Association between anxiety and depression and sleep quality in benign laryngotracheal stenosis patients and analysis of risk factors

Abstract

BACKGROUND

Benign laryngotracheal stenosis (LTS) is a condition characterized by mucosal inflammation and fibrosis. It is difficult to treat with a high incidence rate. Respiratory distress and voice disorders of varying severity also affect patients’ sleep quality and quality of life.

AIM

To investigate the association between anxiety and depression and sleep quality in patients with benign LTS and identify significant risk factors for sleep disorders.

METHODS

This retrospective cohort study enrolled 127 consecutive patients with benign LTS admitted to The First People’s Hospital of Changde City between January 2021 and January 2024. Comprehensive assessments included demographic collection and Pittsburgh sleep quality index (PSQI), self-rating anxiety scale (SAS), and self-rating depression scale (SDS) scoring. Correlation analyses were conducted to examine relationships between psychological measures and sleep parameters, followed by multivariate logistic regression to determine independent risk factors.

RESULTS

The cohort demonstrated significantly impaired sleep quality (mean PSQI, 7.79 ± 2.47), with 48.0% (n = 61) meeting the criteria for clinically significant sleep disturbance. The scores of all PSQI dimensions, as well as SAS and SDS scores of patients with LTS, significantly exceeded Chinese normative values. Strong positive correlations emerged between PSQI scores and both SAS and SDS measures. Multivariate logistic analysis identified middle age (41-50 years), multiple surgical interventions (≥ 3 procedures), lower socioeconomic status (monthly household income per capita ≤ 5000 RMB), and concurrent anxiety/depression as independent predictors of sleep disturbance.

CONCLUSION

The results demonstrate a high prevalence of sleep disorders and comorbid anxiety or depressive moods among patients with LTS. These psychological factors both correlate with and independently predict sleep impairment. These results underscore the need for integrated and proactive approaches addressing both physical and mental health components in LTS management, focusing on high-risk subgroups stratified based on age, monthly household income per capita, anxiety/depression status, and number of prior surgeries.

Key Words: Benign laryngotracheal stenosis; Anxiety; Depression; Sleep quality; Sleep disorders

Core Tip: Laryngotracheal stenosis (LTS) is a condition characterized by mucosal inflammation and fibrosis. Changes in the diameter of the laryngotracheal airway and length of the narrowed segment can alter airflow, leading to progressive respiratory distress. Currently, domestic and international research on LTS has primarily focused on treatment modalities, with limited studies on the psychological and sleep-related aspects of patients with LTS. This study aimed to investigate the sleep quality of patients with LTS and its influencing factors, providing a theoretical basis for implementing effective intervention measures to improve the sleep quality of patients with LTS.

INTRODUCTION

Benign laryngotracheal stenosis (LTS) encompasses a spectrum of pathological conditions characterized by the structural narrowing of the airway at the glottic, subglottic, and tracheal levels[1]. LTS is pathologically defined by progressive mucosal inflammation and fibrosis, with resultant alterations in laryngotracheal lumen diameter and stenotic segment length, leading to airflow obstruction, resulting in progressive dyspnea and functional impairment of respiration, phonation, and deglutition[2,3]. As a refractory clinical entity with a significant disease burden, LTS demonstrates considerable epidemiological prevalence[4]. LTS has a multifactorial etiology, and iatrogenic causes such as prolonged endotracheal intubation and external trauma represent the most common predisposing factors[5]. Notably, autoimmune pathologies, such as granulomatosis with polyangiitis, relapsing polychondritis, and sarcoidosis, may also induce subglottic mucosal inflammation, potentially culminating in central airway stenosis[6,7]. The clinical consequences of severe LTS extend beyond basic respiratory compromise[8], with disease manifestations ranging from varying severity of dyspnea and vocal dysfunction to profound effects on sleep architecture, quality of life metrics, and disease prognosis. In critical cases, the condition may progress to life-threatening airway obstruction.

Contemporary therapeutic objectives for LTS management focus on the anatomical restoration of airway patency and functional preservation of laryngeal physiology, particularly phonatory capability and airway protective mechanisms[9]. Furthermore, the lack of standardized treatment protocols necessitates individualized therapeutic strategies, with surgical decision-making incorporating multidimensional assessments of anatomical configuration, lesion characteristics (such as location, longitudinal extent, and degree of luminal compromise), laryngotracheal functional status, patient-specific variables, and institutional resource availability[10,11]. The typically protracted treatment course, often requiring multiple interventions, predisposes this patient population to substantial psychological morbidity, such as anxiety and depressive disorders. Concurrently, disease-related respiratory compromise frequently precipitates sleep disturbances through multiple pathophysiological pathways. Despite these clinically significant ramifications, current research paradigms predominantly emphasize therapeutic interventions; however, investigations into the psychosocial dimensions and sleep-related consequences of LTS are limited. Accordingly, this study was conducted to systematically evaluate anxiety and depression profiles, along with a comprehensive sleep quality assessment, in patients with LTS. Through the identification and analysis of modifiable risk factors influencing sleep parameters, this study aimed to establish an evidence-based framework for targeted interventions to improve sleep quality in this patient population.

MATERIALS AND METHODS

Study population

Clinical records of patients diagnosed with benign LTS who were admitted to The First People’s Hospital of Changde City between January 2021 and January 2024 were analyzed retrospectively.

The inclusion criteria were as follows: (1) Diagnosis of LTS according to the established diagnostic criteria, including both primary and postoperative recurrent cases; (2) Age ≥ 18 years; (3) Adequate language comprehension, auditory/visual function, and cognitive ability to participate in interviews or complete questionnaires either independently or with researcher assistance; and (4) Availability of complete clinical records.

The exclusion criteria were as follows: (1) Concurrent malignant disease; (2) Cognitive impairment or diagnosed psychiatric disorders; (3) Personal or familial history of mental illness; (4) significant visual/hearing impairment, emotional dysregulation, or other psychiatric conditions impairing study compliance; (5) Recent use of neuropsychotropic medications; (6) Comorbid neurological or endocrine disorders (e.g., epilepsy and hypothyroidism) that may confound psychological assessments; and (7) Missing or incomplete clinical data.

Data collection

Patient demographics and clinical characteristics: Patient demographic and clinical data were extracted from patients’ electronic medical records. General information included age, sex, occupation, household income, educational level, and marital status. Clinical characteristics comprised Cotton–Myer stenosis grading, etiology of LTS, number of prior surgeries, and intubation duration.

Stenosis severity assessment: LTS severity was classified using the Cotton-Myer grading system, with higher grades indicating severe obstruction: Grade I, < 70% lumen obstruction; grade II, 70%-90% lumen obstruction; grade III, luminal occlusion > 90% with detectable residual patency, or complete obstruction confined to the subglottic region; grade IV, complete airway obstruction.

Psychological evaluation: Mental health assessments were conducted using standardized instruments. For depression, the 20-item self-rating depression scale was employed. It includes a 4-point Likert system (1-4). Raw scores were converted to standardized scores (raw sum × 1.25, rounded). Using Chinese normative data, scores of 53-62, 63-72, and 72 indicate mild, moderate, and severe depressive symptoms, respectively. For anxiety, the self-rating anxiety scale was used. It contains 20 items (15 items with standardized scores and 5 with reversed scores) rated 1-4. Standardized scores were calculated similarly. Chinese cutoffs of 50-59, 60-69, and ≥ 70 suggest mild, moderate, and severe anxiety, respectively.

Sleep quality evaluation: Sleep quality over the preceding month was evaluated using the Pittsburgh sleep quality index (PSQI), which assesses seven domains: Subjective sleep quality, sleep latency, sleep duration, sleep efficiency, sleep disturbances, use of hypnotic medications, and daytime dysfunction. Each domain is scored 0-3 (total range, 0-21), and a score > 7 indicates clinically significant sleep disturbance, and higher scores denote progressive worsening of sleep quality. Participants were stratified into sleep-disturbed (PSQI > 7) and non-sleep-disturbed (PSQI ≤ 7) groups.

Survey methodology

The study employed a structured questionnaire administered by trained interns from our institution. Before data collection, all survey personnel underwent standardized training to ensure a clear understanding of the research objectives, study protocol, questionnaire administration procedures, and ethical considerations, with particular attention to proper patient communication techniques.

The investigation process involved several key steps: First, the research team thoroughly explained the study purpose and survey instructions to eligible patients diagnosed with LTS. Before questionnaire distribution, written informed consent was obtained from both participants and their family members. Participants with adequate literacy skills completed the forms independently after researchers clarified any potentially confusing items. Conversely, for those with limited education, trained staff conducted face-to-face interviews to collect responses, strictly adhering to the original questionnaire content.

For data management, a dual-entry verification system was implemented using Microsoft Excel. Two independent researchers separately entered all questionnaire responses to create parallel datasets, which were then systematically compared to identify and correct discrepancies. This step enhanced data reliability and minimized potential recording errors.

Statistical analyses

Statistical analyses were performed using IBM SPSS Statistics version 25.0 (IBM Corp., Armonk, NY, United States). Normally distributed continuous variables were reported as means ± SD and compared between groups using independent samples t-tests. Conversely, non-normally distributed continuous variables were analyzed with nonparametric Mann-Whitney U tests. Categorical variables were expressed as frequency counts and percentages, with group differences assessed by Pearson’s χ² test or Fisher’s exact test as appropriate. To identify potential determinants of sleep quality, multivariate logistic regression modeling was applied. Correlation analyses between psychological factors (anxiety and depression scores) and sleep quality measures were conducted using Pearson’s rank correlation coefficients. In all analyses, significance was defined as a two-tailed P value < 0.05.

RESULTS

Sleep quality assessment in patients with LTS

The study cohort demonstrated a mean PSQI score of 7.79 ± 2.47. Notably, 61 out of 127 (48.0%) patients exhibited PSQI scores ≥ 7, indicating clinically significant sleep disturbances. Comparative analysis with Chinese normative data[12] revealed significantly high scores across all PSQI dimensions (P < 0.05) except for the use of hypnotic medications, indicating substantial sleep impairment (Table 1).

Table 1 Comparative sleep quality parameters.

	Laryngotracheal stenosis patients (n = 127)	Chinese normative data (n = 112)	t	P value
Subjective sleep quality	1.22 ± 0.64	0.67 ± 0.88	5.569	< 0.0001
Sleep latency	1.59 ± 0.79	0.70 ± 0.98	7.766	< 0.0001
Sleep duration	1.09 ± 0.89	0.46 ± 0.68	6.086	< 0.0001
Sleep efficiency	1.13 ± 0.93	0.02 ± 0.73	10.167	< 0.0001
Sleep disturbances	1.22 ± 0.71	0.83 ± 0.61	4.524	< 0.0001
Use of hypnotic medications	0.24 ± 0.47	0.18 ± 0.63	0.840	0.402
Daytime dysfunction	1.28 ± 0.83	0.79 ± 0.94	4.280	< 0.0001
Total PSQI score	7.79 ± 2.47	3.23 ± 3.12	13.605	< 0.0001

PSQI: Pittsburgh sleep quality index.

Psychological distress (anxiety and depression) evaluation

Using one-sample t-tests against Chinese normative samples (anxiety, n = 1158; depression, n = 1340)[13], scores for both anxiety and depression were significantly higher in patients with LTS (P < 0.05). These findings indicate a greater psychological burden among the study participants than among the general population (Table 2).

Table 2 Anxiety and depression measures of patients.

	SAS	SDS
Laryngotracheal stenosis patients (n = 127)	41.72 ± 9.78	48.85 ± 7.49
Chinese normative data	29.78 ± 10.07	41.88 ± 10.57
t	12.720	7.260
P value	< 0.0001	< 0.0001

SAS: Self-rating anxiety scale; SDS: Self-rating depression scale.

Psychosocial-sleep correlations

Significant positive correlations emerged between both anxiety/depression scores and total PSQI scores (P < 0.05). Anxiety scores correlated with all PSQI components, except sleep disturbances, use of hypnotic medications, and daytime dysfunction. Depression scores demonstrated associations with all dimensions, except the use of hypnotic medications (Table 3).

Table 3 Correlation between self-rating anxiety scale, self-rating depression scale, and sleep quality.

	SAS		SDS
	r	P value	r	P value
Subjective sleep quality	0.458	< 0.0001	0.268	0.001
Sleep latency	0.379	< 0.0001	0.509	< 0.0001
Sleep duration	0.366	< 0.0001	0.219	0.014
Sleep efficiency	0.218	0.014	0.273	0.002
Sleep disturbances	0.114	0.203	0.265	0.003
Use of hypnotic medications	0.161	0.071	0.013	0.886
Daytime dysfunction	0.023	0.801	0.277	0.002
Total PSQI score	0.523	< 0.0001	0.589	< 0.0001

SAS: Self-rating anxiety scale; SDS: Self-rating depression scale; PSQI: Pittsburgh sleep quality index.

Univariate analysis of demographic and clinical predictors of sleep disorders

Significant differences were found between the 61 patients (48.0%) with sleep disturbances and unaffected ones across multiple parameters (P < 0.05). Univariate analysis identified sex, age, monthly household income per capita, number of prior surgeries, and psychological status (anxiety and depression) as significant differentiating factors (Table 4). To exclude the influence of age on the disease, disease-related information from patients in different age groups was further analyzed. The results showed no significant differences between age groups in terms of Cotton-Myer classification, number of surgeries, tracheal tubes type, and duration of intubation (Table 5).

Table 4 Univariate predictors of sleep disorders, n (%).

	Sleep-disturbed group (n = 61)	Non-sleep-disturbed group (n = 66)	χ2	P value
Gender			4.285	0.038
Male	23 (37.7)	37 (56.1)
Female	38 (62.3)	29 (43.9)
Age (years old)			8.961	0.030
18-30	10 (16.4)	19 (28.8)
31-40	13 (21.3)	22 (33.3)
41-50	24 (39.3)	12 (18.2)
> 50	14 (23.0)	13 (19.7)
Educational level			0.777	0.678
Junior high school or below	20 (32.8)	23 (34.8)
College, technical secondary school or junior high school	23 (37.7)	28 (42.4)
University or above	18 (29.5)	15 (22.7)
Marital status			0.486	0.784
Single	21 (34.4)	25 (37.9)
Married	28 (45.9)	31 (47.0)
Divorced or widowed	12 (19.7)	10 (15.2)
Monthly household income per capita (RMB)			4.158	0.041
≤ 5000	36 (59.0)	27 (40.9)
> 5000	25 (41.0)	39 (59.1)
Etiology of laryngotracheal stenosis			0.647	0.958
Congenital	4 (6.6)	3 (4.5)
Traumatic	36 (59.0)	41 (62.1)
Chemical injury	2 (3.3)	3 (4.5)
Specific inflammation	4 (6.6)	3 (4.5)
Undetermined	15 (24.6)	16 (24.2)
Cotton-Myer grading			0.977	0.807
I	8 (13.1)	7 (10.6)
II	6 (9.8)	9 (13.6)
III	32 (52.5)	37 (56.1)
IV	15 (24.6)	13 (19.7)
Number of prior surgeries			9.920	0.019
None	4 (6.6)	10 (15.2)
1	18 (29.5)	30 (45.5)
2	17 (27.9)	16 (24.2)
≥ 3	22 (36.1)	10 (15.2)
Type of tracheal tubes			0.034	0.984
T-tube	28 (45.9)	31 (47.0)
Metal tracheostomy tube	25 (41.0)	27 (40.9)
Cuffed tracheostomy tube	8 (13.1)	8 (12.1)
Duration of intubation (months)			0.775	0.679
≤ 6	19 (31.1)	25 (37.9)
6-12	26 (42.6)	27 (40.9)
> 12	16 (26.2)	14 (21.2)
Anxiety	27 (44.3)	6 (9.1)	20.391	< 0.0001
Depression	30 (49.2)	9 (13.6)	18.821	< 0.0001

Table 5 Disease-related information among patients of different age groups, n (%).

	18-30 years old (n = 29)	31-40 years old (n = 35)	41-50 years old (n = 36)	> 50 years old (n = 27)	χ2	P value
Cotton-Myer grading					6.058	0.734
I	1 (3.4)	5 (14.3)	5 (13.9)	4 (14.8)
II	4 (13.8)	5 (14.3)	4 (11.1)	2 (7.4)
III	17 (58.6)	16 (45.7)	22 (61.1)	14 (51.9)
IV	7 (24.2)	9 (25.7)	5 (13.9)	7 (25.9)
Number of prior surgeries					4.595	0.868
None	1 (3.4)	6 (17.1)	4 (11.1)	3 (11.1)
1	11 (38.0)	14 (40.0)	12 (33.3)	11 (40.7)
2	9 (31.0)	7 (20.0)	10 (27.8)	8 (29.6)
≥ 3	8 (27.6)	8 (22.9)	10 (27.8)	5 (18.6)
Type of tracheal tubes					7.114	0.311
T-tube	13 (44.8)	19 (54.3)	16 (44.5)	11 (40.7)
Metal tracheostomy tube	12 (41.4)	14 (40.0)	17 (47.2)	9 (33.4)
Cuffed tracheostomy tube	4 (13.8)	2 (5.7)	3 (8.3)	7 (25.9)
Duration of intubation (months)					5.153	0.525
≤ 6	12 (41.4)	14 (40.0)	9 (25.0)	9 (33.4)
6-12	9 (31.0)	12 (34.3)	20 (55.6)	12 (44.4)
> 12	8 (27.6)	9 (25.7)	7 (19.4)	6 (22.2)

Multivariate logistic regression analysis of sleep quality determinants in patients with LTS

Significant variables identified in the univariate analysis of sleep disorders among 127 patients were entered into a multivariate logistic regression model. The sleep disorder status (0 = no, 1 = yes) was the dependent variable, with significant univariate factors as covariates. Using the 18-30 year age group as the reference category, patients aged 41-50 years exhibited a significantly higher risk of developing sleep disorders (HR = 4.512, P = 0.030). Similarly, patients who had undergone three or more surgical procedures showed a markedly higher risk than those who had no surgical history (HR = 8.527, P = 0.023). Furthermore, several socioeconomic and psychological factors were independently associated with sleep disturbance risk: A monthly household income per capita < 5000 yuan (HR = 4.527, P = 0.004), coexisting anxiety disorder (HR = 8.114, P < 0.0001), and depressive symptoms (HR = 6.977, P = 0.001) all emerged as significant predictors of sleep pathology. The results of the multivariate analysis are presented in Table 6.

Table 6 Multivariate logistic regression analysis of sleep quality determinants in laryngotracheal stenosis patients.

Variable	β	SE	Wald	P value	HR	95%CI
Constant	-3.580	1.148	9.730	0.002	0.028	-
Gender (0 = female, 1 = male)	-0.443	0.490	0.819	0.366	0.642	0.246-1.676
Age	-	-			-	-
18-30			8.066	0.045
21-40	0.111	0.706	0.025	0.785	1.118	0.280-4.457
41-50	1.507	0.692	4.737	0.030	4.512	1.162-17.527
> 50	1.309	0.718	3.327	0.068	3.703	0.907-15.117
Monthly household income per capita (0 = > 5000 RMB, 1 = ≤ 5000 RMB)	1.510	0.521	8.398	0.004	4.527	1.630-12.570
Number of prior surgeries	-	-			-	-
None			9.385	0.025
1 surgery	0.528	0.884	0.356	0.551	1.695	0.300-9.592
2 surgeries	1.626	0.919	3.132	0.077	5.086	0.840-30.810
≥ 3 surgeries	2.143	0.943	5.169	0.023	8.527	1.344-54.096
Anxiety (0 = no, 1 = yes)	2.094	0.599	12.211	0.000	8.114	2.508-26.255
Depression (0 = no, 1 = yes)	1.943	0.596	10.630	0.001	6.977	2.170-22.431

DISCUSSION

LTS is a rare clinical condition characterized by structural narrowing of the upper airway, involving the larynx, trachea, or both[14]. Although multiple etiological factors contribute to its development in adults, the predominant clinical manifestations typically include progressive dyspnea and inspiratory stridor. Current management strategies of progressively worsening respiratory symptoms primarily involve surgical interventions, ranging from temporary procedures to more definitive approaches, such as laryngotracheal reconstruction[15]. Notably, despite the significant clinical burden of this condition, psychological distress and quality-of-life impairments experienced by patients with LTS throughout their disease course remain substantially understudied.

This study into sleep quality among patients with LTS revealed clinically significant findings: Among 127 cases evaluated, nearly half (48.0%) exhibited varying severity of sleep disorders. Comparative analysis with normative Chinese population data demonstrated markedly high scores across all assessed sleep quality dimensions in the LTS cohort, except for the use of hypnotic medications. This sleep impairment likely stems from multiple pathophysiological mechanisms: Anatomical derangements in LTS-including deformities, collapse, or defects of the laryngotracheal cartilage framework, as well as scar tissue or submucosal tissue hyperplasia in the laryngotracheal mucosa[16]-persistently cause airway compromise that becomes particularly problematic during sleep. Furthermore, patients with airway prosthetics frequently report device-related discomfort. The iatrogenic effects of therapeutic interventions also have a substantial contribution; stents and T-tubes disrupt normal mucociliary clearance mechanisms, predisposing to the accumulation of distal secretions and subsequent obstruction. Necessary nursing care protocols after stent or T-tube placement-such as continuous humidification and atomized sputum induction-compound these issues, inevitably interfering with sleep continuity and quality[17]. In a recent study, the prevalence of obstructive sleep apnea (OSA) was high in a cohort of patients with subglottic stenosis[18]. Thus, the effect of airway dilation on OSA must be studied. Patients’ psychological status was further evaluated, revealing clinically significant levels of anxiety and depression in patients with LTS. LTS contributes to these mood disturbances through multiple pathways, such as physical distress of respiratory impairment, voice-related symptoms, ranging from hoarseness to complete aphonia, and concerns about disease progression. As the disease progresses, patients may worry about postoperative complications or poor recovery. Furthermore, patients who had undergone surgery, particularly those with T-tubes, frequently experience body image disturbances that may evolve into negative and depressive emotions, and a heavier psychological burden correlates with poorer sleep quality. Notably, a dose-dependent relationship was observed between psychological distress and sleep impairment, and greater anxiety/depression severity predicts poorer sleep quality, and vice versa. This bidirectional relationship aligns with emerging neurobiological evidence suggesting sleep dysregulation as a potential shared mechanism underlying anxiety/depression[19]. In the transdiagnostic model of sleep cognition, insomnia is identified as a candidate mediator in the longitudinal development of both generalized anxiety disorder and major depressive disorder[20]. Moreover, sleep deprivation appears to compromise emotional regulation while amplifying stress reactivity, creating a vicious cycle that perpetuates psychological disorders[21]. Finally, the following independent risk factors for sleep disorders were identified in the multivariate analysis: Age (41-50 years), multiple surgical interventions (≥ 3 procedures), low socioeconomic status (household per capita monthly income ≤ ¥5000), and concurrent anxiety/depression. Middle-aged patients (41-50 years) appear particularly vulnerable, which is likely due to the connection of disease burden with socioeconomic pressures, family obligations, and psychological stress during treatment, which may contribute to the development of sleep disorders. The financial toxicity associated with this condition-characterized by complex, protracted treatments and high recurrence rates-disproportionately affects lower-income individuals, compounding psychological distress and sleep dysfunction[22]. In some patients, restenosis may develop after surgery, necessitating further interventions. Patients who undergo multiple surgeries experience increased financial and mental strain due to repeated hospitalizations and procedures, which exacerbate anxiety and depression, thereby further disrupting sleep.

This study has several limitations. First, given the retrospective nature of this study, data were obtained solely from electronic medical records, which might miss details such as unrecorded sleep symptoms. In addition, selection bias is possible, which limits establishing causal relationships. Second, patients’ sleep quality was mainly assessed through subjective tests rather than quantifying sleep through objective tests, such as polysomnography; therefore, the actual sleep quality results may be biased. Third, patients with narrowed airways are more likely to have breathing-related sleep issues. These sleep issues may worsen sleep quality. Fourth, the sample size was relatively small; thus, some subgroup comparisons may lack the ability to detect significant differences in selected variables, limiting the generalizability of the results. Moreover, follow-up data are lacking, so the effect of sleep disorders on LTS prognosis could not be explored. Thus, a prospective study with a larger sample size and long-term follow-up is needed to confirm the present results.

CONCLUSION

Patients with LTS frequently exhibit varying severity of sleep disorders, often accompanied by anxiety or depression. Notably, anxiety and depression are not only correlated with sleep disorders but also constitute independent risk factors for their development. In clinical settings, healthcare providers should apply a holistic approach by monitoring disease progression while evaluating and addressing sleep quality.

To mitigate sleep disturbances, targeted interventions should be implemented. First, family support must be enhanced by educating caregivers and fostering effective communication to ensure that patients receive both emotional and practical assistance, thereby reducing psychological distress. Second, facilitating access to social support systems is important to alleviate financial burdens and improve overall well-being. Moreover, social assistance programs can be provided to low-income patients, and various measures can be taken to improve the “safety net” for low-income populations. This is not only an objective requirement for ensuring the basic needs of low-income populations. Such measures can significantly enhance sleep quality and contribute to better patient outcomes. Third, providing preoperative psychological counseling/psychotherapy/relaxation training, etc., is necessary for patients who have undergone multiple surgeries. These methods can help patients adjust their mindset and relieve psychological pressure.