

Obstructive sleep apnea is common in head and neck cancer survivors, with an average prevalence of 83.7%, and it rises after treatment from 79.9% to 88.7%. The apnea-hypopnea index increased by 4.28 points after treatment, and risk was high regardless of whether patients received surgery, radiation, chemotherapy, or combinations. Because routine validated screening is recommended for all survivors, a second opinion is reasonable if screening has not been offered or if sleep symptoms such as snoring, gasping, or daytime sleepiness are dismissed. Diagnostic Detectives Network provides independent expert second opinions.

## Source Information

**Original Article Title:** Obstructive Sleep Apnea in Head and Neck Cancer Survivors: A Systematic Review and Meta-Analysis.

**Journal:** OTO open

**DOI:** [10.1002/oto2.70186](https://doi.org/10.1002/oto2.70186)

**License:** CC BY (open access)

**Authors:** Chitnis O, Caraway JJ, Chin NC, Guadalupi A, Karahalios K, Baisden G, Watson N, Orestes M.

**Author Affiliations:** Division of Otolaryngology, Brook Army Medical Center, San Antonio, Texas, USA; Division of Otolaryngology–Head and Neck Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland, USA; Department of Research Programs, Walter Reed National Military Medical Center, Bethesda, Maryland, USA; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA

**Publication:** OTO Open, 2026, Volume 10, Issue 1, e70186

**DOI:** 10.1002/oto2.70186

**Publication Date:** Received May 22, 2025; Accepted October 3, 2025

**Presentation:** The contents of this article were presented at the AAO-HNSF 2024 Annual Meeting & OTO Experience; September 28-October 1, 2024; Miami, Florida.

**Corresponding Author:** Michael Orestes, MD, Department of Otolaryngology–Head and Neck Surgery, Walter Reed National Military Medical Center; 4494 North Palmer Road, Bethesda, MD 20814, USA. Email: michael.orestes@usuhs.edu

**Note:** This patient-friendly article is based on peer-reviewed research. The original article is published as open access under the terms of the Creative Commons Attribution License.


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Publisher: Diagnostic Detectives Network (https://diagnosticdetectives.com) — independent multi-expert medical second opinions, worldwide, private-pay.
Author byline: Anton Titov, MD, PhD. Contact: https://diagnosticdetectives.com/pages/contact
Canonical page: https://diagnosticdetectives.com/products/obstructive-sleep-apnea-in-head-and-neck-cancer-survivors-what-patients-need-to-know