Nasal obstruction in sleep-disordered breathing

It has been 30 years since Cottle suggested that "sleeping patterns are in great measure dependent on good nasal function" [1]. During this time, we have identified the OSAHS and related forms of sleep-disordered breathing such as UARS, and better appreciate the clinical sequelae of recurrent arousals and sleep fragmentation. Yet the exact role that obstructed nasal breathing plays in the pathogenesis of such sleep disorders remains presumptive, and robust clinical studies to corroborate this theory remain elusive; however, patients who may benefit most from correction of nasal obstruction as a sole intervention may be those with the mildest forms of sleep-disordered breathing without other significant predisposing anatomic abnormalities. Clearly, more stringently controlled studies [17,105] are needed, particularly in these types of patients. Until such time, it is reasonable to address issues of nasal obstruction as an adjunct to surgical and nonsurgical treatment in all patients who are diagnosed with a sleep-related breathing disorder.     

Nasal obstruction and sleep-disordered breathing: a study using acoustic rhinometry

BACKGROUND: The relationship between nasal airway function and sleep-disordered breathing (SDB) remains unclear. Although correction of nasal obstruction can significantly improve nighttime breathing in some patients, nasal obstruction may not play a role in all cases of SDB. An effective method of stratifying these patients is needed. Acoustic rhinometry (AR) is a reliable, noninvasive method of measuring the dimensions of the nasal airway. METHODS: In 44 patients, we performed acoustic rhinometric measurements of nasal airway cross-sectional area, followed by hospital-based polysomnography and nasal continuous positive airway pressure (nCPAP) level titration. We compared anatomic nasal obstruction to perceived nasal obstruction, as well as respiratory distress index and nCPAP titration level, using the Pearson correlation and multiple linear regression analysis within body mass index groups. RESULTS: Perceived nasal obstruction correlated significantly with objective anatomic obstruction as measured by AR (r = 0.45, p < 0.01). For certain subgroup analyses in patients with a body mass index below 25, AR measurements correlated significantly with both nCPAP titration pressure (r = 0.85, p < 0.01) and respiratory distress index (r = 0.67, p = 0,03). CONCLUSION: Nasal airway function may be a significant component of SDB in some patients, perhaps playing a larger role in patients who are not overweight. The best responders to nasal surgery for SDB may be nonoverweight patients with nasal obstruction. AR along with nasal examination may be helpful in the evaluation and treatment of the SDB patient.     

Postural cephalometric analysis and nasal resistance in sleep-disordered breathing

OBJECTIVES: The study was designed to compare upright and supine cephalometric measurements in snorers and to evaluate the effects of mandibular position and nasal resistance on pharyngeal dimensions. Anthropometric, rhinomanometric, and cephalometric measurements were used to investigate predictors of apnea-hypopnea index. STUDY DESIGN: Prospective, cross-sectional. METHODS: Forty consecutive habitually snoring men waiting for nasal surgery (mean age, 44 y; mean body mass index, 28 kg/m2) underwent an overnight polysomnographic, anterior rhinomanometric, and cephalometric analysis in upright and supine positions. RESULTS: Nasal resistance correlated positively with minimal pharyngeal airspace at the level of tongue. The opening of jaws after voluntary relaxation of the mandibular position on lying down correlated with decrease in pharyngeal airway measurements at both velopharyngeal and tongue-base levels. In stepwise multiple regression analysis the overall patient model explained 68% of the variation in apnea-hypopnea index with body mass index as the largest predictor. In the nonobese patients, the model explained 86% of variation in apnea-hypopnea index with change in anteroposterior position of the lower jaw in upright and supine measurements and combined nasal resistance after mucosal decongestion as independent determinants. In selected skeletal subtypes the models predicted 83%, 79%, 61%, and 90% of the variation in apnea-hypopnea index. CONCLUSIONS: In the nonobese patients nasal resistance and change in mandibular position on lying down were found to be independent contributing factors to the apnea-hypopnea index. Further research on supine cephalometry and relaxed mandibular position may improve prediction of sleep-disordered breathing in snorers.     

Nasal obstruction and its impact on sleep-related breathing disorders

Upper airway patency is essential during sleep in order to avoid sleep-related breathing disorders (SRBD). Nasal obstruction may have a negative impact on sleep quality and must be considered to be a co-factor in the pathophysiology of SRBD. In this paper we will discuss the relation between nasal physiology at night and sleep quality and the possible mechanisms between nasal obstruction and obstructive sleep apnea-hypopnea syndrome (OSAS). We will review the effect of the relief of nasal obstruction (with nasal dilators, medication and/or surgery) on SRBD. Also an algorithm on the management of OSAS patients when nasal surgery is indicated will be proposed.     

The Effect of nasal packing on sleep-disordered breathing and nocturnal oxygen desaturation.

Nasal obstruction is known to cause abnormal ventilation during sleep in infants, but its effects on breathing and oxygenation during sleep in adults are unknown. However, in adults, obstruction of the nose by nasal packing has been shown to cause hypoxia, and on occasion, hypercarbia and sudden death. We have investigated the pattern of ventilation and the level of oxygenation during sleep in seven patients who had nasal packs after nasal polypectomy or septoplasty. Using standard polysomnographic techniques, we monitored chest wall motion, nasal and oral airflow, and arterial oxygen saturation and sleep stages. Nasal packing either caused or worsened sleep-disordered breathing in all patients and significantly increased the number, duration, and frequency of episodes for the group as a whole. Several patients also had a greatly increased number and severity of episodes of nocturnal oxygen desaturation. This study shows that obstruction of the nose by packing causes marked alterations in breathing during sleep in adults.     

Influence of nasal obstruction on sleep-associated breathing disorders]

BACKGROUND: The influence of nasal obstruction on sleep associated breathing disorders (SABD) and the controversial effects of surgical treatment are discussed. RESULTS: Complete nasal obstruction caused by nasal packing increases SABD, but varies from patient to patient and depends on age and individual anatomy. Especially patients with preexisting obstructive sleep apnea syndrome (OSAS) can develop severe complications. Some authors found a higher frequency of SABD in patients with nasal obstruction due to anatomical alterations, i.e. septal deviation, while others denied this connection. Major causes for the development of SABD in nasal obstruction include certain reflex mechanisms, increased negative inspiration pressure with a tendency for pharyngeal collapse, and transition to transoral breathing. Intermittent dilatation of the nasal valve using stents or tapes will lead to a decrease of nasal airway resistance and might also result in an improvement of SABD according to some studies, while others did not find any improvement. The results of controversial operative treatment in nasal airway obstruction are also described and include complete healing of high degree OSAS, improvement of sleep quality, and elimination of snoring. On the other hand, surgery might also be completely unsuccessful or even induce OSAS. CONCLUSION: As the effect of any kind of nasal operation on SABD is unpredictable from our present knowledge, the decision whether or not nasal surgery is indicated should depend on the individual situation of the patient. If OSAS is suspected, preoperative and post-operative polysomnography should be performed.     

塞纳斯凝胶在鼻息肉伴睡眠呼吸障碍成年患者鼻内镜术中的应用

目的 为选择更适合鼻内镜术临床应用的填塞材料,总结归纳塞纳斯凝胶在慢性鼻-鼻窦炎伴鼻息肉(CRSwNP)引起的睡眠呼吸障碍(SDB)患者行鼻内镜术中的应用情况,探讨SDB患者与非SDB患者应用塞纳斯凝胶后其舒适度的差异。 方法 双侧CRSwNP成人患者216例施行鼻内镜手术,其中伴SDB 156例,不伴SDB 60例。分为4个组,其中A组为不伴SDB患者术中填塞塞纳斯凝胶60例、B组为伴SDB患者术中填塞塞纳斯凝胶组56例, C组为伴SDB患者术中填塞纳吸棉组47例, D组为伴SDB患者术中填塞医用膨胀海绵组53例。采用视觉模拟评分法(VAS)对其鼻腔反应进行比较。 结果 A组和B组比较,塞纳斯凝胶在头痛、鼻痛及术后出血三方面差异有统计学意义(P<0.05),SDB患者在这三方面更不耐受。B组与C组比较,在头痛、鼻痛、鼻塞感、流泪四方面差异有统计学意义(P<0.05),塞纳斯凝胶优于纳吸棉。B组与D组比较,在头痛、鼻痛、鼻塞感、流泪、吞咽障碍、术后出血6个方面差异均有统计学意义(P<0.05),但临床意义不同,在术后出血方面塞纳斯凝胶组的效果虽差于医用膨胀海绵组,但仍可接受,其余方面塞纳斯凝胶明显优于膨胀海绵。 结论 塞纳斯凝胶是更适合于临床应用的填塞材料,能为患者带来更高的术后舒适度。另外SDB能加重患者头痛、鼻痛和术后出血症状,可能与长期缺氧致炎症反应较重有关。     

Relationships of craniofacial morphology and body mass index with sleep-disordered breathing in Japanese men

OBJECTIVE/HYPOTHESIS: Obesity is an established risk factor for sleep-disordered breathing, but the impact of craniofacial morphology is uncertain. The aim of this study was to assess the impact of craniofacial morphology and body weight on sleep-disordered breathing in Japanese men. STUDY DESIGN: A cross-sectional study. METHODS: We measured body mass index, seven cephalometric variables, and 3% oxygen desaturation index recorded by a pulse oximeter in 313 Japanese men aged 20 to 65 years who attended a sleep clinic. We defined craniofacial score as the sums of quartile points (0-3) for distance from sella to nasion and that from hyoid bone to mandibular plane. RESULTS: The mean value of 3% oxygen desaturation index and odds ratios of 3% oxygen desaturation index 15 or greater progressively increased with craniofacial score as well as body mass index. Multivariate odds ratios associated with craniofacial score were higher in men with body mass index 25.0 kg/m or greater (odds ratio = 4.2, 95% confidence interval [CI] = 2.1-8.6) than in men with lower body mass index (odds ratio = 1.6, 95% CI = 0.7-3.6). CONCLUSIONS: Our results imply the importance of cephalometric assessment in overweight patients.     

Radiofrequency techniques in the treatment of sleep-disordered breathing

The current medical information reviewing the use of radiofrequency in tissue volumetric reduction in the upper airway for nasal obstruction, primary snoring, and sleep-disordered breathing is reviewed. Reviews of the pathophysiology of sites of obstruction of the upper airway, indications for radiofrequency, procedure, technique, results, limitations and potential complications for each procedure, with the author's recommendations, are presented. The radiofrequency procedures are technically simple, minimally invasive, are associated with reduced postoperative pain compared with traditional surgical approaches, and can be performed on an outpatient basis under local anesthesia with a low complication rate and generally good therapeutic results. Future studies will aid in delineating the specific role of radiofrequency in nasal obstruction and sleep-disordered breathing.     

Anatomical basis of sleep-related breathing abnormalities in children with nasal obstruction

OBJECTIVE: To define, in a group of children with nasal obstruction, the anatomical differences that differentiate those with quiet, unobstructed nocturnal respiration from those with obstructive sleep-related breathing abnormalities (snoring and obstructive sleep apnea). DESIGN: Case series. PATIENTS: Fifty-nine children aged 3 to 13 years (35 boys and 24 girls) with nasal obstruction and without tonsillar hypertrophy, known craniofacial syndromes, or neuromuscular diseases were included in the study. MAIN OUTCOME MEASURES: Each patient was categorized as to severity of nocturnal obstructive breathing symptoms. Angular and linear cephalometric measurements were used for assessment of craniofacial features. Clinical symptom scores were correlated with the cephalometric measurements. RESULTS: Significant craniofacial abnormalities were identified in patients prone to obstructive breathing patterns: increased flexure of the cranial base and bony nasopharynx, opening of the gonial angle, shortened mandibular length, dorsocaudal location of the hyoid, reduced posterior airway space, and increased velar thickness. CONCLUSIONS: A number of anatomical abnormalities may contribute to sleep-related abnormal breathing in otherwise normal children with nasal obstruction. Our results suggest that symptomatic children show some of the same skeletal and soft-tissue configurations that are found in adults with obstructive sleep apnea. While adenoidectomy is generally an effective treatment in children with obstructive sleep-related breathing abnormalities, the underlying craniofacial variances that remain after adenoidectomy may predispose these patients to redevelopment of obstructive breathing abnormalities in adulthood.     

Flexible fiberoptic laryngoscopy in children: effect of sitting versus supine position

Currently no standard exists as to the exact technique of flexible fiberoptic laryngoscopy (FFL) for children. Our objective was to determine the effects of examination in the sitting versus supine position on upper airway findings during FFL in children using a standardized technique and a grading system. In this prospective study, each child acted as his or her own control. Thirty children underwent FFL at a tertiary care children's hospital (mean age 4.5 years). FFL was performed during spontaneous ventilation in both positions, using a standardized sedation technique administered by a single paediatric anaesthesiologist. The findings of inspiratory prolapse of the base of tongue, epiglottis, aryepiglottic folds and arytenoids, and presence of retractions were graded. The results indicated no differences in laryngeal findings between the two positions in 19 (63%) out of 30 children. Differences were observed in 11 (37%) children (p<0.01), but were of small magnitude (one grade) in 10 (91%) of 11 children. Only one child (9%) with severe hypotonia had a difference of two grades. For children with positional differences, 6 (55%) had more obstruction in the supine position, while 5 (45%) had more obstruction in the sitting position. We conclude that although sitting versus supine position statistically significantly affects upper airway findings during FFL in children, examination in either position is usually acceptable. Examination in both positions may detect small differences in approximately one third of children, but we believe this would usually not alter management. Investigators are encouraged to adopt standardized techniques for FFL and grading systems that will allow meaningful comparisons between patients, techniques, and centers.     

Nasal sound analysis: a new method for evaluating nasal obstruction in allergic rhinitis

OBJECTIVE: Current measurements of nasal obstruction are unreliable and may be improved with the development of new techniques. The effectiveness of odiosoft-rhino (OR) in the evaluation of nasal obstruction was investigated in a blind comparison at a referral center, institutional practice. PATIENTS: Forty-eight patients with perennial allergic rhinitis and 52 healthy subjects were studied. Nasal endoscopic examination, acoustic rhinometry (AR), and OR were performed and symptom scores compared. MAIN OUTCOME MEASURE: Assessment of nasal blockage with OR method was the main outcome measure. RESULTS: Using the OR technique, significant differences were observed between the patient and control groups. OR data correlated with symptom scores and endoscopic examination. However, this was not observed with AR. A 15.5-dB cutoff point for the left side and 14.5 dB cutoff point for the right side at the 2,000 to 4,000 Hz frequency interval resulted in 93.8% sensitivity and 92.3% specificity and 72.9% sensitivity and 80.8% specificity, respectively. A 8.5-dB cutoff point for the left and right sides at the 4,000 to 6,000 Hz frequency interval resulted in 87.5% sensitivity and 80.8% specificity and 70.8% sensitivity and 78.8% specificity, respectively. CONCLUSION: OR is a simple, noninvasive test for assessing nasal obstruction. The OR technique can detect nasal obstruction with high sensitivity and specificity, and these findings correlate with symptoms and physical examination.