Nasal symptoms are independently associated with subjective sleep impairment and symptom awareness in obstructive sleep apnea: an otolaryngology-based cohort study

Purpose Nasal disorders are common in obstructive sleep apnea (OSA). We previously reported an association between nasal symptoms and impaired sleep in non-obese OSA patients without multivariate adjustment. This study examined whether nasal symptoms are independently associated with subjective sleep quality and characterized the discordance phenotype in an otolaryngology-based cohort. Methods This retrospective study included 628 OSA patients (AHI ≥ 5 events/h). Nasal symptoms were assessed using the JRQLQ. Sleep quality was measured by the ESS, AIS, and PSQI. Discordance was defined as AHI ≥ 30 events/h with absent subjective impairment (ESS ≤ 10, AIS ≤ 5, or PSQI ≤ 5). Results All questionnaire scores worsened with nasal symptom severity (all p < 0.001), whereas polysomnographic parameters did not differ. Nasal symptom score was independently associated with ESS ≥ 11 (OR 1.159), AIS ≥ 6 (OR 1.163), and PSQI ≥ 6 (OR 1.247; all p < 0.001); AHI was non-significant. Nasal obstruction retained significance for AIS ≥ 6 and PSQI ≥ 6 after adjustment. Objective nasal resistance did not correlate with symptoms ( r = − 0.022). Discordance was present in 63.0% by ESS, rising to 90.3% at age ≥ 75 years. Nasal symptom score was associated with discordance across all definitions (OR 0.755–0.871; all p ≤ 0.027); AHI was non-significant. Conclusions Nasal symptoms are independently associated with subjective sleep impairment in OSA beyond polysomnography-defined severity. Daytime rhinomanometry does not reflect nasal symptoms or sleep quality. Most patients with severe OSA lacked perceived impairment; nasal symptom burden was the only factor consistently associated with discordance. Multidimensional nasal and sleep assessment is recommended.