Abstract
Importance
Chronic rhinitis (CR) affects quality of life and often coexists with obstructive sleep apnea (OSA), a comorbidity that may increase surgical risks. Understanding OSA’s impact on outcomes of minimally invasive nasal surgery is clinically relevant.
Objective
To evaluate the efficacy and safety of minimally invasive nasal surgery for CR and assess the influence of OSA on postoperative complications and symptom relief.
Design
Retrospective cohort study.
Setting
Single tertiary medical center in Taiwan.
Participants
A total of 325 CR patients underwent nasal surgery between March 2023 and June 2024. Based on sleep study results, patients were stratified into OSA (n = 48) and non-OSA (n = 277) groups.
Exposure or Intervention
Minimally invasive nasal surgery, including radiofrequency inferior turbinate reduction and/or posterior nasal nerve neurolysis. Patients receiving adjunctive procedures (eg, septoplasty, uvulopalatopharyngoplasty, and tonsillectomy) were excluded.
Main Outcome Measures
Postoperative complications (eg, epistaxis) within 1 month and symptom relief based on reflective total nasal symptom score and nasal obstruction symptom evaluation.
Results
OSA [odds ratio (OR), 5.105; 95% confidence interval (CI), 1.222-21.328; P = .025] and hypertension (OR, 5.809; 95% CI, 1.134-29.744; P = .035) were independent risk factors for major epistaxis. OSA patients had higher overall complication rates (22.9% vs 4.3%, P = .005), epistaxis (18.8% vs 3.6%, P = .012), and major epistaxis (14.6% vs 1.8%, P = .018). Both groups showed significant symptom improvement postoperatively (P < .001).
Conclusion
Minimally invasive nasal surgery improves CR symptoms regardless of OSA. However, OSA and hypertension are linked to increased complication risk and require careful perioperative management.
Relevance
These findings support tailored preoperative assessment and multidisciplinary care to optimize safety and outcomes in CR patients with OSA.
Keywords
Key Messages
Minimally invasive nasal surgery significantly improves nasal symptoms in patients with chronic rhinitis, regardless of the presence of obstructive sleep apnea (OSA).
Patients with OSA and hypertension have substantially higher risks of postoperative complications, particularly epistaxis, following nasal surgery.
Comprehensive preoperative screening and multidisciplinary perioperative management are essential to balance surgical benefits with safety in high-risk patients.
Summary
This study evaluated the outcomes of minimally invasive nasal surgery in patients with chronic rhinitis (CR), focusing on the impact of obstructive sleep apnea (OSA) on postoperative complications and symptom relief. Minimally invasive nasal surgery is effective in alleviating CR symptoms, regardless of OSA status. However, OSA and hypertension significantly increase the risk of postoperative complications, emphasizing the need for comprehensive preoperative evaluation and multidisciplinary perioperative management.
Introduction
Chronic rhinitis (CR) is a prevalent condition, with studies indicating that its global prevalence ranges from ~1% to over 60%, depending on the definition and region, with a median prevalence of around 29.4%.1,2 Characterized by persistent symptoms such as nasal obstruction, rhinorrhea, sneezing, and nasal pruritus, this condition profoundly disrupts patients’ quality of life by impairing sleep, work performance, and social interactions.3 -5 On a broader scale, CR significantly burdens healthcare systems through frequent medical consultations, medication use, and surgical interventions.6,7 In addition, it contributes to economic losses due to reduced productivity and absenteeism. 6 Patients often face emotional distress, including anxiety and depression, resulting from the chronic nature of their symptoms and the associated social limitations.8 -10
Management of CR ranges from pharmacological therapies, such as intranasal corticosteroids and antihistamines, to surgical interventions for refractory cases.11 -13 Surgery is typically reserved for patients unresponsive to prolonged medical treatment. Traditional nasal surgeries, including septoplasty and turbinate reduction, are effective but associated with complications such as epistaxis (4% anterior, 2.4% posterior), infections (~1%), and rare cases of olfactory dysfunction (<0.5%).7,14 -17 In contrast, minimally invasive procedures, such as radiofrequency inferior turbinate (RFIT) reduction and posterior nasal nerve neurolysis (PNNN), offer shorter recovery times and reduced perioperative risks. 18 These techniques target anatomical and functional abnormalities while preserving mucosal integrity. 18
The impact of minimally invasive nasal surgery on patients with obstructive sleep apnea (OSA) remains underexplored. Previous studies have primarily examined OSA’s effects on general anesthesia or nasal surgery outcomes without specifically addressing minimally invasive techniques.19 -21 Notably, the literature lacks focused evaluations of postoperative complications and symptom improvement in OSA patients undergoing these advanced procedures.19 -21 Our study aims to fill this gap by investigating the efficacy and safety of minimally invasive nasal surgery in OSA patients, identifying independent risk factors for adverse outcomes, and developing strategies to mitigate these risks. By addressing these critical questions, the findings aim to advance evidence-based approaches for optimizing surgical care and outcomes in this potentially high-risk population.
Materials and Methods
Study Population
This retrospective cohort study included patients treated for CR with suspected sleep-disordered breathing (SDB) at Chiayi Christian Hospital between March 2023 and June 2024. Eligible patients were aged 18 to 65 years old and underwent nasal surgery after experiencing symptoms refractory to medical treatment for over 6 months, including the use of nasal sprays and/or oral antihistamines. 22 Patients with high-risk SDB were identified using snoring, tiredness, observed apneas, high blood pressure, body mass index (BMI), age, neck circumference, and gender (STOP-Bang) scores, polysomnography (PSG), or home sleep testing (HST). 23 The study was conducted with the approval of the Chia-Yi Christian Hospital Ethics Committee (approval no: CYCH2024022).
Criteria for Inclusion and Exclusion
This retrospective cohort study included patients who had CR refractory to or unsatisfied with medical treatment who underwent nasal surgery for CR between March 2023 and June 2024. The diagnosis of CR is based on the patient’s chief complaint of chronic nasal obstruction, rhinorrhea, nasal itching, and sneezing refractory to medical treatment for >6 months with at least 4 weeks of treatment with intranasal corticosteroid spray and/or oral antihistamine with unsatisfactory results. The commonly prescribed ipratropium bromide was not available in the author’s practice countries, so it was not provided or tested. An endoscopy exam to confirm chronic hypertrophic rhinitis with pale turbinate mucosa was mandatory to exclude those with polyps and sinusitis.
Patients diagnosed with OSA were confirmed via PSG or HST. 23 For those who had not been diagnosed with OSA before receiving surgery, PSG or HST was arranged to confirm the diagnosis unless they exhibited a low risk for OSA, defined as STOP-Bang scores ≤5 and BMI <24 24 absence of OSA-related symptoms, such as snoring or excessive daytime sleepiness and among individuals who declined sleep studies.
Patients were excluded from the study cohort if they had acute or chronic rhinosinusitis with/without polyps or significant anatomical abnormalities that precluded posterior nasal surgery. For patients with significant septal deviation that obstructed nasal airflow or hindered surgical access and received septoplasty, in cases of grade III to IV adenoid hypertrophy receiving adenoidectomy, and those who received concurrent pharyngeal surgeries, such as uvulopalatopharyngoplasty or transoral robotic surgery, were excluded to minimize the confounding of complication analysis. Patients unable to discontinue anticoagulation therapy for at least 1 week and those with cardiovascular diseases associated with coagulopathy were excluded to minimize perioperative risks and ensure accurate complication assessments. The flowchart of patient selection and outcome evaluation is summarized in Figure 1.
Flowchart of patient selection and outcome evaluation.
Surgical Procedures
All patients underwent minimally invasive nasal surgery performed by a single experienced surgeon, ensuring consistency in procedural techniques. Surgical approaches were tailored to address the specific anatomical and functional abnormalities contributing to nasal obstruction and CR symptoms. Additional procedures were performed as clinically indicated to optimize patient outcomes.
RFIT using CelonLab ENT (Celon AG Medical Instruments, Teltow, Germany), a disposable stylus delivered bipolar radiofrequency (RF) energy at 15 W to the inferior turbinates, served as the primary intervention for all patients, targeting inferior turbinate hypertrophy to alleviate nasal obstruction. Controlled radiofrequency energy was utilized to achieve volume reduction while preserving the integrity of the nasal mucosa. For patients with severe allergic rhinitis or refractory nasal symptoms, PNNN was performed using a 2 W continuous wave laser with the AcuPulse™ CO2 laser (Lumenis Ltd, Yokne’am Illit, Israel) in conjunction with RFIT. This adjunct procedure targeted sensory nerve pathways to reduce hyperreactivity and improve symptom control. 18
Primary Endpoints and Sleep Evaluation
The primary endpoint was the incidence of postoperative complications within 1 month following nasal surgery. Complications were categorized as overall complications (eg, bleeding, wound necrosis, dry eye, rhinosinusitis, and wound infection) and epistaxis-related complications. Epistaxis complications were analyzed as all cases of epistaxis, including those with obvious blood but self-limiting and not requiring medical assistance, as well as major epistaxis, defined as severe bleeding necessitating an emergency room visit and requiring nasal packing with cotton or sponge, or surgical intervention in a hospital setting.
The secondary endpoints included postoperative symptom improvement assessed using the reflective total nasal symptom score (rTNSS, 0-12 scale, with higher the worse of the symptoms) and nasal obstruction symptom evaluation (NOSE, 0-20 scale, with higher the worse of the symptoms), evaluated at baseline (preoperatively) and 1 month postoperatively. These endpoints provided a comprehensive evaluation of surgical safety and efficacy.
The severity of sleep disturbance was assessed using the preoperative NOSE scale, which evaluates the patient’s quality of life during the month prior to completing the questionnaire. On the NOSE scale, the fourth question asked patients if they experienced “Trouble sleeping,” with responses rated on a scale from 0 to 4. A score of 0 was defined as “Not a problem,” 1 as “Very mild problem,” 2 as “Moderate problem,” 3 as “Fairly bad problem,” and 4 as “Severe problem,” as specified in the original questionnaire.
Statistical Analysis
Univariate and multivariate logistic regression analyses were performed to identify risk factors associated with postoperative complications, including overall complications and epistaxis-related events. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to quantify the strength of associations. For continuous variables such as rTNSS and NOSE scores, paired t-tests or Wilcoxon signed-rank tests were utilized to compare preoperative and postoperative scores based on the distribution of the data. Subgroup analyses were conducted for patients with and without OSA to evaluate differences in symptom improvement and complication rates. To address potential issues of multicollinearity, variance inflation factor analysis was performed, and no significant collinearity was identified in the multivariate models. All statistical tests were 2-sided, and a P < .05 was considered statistically significant. Data were analyzed using SPSS software, version 18 (SPSS, Inc., Chicago, IL, USA). The results were presented as mean ± standard deviation or median (interquartile range), as appropriate.
Results
Baseline Characteristics
A total of 325 patients undergoing nasal surgery for CR were included, with 48 patients (14.8%) classified as having OSA and 277 patients (85.2%) as non-OSA. The mean age was similar between groups (41.1 ± 7.7 vs 38.9 ± 10.0 years, P = .147). Males constituted a significantly higher proportion in the OSA group compared to the non-OSA group (91.7% vs 62.5%, P < .001). BMI was also higher in the OSA group (28.9 ± 4.9 vs 25.1 ± 4.3 kg/m², P < .001; Table 1).
Baseline Characteristics of Patients Undergoing Nasal Surgery, Stratified by OSA Diagnosis.
Abbreviations: BMI, body mass index; NOSE, nasal obstruction symptom evaluation; OSA, obstructive sleep apnea; PNNN, posterior nasal nerve neurolysis; rTNSS, reflective total nasal symptom score; UPPP, uvulopalatopharyngoplasty.
Hypertension was more prevalent in OSA patients (20.8% vs 1.1%, P < .001). There were no significant differences between groups in the rates of rhinitis medicamentosa (8.3% vs 10.8%, P = .603) or prior nasal surgery (12.5% vs 11.6%, P = .603). The OSA group had a lower rate of PNNN (52.1% vs 76.5%, P = .002). Initial rTNSS and NOSE scores were comparable between groups (6.4 ± 2.8 vs 6.3 ± 2.8, P = .882; 12.0 ± 3.3 vs 11.4 ± 4.2, P = .366).
Distribution of sleep disturbance severity between OSA and non-OSA groups in Figure 2. In the OSA group, a higher proportion of patients experienced “fairly bad” or “severe” sleep disturbances compared to the non-OSA group (58.3% vs 40.1%, P = .018). This finding underscores the heightened baseline burden of sleep-related symptoms among OSA patients, further emphasizing the importance of targeted interventions in this population.
Sleep disturbance severity distribution between OSA and non-OSA groups.
Postoperative Complications
The overall complication rate within 1 month following nasal surgery was significantly higher in the OSA group compared to the non-OSA group (22.9% vs 4.3%, P = .005; Table 2). Epistaxis was the most common complication, with 18.8% of patients in the OSA group experiencing at least 1 event, compared to 3.6% in the non-OSA group (P = .012). Major epistaxis, defined as bleeding requiring emergency department evaluation or surgical intervention, was notably more frequent in the OSA group (14.6% vs 1.8%, P < .018). Among the 12 major epistaxis cases, 11 were anterior nasal bleeds, which required only local treatment and nasal sponge packing for 2 to 3 days. The only case of posterior nasal bleeding occurred in the PNNN group, presenting as intermittent bleeding 2 weeks after the procedure. To prevent major posterior bleeding, the patient underwent prophylactic sphenopalatine artery ligation under general anesthesia.
Postoperative Complications Within 1 Month Following Nasal Surgery for Chronic Rhinitis, Stratified by OSA Diagnosis.
Abbreviations: n, number of patients/events; OSA, obstructive sleep apnea.
Major epistaxis is defined as bleeding requiring emergency department evaluation or surgical intervention.
Dry eye and posterior nasal epistaxis are complications specifically associated with the posterior nasal nerve neurolysis procedure.
Other complications, such as wound necrosis, rhinosinusitis, wound infection, and dry eye, were infrequent, with each having only 1 case recorded in the whole cohort. The wound infection was observed exclusively in 2.1% of OSA patients compared to wound necrosis exclusively in 0.4% of non-OSA patients, while dry eye, associated with PNNN, was reported exclusively in the non-OSA group. These findings highlight the increased risk of postoperative complications among patients with OSA undergoing nasal surgery.
Independent Risk Factors for Postoperative Complications
Univariate analysis was performed, showing BMI, hypertension, OSA, OSA—moderate to severe, and apnea-hypopnea index (AHI) were significant risk factors for all complications and epistaxis-related complications (Table 3). Multivariate analysis identified OSA as a significant independent predictor of overall postoperative complications (OR, 4.966; 95% CI, 1.807-13.648; P = .002), all epistaxis-related complications (OR, 3.984; 95% CI, 1.301-12.203; P = .016) and major epistaxis-related complications (OR, 5.105; 95% CI, 1.222-21.328; P = .025; Table 4). Hypertension was significantly associated with major epistaxis-related complications (OR, 5.809, 95% CI, 1.134-29.744; P = .035). However, BMI was not found to be an independent risk factor for any of the complication categories analyzed (P > .05). These findings underscore the importance of OSA and hypertension as critical contributors to postoperative risks in patients undergoing nasal surgery for CR.
Univariate Analysis of Risk Factors for Overall and Epistaxis-Related Complications in Patients Undergoing Nasal Surgery.
Abbreviations: AHI, apnea-hypopnea index; BMI, body mass index; CI, confidence interval; n, number; NOSE, nasal obstruction symptom evaluation; OR, odds ratio; OSA, obstructive sleep apnea; PNNN, posterior nasal nerve neurolysis; rTNSS, reflective total nasal symptom score; UPPP, uvulopalatopharyngoplasty.
Multivariate Analysis of Risk Factors for Overall and Epistaxis-Related Complications in Patients Undergoing Nasal Surgery.
Abbreviations: BMI, body mass index; CI, confidence interval; n, number; OR, odds ratio; OSA, obstructive sleep apnea.
Symptom Improvement Post-Surgery
As illustrated in Figure 3, significant improvements were observed in both the rTNSS and NOSE scores at 1 month postoperatively. In the overall cohort (n = 325), the rTNSS score (6.3 ± 2.8 vs 2.5 ± 2.0, P < .001) and all subscores, including congestion, rhinorrhea, itching, and sneezing, demonstrated significant reductions compared to preoperative values. Similarly, the NOSE score (11.5 ± 4.1 vs 2.7 ± 3.7, P < .001) and all subscores—obstruction, stuffiness, trouble breathing, trouble sleeping, and trouble exercising—improved significantly. Comparison of the 1-month changes in rTNSS and NOSE scores by OSA status showed significant improvements (P < .001) in all subscores for the entire study cohort (n = 325) at 1 month postoperatively (1M) compared to preoperative values. However, no significant differences in score changes were observed when comparing OSA and non-OSA patients across all subscores (P > .05). Among patients with fairly bad to severe sleep disturbances (n = 139), significant improvements (P < .001) in all subscores were also observed at 1M compared to preoperative values. However, patients diagnosed with OSA showed significantly smaller improvements in the first 4 NOSE subscores (nasal obstruction and stuffiness, P < .05; trouble breathing and trouble sleeping, P < .01).
Changes in rTNSS and NOSE scores following nasal surgery. (a) Comparison of changes in rTNSS subscores between patients diagnosed with OSA and those not diagnosed with OSA. (b) Comparison of changes in NOSE subscores between patients diagnosed with OSA and those not diagnosed with OSA. NOSE, nasal obstruction symptom evaluation; rTNSS, reflective total nasal symptom score.
Discussion
Nasal surgery has been widely explored as a treatment for patients with CR and as an adjunctive surgery for treating OSA, aiming to alleviate nasal obstruction and improve sleep-related symptoms.25,26 Previous studies have shown that procedures such as septoplasty and turbinate reduction can enhance nasal airflow and reduce subjective symptoms like snoring and daytime sleepiness.7,27,28 However, the impact of nasal surgery on objective measures, such as the AHI, remains inconsistent, with some research indicating minimal changes in AHI post-surgery. 29 These findings suggest that while nasal surgery may improve patient-reported outcomes, its effect on the severity of OSA may be limited.20,29 Our study contributes to this body of knowledge by examining the safety and efficacy of nasal surgery in CR patients with and without OSA. Among 325 patients, those with OSA (n = 48) had a significantly higher incidence of complications than non-OSA patients (22.9% vs 4.3%, P = .005; Table 2). Epistaxis was the most common complication, occurring in 18.8% of OSA patients versus 3.6% of non-OSA patients (P = .012). Major epistaxis was notably more prevalent in the OSA group (14.6% vs 1.8%, P = .018). These findings highlight the elevated surgical risks associated with OSA and the need for meticulous perioperative care. Despite increased complication risks, nasal surgery led to substantial symptom improvement in both groups (Figure 3). At 1 month postoperatively, rTNSS scores significantly decreased across all subscores (P < .001), confirming the procedure’s efficacy in relieving nasal obstruction and related symptoms, irrespective of OSA status (Figure 3). Clinically, our findings emphasize the dual importance of symptom relief and surgical safety, particularly in high-risk populations. Identifying OSA and hypertension as independent risk factors (Table 4) reinforces the need for a multidisciplinary approach involving otolaryngologists and sleep specialists to optimize outcomes.
Our study represents the first cohort to specifically investigate the association between OSA and postoperative complications following minimally invasive nasal surgery for CR, distinguishing it from prior research focused on either the general surgical risks of OSA or the efficacy of traditional nasal surgeries.19 -21 While earlier studies have identified OSA as a risk factor for perioperative complications in diverse surgical settings, few have addressed its direct impact on minimally invasive nasal procedures.30,31 Our findings highlight the significantly elevated risk of postoperative complications (Tables 3 and 4), particularly epistaxis, in OSA patients compared to non-OSA individuals, filling a critical gap in the literature.19 -21,30,31 Unlike prior investigations that broadly examined surgical outcomes,19 -21,30,31 our study concentrated on CR patients undergoing minimally invasive techniques. The use of these advanced techniques likely contributed to the overall favorable safety profile, even among high-risk OSA patients (Table 2). Moreover, the multivariate analysis confirmed OSA and hypertension as independent risk factors for complications, which extends beyond the observations of previous studies by emphasizing the compounded perioperative risks in this specific population.19 -21,30,31 In addition to assessing risks, our study uniquely demonstrated that both OSA and non-OSA groups experienced substantial symptom improvement postoperatively (Figure 3). This dual emphasis on risk and benefit provides a more balanced perspective, underscoring the clinical value of these procedures despite the heightened complication risk in OSA patients. These findings advocate for meticulous perioperative management while supporting the continued use of minimally invasive techniques to achieve meaningful symptom relief in CR, even among OSA patients.
Our study underscores the critical need for enhanced clinical strategies when managing patients with CR undergoing nasal surgery, particularly those with OSA. Routine preoperative screening for OSA, employing tools such as PSG or HST, should be integrated into surgical workflows to identify high-risk individuals and tailor perioperative care. Individualized risk assessments and informed consent processes must highlight the increased likelihood of postoperative complications, including epistaxis, in OSA patients. For this population, optimized perioperative strategies, such as preoperative continuous positive airway pressure therapy, rigorous intraoperative bleeding control, and vigilant postoperative monitoring, are essential. Additionally, a multidisciplinary approach, involving otolaryngologists and sleep specialists, is vital to address the complex needs of these patients comprehensively. Our findings emphasize the importance of revising clinical guidelines to incorporate routine OSA screening and management as standard practice, ensuring improved surgical safety and symptom relief while addressing the unique risks associated with OSA.
Our study stands out for its rigorous design, innovative focus, and significant clinical implications. By employing a clearly defined retrospective cohort design with a large sample size (n = 325), we systematically compared outcomes between OSA (n = 48) and non-OSA (n = 277) patients, making it the first to directly explore the relationship between OSA and postoperative complications in CR surgery. Unlike previous studies that either generalized OSA’s surgical risks or focused on nasal surgery outcomes without stratifying by OSA status, our research provides targeted insights into the higher complication rates, particularly epistaxis, in OSA patients.13,19 -21 All surgeries in our study were performed by a single experienced surgeon, minimizing variability in surgical technique and enhancing the consistency of results. In addition, this is the first study to explicitly compare complication rates between OSA and non-OSA patients undergoing minimally invasive procedures, rather than traditional nasal surgeries. The findings revealed a significantly higher risk of complications in OSA patients. The use of validated tools, such as rTNSS and NOSE scores, ensures reliable symptom assessment, while multivariable analyses definitively identified OSA and hypertension as independent risk factors for complications specific to minimally invasive nasal surgery, a distinction not previously established in the literature.31,32
Previous studies on minimally invasive nasal surgery for CR have shown low complication rates. For instance, posterior nasal neurectomy reported only 0.3% postoperative epistaxis managed endoscopically, with no major complications, while inferior turbinate radiofrequency reduction showed minimal adverse events in long-term follow-up.33,34 Similarly, our cohort had a low overall complication rate (7.1%) and only 1 bleeding-related readmission (0.3%). However, in patients with both OSA and hypertension, the epistaxis rate rose markedly to 22.9%, indicating that these comorbidities may predispose to early postoperative bleeding even in low-risk procedures. This finding supports the need for individualized perioperative strategies in high-risk CR patients.
While our study provides valuable insights into the relationship between OSA and postoperative outcomes in CR patients undergoing minimally invasive nasal surgery, it has several limitations. As a retrospective cohort study from a single institution, selection bias and unmeasured confounders may limit generalizability. Although all surgeries were performed by a single experienced surgeon to standardize techniques, this may not reflect real-world variability. The differentiation of allergic rhinitis and non-allergic rhinitis was not regularly tested and reported since there was already abundant evidence that proved surgical intervention was effective for both allergic and non-allergic CR. While validated tools such as rTNSS and NOSE scores assessed symptom improvement, they remain subjective and may not fully capture objective physiological changes. The 1-month follow-up may underestimate late-onset complications or long-term efficacy. In addition, excluding patients unable to discontinue anticoagulation or with significant anatomical abnormalities may limit applicability to higher-risk groups. Finally, despite multivariable analyses, residual confounding from unmeasured variables, such as socioeconomic status or unassessed comorbidities, cannot be ruled out. Nonetheless, this study provides critical evidence linking OSA and hypertension to increased surgical risks, emphasizing the need for personalized perioperative management.
Conclusions
Our study highlights the impact of OSA on minimally invasive nasal surgery outcomes in CR patients, emphasizing the need for enhanced screening, individualized risk assessment, and tailored perioperative management. A multidisciplinary approach, addressing OSA and hypertension while strengthening patient education, can improve surgical safety, effectiveness, and patient-centered care.
Footnotes
Author Contributions
Chien-Yu Huang: contributed to study design, data collection, and manuscript preparation. Reviewed and approved the final version of the manuscript. Chia-Hao Chang: contributed to data collection, statistical analysis, and critical review of the manuscript. Approved the final manuscript for publication. Yi-Li Hwang: participated in data analysis, interpretation of results, and critical revision of the manuscript. Reviewed and approved the final version of the manuscript. Ying-Shuo Hsu: played a key role in conceptualizing the study, supervising data collection, and drafting the manuscript. Provided substantial intellectual contributions and approved the final version of the manuscript. Szu-Yuan Wu: designed the study, supervised all stages of research, and provided critical revisions to the manuscript. Served as the senior author and guarantor of the study. All authors approved the final manuscript and agreed to be accountable for all aspects of the work.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: We thank Ditmanson Medical Foundation Chia-Yi Christian Hospital Research Program (R113-056) for supporting this research.
Ethical Considerations
The study was conducted with the approval of the Chia-Yi Christian Hospital Ethics Committee (approval no: CYCH2024022).
Data Availability Statement
The data supporting the findings of this study are available from the author, Dr Chien-Yu Huang, upon reasonable request. Due to ethical and privacy considerations, access to individual-level data is restricted to protect patient confidentiality. Aggregated data and additional materials related to the study are available to researchers who meet the criteria for access to confidential data.
