Continuous Positive Airway Pressure (CPAP) therapy has long been hailed as the gold standard for managing Obstructive Sleep Apnea (OSA). Yet, despite its proven effectiveness, there’s a glaring issue in real-world practice—adherence. Nearly 70% of patients struggle to stick with CPAP therapy long-term, undermining its potential to save lives and improve quality of sleep.
So why is such a life-changing treatment so hard to stick with? The answer often lies in the nose.
This article dives deep into the role of nasal obstruction and structural abnormalities in CPAP failure—and how sleep surgery might be the missing piece in solving this adherence puzzle.
For patients with obstructive sleep apnea, CPAP therapy works by delivering a steady stream of air to keep the upper airway open during sleep. This prevents the repetitive episodes of airway collapse that lead to snoring, gasping, and frequent awakenings.
But for CPAP to work, you have to actually use it. And therein lies the problem.
A seminal study by Brian Rottenberg and Kenny Pang in 2015 revealed that 17% to 70% of patients are non-adherent to CPAP therapy. The commonly accepted benchmark for “compliance” is using the device for at least 4 hours per night on 70% of nights. Yet many fall far short of this.
And here’s the catch: research shows that just 4 hours a night may not be enough to confer cardiovascular or metabolic benefits. The implications? Patients may be “technically compliant” but still at risk for stroke, arrhythmias, diabetes complications, and uncontrolled hypertension.
Some of the frequently reported issues include:
Discomfort with the mask or pressure
Claustrophobia
Dry mouth or nasal passages
Feeling tethered or restricted in bed
Noise from the device
While many believe that fixing the mask or adjusting pressure settings might help, long-term data shows these interventions often don’t solve the underlying issue.
That’s because a key contributor to non-adherence is often overlooked: nasal obstruction.
Let’s face it—if your nose is blocked, forcing air through it all night can feel like torture.
A study of 193 patients in French sleep centers found:
65% experienced dry nose or mouth
35% reported sneezing and post-nasal drip
25% complained of significant nasal congestion
Another key metric, nasal resistance (measured using rhinometrics), showed that patients with resistance greater than 0.3 Pascals/cm/sec were far less likely to tolerate CPAP.
Deviated nasal septum
Inferior turbinate hypertrophy
Nasal valve collapse
Chronic sinusitis
Allergic rhinitis
These conditions make it difficult to breathe even during the day—let alone with positive pressure air being forced through the nose at night.
Your nasomaxillary complex—the bones and tissues that make up the nasal passages and upper jaw—play a pivotal role in breathing and CPAP success.
A high-arched palate or narrow maxilla can reduce the volume of your nasal airway. When this occurs, even slight congestion can result in a feeling of suffocation while using CPAP.
The roof of the mouth is the floor of the nose, and any structural deviation affects airflow. Without correcting these anatomical barriers, expecting patients to tolerate CPAP long-term is unrealistic.
Patients are often prescribed:
Intranasal corticosteroids (INCS)
Nasal saline sprays
Antihistamines
Heated humidifiers
However, INCS have limitations. While useful for allergic rhinitis, they often worsen dryness and can cause nasal bleeding (epistaxis) in CPAP users.
Heated humidification, on the other hand, has been shown to improve comfort and reduce nasal symptoms in OSA patients, enhancing CPAP tolerance.
For many patients, surgery is the definitive solution.
Septoplasty – Corrects a deviated septum
Turbinate reduction – Shrinks hypertrophic turbinates
Nasal valve stabilization – Addresses collapse during inhalation
Functional endoscopic sinus surgery (FESS) – Clears chronic sinus blockages
Palatal expansion (DOME or MARPE) – Widens the upper jaw to improve nasal volume
When these procedures are performed by experienced sleep surgeons, CPAP adherence dramatically improves, often turning a non-compliant patient into a long-term user.
The most effective centers follow a multi-tiered surgical algorithm. Rather than offering one-size-fits-all treatments, they tailor interventions based on the root cause of obstruction.
DISE (Drug-Induced Sleep Endoscopy) to visualize dynamic collapse
Rhinometry to measure nasal resistance
CT Sinus imaging to detect sinus disease or skeletal issues
Nasal Obstruction
Deviated septum
Turbinate hypertrophy
Nasal valve collapse
Skeletal Deficiency
Narrow maxilla
High-arched palate
Mandibular deficiency
Soft Tissue Collapse
Elongated soft palate
Enlarged tonsils
Tongue base obstruction
For Nasal Obstruction:
Septoplasty
Turbinate reduction
Internal valve repair
Palatal expansion
For Skeletal Issues:
Maxillomandibular advancement (MMA)
Rapid palatal expansion (RPE)
DOME (Distraction Osteogenesis Maxillary Expansion)
For Soft Tissue Collapse:
Uvulopalatopharyngoplasty (UPPP)
Midline glossectomy
Tongue base reduction
Hypoglossal nerve stimulation
When anatomical barriers are addressed:
Patients experience fewer side effects from CPAP
They report less mouth breathing and better sleep quality
Cardiovascular risk markers improve
Many previously non-adherent patients become regular users
In some cases, surgery alone may eliminate the need for CPAP, particularly when combined with weight loss and positional therapy.
For too long, patients have been blamed for “failing” CPAP therapy. But in reality, many are trying their best—and their anatomy is the problem.
If we want to improve long-term outcomes in OSA management, we must shift the conversation from patient behavior to physiological feasibility.
Sleep surgery, especially when guided by objective diagnostics and a structured algorithm, offers a life-changing solution for the right patients. Rather than abandoning CPAP entirely, patients can finally use it effectively—and reclaim restful, restorative sleep.
CPAP (Continuous Positive Airway Pressure) therapy is a treatment for obstructive sleep apnea. It delivers constant air pressure through a mask to keep your airway open during sleep.
Discomfort, dry nose, poor mask fit, and especially nasal obstruction are major reasons. If breathing through your nose is difficult, CPAP becomes intolerable.
No. While 4 hours/night on 70% of nights is the minimum to be considered compliant, studies show that full-night use (6–7+ hours) is needed for heart and metabolic benefits.
Common culprits include:
Deviated nasal septum
Enlarged turbinates
Chronic sinusitis
Narrow nasal passages
Nasal valve collapse
Not always. While they can help with allergies, they often dry out the nasal lining in CPAP users, leading to bleeding and discomfort. Heated humidification is usually a better option.
Surgeries include:
Septoplasty
Turbinate reduction
Palatal expansion
Nasal valve repair
Maxillary advancement or expansion
These help improve nasal airflow and make CPAP more tolerable.
In some cases, yes—especially when surgeries like MMA or multilevel soft tissue procedures resolve the anatomical issues causing apnea. But for many, the goal is to make CPAP more comfortable and effective, not eliminate it.
If you have:
Nasal obstruction despite medical therapy
Anatomical abnormalities (seen on CT or DISE)
Poor CPAP tolerance
Motivation for long-term treatment success
… you may be a good candidate for surgical intervention.
Consult a sleep surgeon or ENT who specializes in sleep apnea. They can perform a nasal endoscopy, rhinometry, or a DISE to pinpoint the problem.