Neuromuscular function of the soft palate and uvula in snoring and obstructive sleep apnea: A systematic review

Objective

A collapsible upper airway is a common cause of obstructive sleep apnea. The exact pathophysiology leading to a more collapsible airway is not well understood. A progressive neuropathy of the soft palate and pharyngeal dilators may be associated with the progression of snoring to OSA. The purpose of this study is to systematically review the international literature investigating the neurophysiologic changes in the soft palate and uvula that contribute to progression from snoring to OSA.

悬雍垂-软腭折叠成形术治疗阻塞性睡眠呼吸暂停低通气综合征

目的　改进经典悬雍垂腭咽成型术 (uvulopalatopharyngoplasty ,UPPP)的手术方法 ,提高治疗阻塞性睡眠呼吸暂停低通气综合征 (obstructivesleepapnea hypopneasyndrome ,OSAHS)的治疗效果 ,减少术后并发症。方法　用新改进的术式治疗OSAHS患者 3 6例 ,轻度 8例 ,中度 2 1例 ,重度 7例。在常规UPPP手术基础上完整保留悬雍垂及腭肌 ,切除软腭口咽面下段 1/ 3～ 1/ 2的黏膜及黏膜下部分脂肪组织 ,再将软腭自游离缘向上折叠并与上切缘缝合 ,形成新软腭。保留软腭的活动与功能。结果　 3 1例 ( 86 1% )诉睡眠时鼾声、白天嗜睡和晨起头痛等症状明显改善。术后 6个月复查 ,3 0例( 83 3 3 % )低通气指数下降超过 5 0 % ,19例 <5次 /h ,9例≤ 2 0次 /h ,6例≤ 40次 /h。没有出现术后出血、开放性鼻音、长期饮食返流、鼻咽腔瘢痕性狭窄等并发症。结论　此改进术式在有效扩大咽腔 ,尤其是软腭后间隙的基础上 ,避免了腭咽关闭不全、饮食返流、鼻咽腔瘢痕性狭窄等并发症 ,疗效良好     

鼾症和轻中度阻塞性睡眠呼吸暂停低通气综合征治疗

目的探讨两种治疗睡眠呼吸障碍性疾病的方法。方法①4例习惯性打鼾(鼾症)和2例轻度阻塞性睡眠呼吸暂停低通气综合征(obstructive sleep apnea hypopnea syndrome,OSAHS)患者行小柱软腭植入术(pillar system);②11例鼾症和15例轻、中度OSAHS患者行双侧扁桃体射频消融术(radiofrequency ablation,RFA)。术前、术后均行多道睡眠图(polysomnography,PSG)监测、鼾声视觉模拟评分(visual analogous scale,VAS)、Epworth嗜睡量表(Epworth sleepiness score,ESS)评分及疼痛评分。结果术后均随访6个月以上。①小柱软腭植入:4例鼾症患者鼾声VAS平均分由术前的6.9±0.68下降至3.8±0.54,2例轻、中度OSAHS患者由9.2±1.21下降至3.1±0.52,患者及家属尚感满意;②扁桃体RFA:11例鼾症患者治愈7例,有效2例,无效2例;15例轻度、中度OSAHS患者治愈10例,有效3例,无效2例;总有效率84.6%(22/26)。结论①小柱软腭植入术对腭咽平面狭窄(软腭过长)引起鼾症和轻度OSAHS患者近期疗效满意;②扁桃体RFA对口咽左右径狭窄(扁桃体肥大)引起的鼾症及轻、中度OSAHS患者有效;③根据患者的不同情况及手术适应证制定不同的治疗方法。     

Histological analysis of palatopharyngeal muscle from children with snoring and obstructive sleep apnea syndrome

Obstructive sleep apnea syndrome (OSAS) is an upper airway obstruction that occurs during the sleep. One of the suggested mechanisms involved in this process is a neuromuscular abnormality of the palatal muscles. Whether children with OSAS develop into OSAS adults, or children and adult OSAS are two distinct disorders occurring at different ages are questions to be answered. Here, we made the histological analysis of palatophryngeal muscle in 34 oral-breathing children of both genders, aged 5-12 years old, with hypertrophic tonsils and adenoids. According to the polysomnographic study the participants were divided into children without sleeping disorders (group I) and children with primary snoring (group II) or apnea (group III). The main histological findings were fiber size variability in 70% cases from groups II and III and in 71% from group I; perimysial connective tissue infiltration in 48% children from groups II and III and in 71% from group I; intracytoplasmatic mitochondrial proliferation in 63% cases from groups II and III and in 57% cases from group I. Muscle necrosis was only observed in one case, in association with subglandular inflammation. Others findings observed in all groups included fibers with internal architecture alteration, such as moth-eaten and lobulated fibers, type 2 fiber predominance, and small areas of fiber type grouping. The presence of similar histological findings in the palatopharyngeal muscle in children with primary snoring or apnea but also in children without sleeping disorders indicate that such changes could be a normal histological feature of this muscle rather than a neurogenic or myopathic pathology.     

低温等离子辅助软腭外展加折叠术治疗阻塞性睡眠呼吸暂停低通气综合征

目的　探讨腭咽成形术的改良手术方法,在解除腭咽部解剖性狭窄的同时,通过软腭外展增强软腭紧张度,避免睡眠中软腭功能性塌陷,提高手术疗效。方法 手术治疗以腭咽部狭窄、软腭松弛为主的阻塞性睡眠呼吸暂停低通气综合征患者55例（重度43例,中度12例）,利用软腭两侧斜三角形以及悬雍垂软腭交界处横矩形黏膜瓣切口,在低温等离子刀辅助下,解剖切除双侧腭帆间隙及软腭前方间隙内肥厚黏膜及沉积的脂肪组织,同时行黏膜切缘连同深部肌肉拉拢缝合,缝合后使软腭向两侧外展,悬雍垂-软腭前倾。分别于术前及术后6个月进行Epworth嗜睡量表评分及多道睡眠图监测,对所获得的资料进行统计学分析。结果　55例患者中,治愈8例,显效41例,有效3例,无效3例,手术成功率89.1%。术后Epworth嗜睡量表评分、呼吸暂停低通气指数、最低动脉血氧饱和度与术前比较均有显著性差异（P <0.001）。未出现术后开放性鼻音、长期饮食反流、鼻咽腔瘢痕性狭窄等并发症。结论　低温等离子辅助下软腭外展加悬雍垂-软腭折叠术,使软腭向两侧牵拉外展,悬雍垂及软腭前倾,软腭紧张度增加,可有效解除软腭塌陷,手术疗效满意,无严重并发症发生。     

咽部肌肉和结构与阻塞性睡眠呼吸暂停的关系

上呼吸道包括鼻、咽、喉和胸腔外气管。研究最为关注的是咽部气道,这是阻塞性睡眠呼吸暂停综合征(OSAS)患者睡眠中发生部分或完全性阻塞的部位。在神经调节和化学调节下,咽部气道周围的肌肉可根据需要来调节气道口径和强直度。就睡眠期咽部肌肉和结构相互作用所维持的正常咽部气道,以及可能与睡眠呼吸障碍病理生理学相关的新研究作了阐述。     

小柱软腭植入术治疗习惯性鼾声及轻中度睡眠呼吸暂停

目的探讨小柱软腭植入术对习惯性鼾声及轻中度阻塞性睡眠呼吸暂停低通气综合征(obstructivesleepapneahypopneasyndrome,OSAHS)的疗效。方法6例经多导睡眠监测(polysomnography,PSG)确诊为轻及中度OSAHS,呼吸暂停低通气指数(apneahypopneaindex,AHI)<40,2例习惯性鼾声患者行小柱软腭植入术,术前、术后均行PSG,鼾声VAS评分及ESS评分。结果术后随访3个月,6例轻及中度OSAHS患者的AHI由术前的23±8.29次/小时下降至11.75±5.62次/小时,鼾声VAS评分从8.5±1.29降至3.5±0.82,ESS评分由术前的15.75±4.11下降至10.25±4.32;2例习惯性鼾声患者的鼾声VAS评分由术前的平均6.5下降至3.5,患者及家属都感满意。1例患者有异物感。未发生植入物排出、感染、出血及腭咽闭合功能不全等并发症。结论小柱软腭植入术对改善鼾声及睡眠呼吸暂停有较确切的近期疗效,而长期疗效有待进一步观察。     

咽侧壁成形术联合软腭低温等离子消融治疗重度阻塞性睡眠呼吸暂停低通气综合征

目的　探索咽侧壁成形术联合软腭低温等离子消融治疗重度阻塞性睡眠呼吸暂停低通气综合征（obstructive sleep apnea hypopnea syndrome,OSAHS）的 可行性和临床效果。方法　收集整理我科2011年4月～2012年12月行咽侧壁成形术联合软腭低温等离子消融的21例重度OSAHS患者临床资料,并进行回顾性分析。结果　治愈1例（5%）,显效19例（90%）,有效1例（5%）,无效0例。术前平均呼吸暂停低通气指数（AHI）为（54.2±15.7）次/ h,术后平均AHI为（8.3±2.8）次/h（t =-9.631,P＜0.05）;术前平均最低动脉血氧饱和度（lowest SaO2,LSaO2）为（66.6±6.4）%,术后平均LSaO2为（78.6±5.6）%（t =4.689,P＜0.05）;术前Epworth嗜睡量表（Epworth sleepiness score,ESS）平均评分为17.0±1.5,术后ESS平均评分为7.6±2.2（t =-11.376,P＜0.05）。主观症状均明显改善,术后1个月随访未出现反流及吞咽困难。结论　咽侧壁成形术联合软腭低温等离子消融术后患者AHI、LSaO2及ESS指标均改善明显,咽侧壁成形术联合软腭低温等离子消融可以作为治疗重度OSAHS的一个选择。     

微波消融术治疗上气道阻塞

目的探讨微波消融术治疗鼾症和阻塞性睡眠呼吸暂停低通气综合征（obstructive sleep apneahypopnea synd rome,OSAHS）的临床疗效.方法应用微波微创技术对8例鼾症和48例OSAHS患者进行治疗,术前及术后6个月进行多导睡眠监测（polysomnography,PSG）.结果56例患者治疗后咽腔宽敞,手术前后比较呼吸暂停低通气指数（apnea hyponeaindex,AHl）均值、最低血氧饱和度（LSaO2）均值及鼾声指数差异有高度显著性（P＜0.01）.治愈36例,有效15例,无效5例,总有效率91.1%.结论微波消融术是一项新的微创、安全、有效的治疗方法,在治疗鼾症和轻及中度OSAHS中具有一定的优越性.     

螺旋CT在诊断阻塞性睡眠呼吸暂停低通气综合征患者咽部阻塞平面中的应用

目的:探讨螺旋CT扫描对阻塞性睡眠呼吸暂停低通气综合征(OSHAS)患者咽部阻塞平面的诊断意义.方法:采用螺旋CT对自鼻咽顶部到声门之间的区域进行连续扫描,测量鼻咽区、口咽区、喉咽区及咽腔最狭窄区的咽腔横截面积和前后径、左右径以及咽壁厚度等指标.通过67例中、重度OSAHS患者(OSAHS组)CT资料相关指标的测量,并与40例健康者(对照组)的CT资料进行比较.结果:①OSAHS组患者CT资料显示,口咽部截面积、左右径、前后径分别(133.5±32.9)mm2、(12.5±2.0)mm、(10.4±1.8)mm,对照组的相关数据分别为(238.5±46.5)mm2、(20.4±3.1)mm、(21.1±4.0)mm,2组数据比较差异有统计学意义.②67例OS-AHS组患者,有61例(61/67)出现最狭窄平面,其中位于口咽区者58例,鼻咽区者3例,未见喉咽区明显狭窄平面.58例口咽区出现最狭窄平面中,在舌后区占48.5%(28/58)、软腭区域占32.8%(19/58)、悬雍垂区域占19.0%(11/58);对照组中24例(24/40)出现最狭窄平面,该平面均在口咽区.③58例口咽区存在最狭窄平面者,其截面积、左右径、前后径分别为(75.6±17.9)mm2、(10.6±2.1)mm、(6.9±1.0)mm;而对照组的最狭窄平面相关数据分别为(187.3±35.6)mm2、(21.4±4.3)mm、(15.6±2.7)mm,2组比较差异有统计学意义.结论:咽部螺旋CT扫描可较好地判断OSAHS患者的具体狭窄平面,大部分OSAHS患者存在咽腔解剖性狭窄,主要狭窄部位在口咽区.     

阻塞性睡眠呼吸暂停低通气综合征患者腭咽成形术后并发症发生率对比分析

目的：评估悬雍垂腭咽成形术(UPPP)手术治疗OSAS患者术后出现咽部干燥、咽异物感等并发症发生率。方法：对经UPPP手术治疗后OSAS患者52例,进行术后随访评估。随访采用问卷方法,与正常人咽部干燥及咽异感症作对比。结果：随访5年中,OSAS组46例排除糖尿病的患者中,16例出现咽部干燥,对照组63例中12例出现,差异有统计学意义(P＜0.05);OSAS组22例出现咽异感症,对照组12例出现,差异有统计学意义（P＜0.01）。结论：OSAS患者UPPP术后咽异感症及咽部干燥患者较多,为创伤刺激及瘢痕愈合所致,应予重视。UPPP术后出现音色改变的可能性不大。     

The role of sleep position in obstructive sleep apnea syndrome

We analyzed the role of sleep position in obstructive sleep apnea syndrome (OSAS). The polysomnograms of 120 patients with sleep apnea syndrome were analyzed. We associated the apnea hypopnea index (AHI) of the supine position with the AHI of the other positions. Patients were stratified in a group of positional patients (PP) (AHI supine ≥ 2 × AHI other positions) and a group of non-positional patients (NPP). In 55.8% of our patients, OSAS was position dependent. PP patients were significantly (6.7 years) younger. BMI and AHI were higher in the NPP group, but the difference was not significant. Level of obstruction in the upper airway (retropalatinal vs retrolingual vs both levels) as assessed by sleep endoscopy was not significantly different between the two groups. Total sleep time (TST) was equal in both groups, but the average time in supine position was 37 min longer in the PP group. This study confirms the finding that in more than 50% of patients, OSAS is position dependent. Apart from age, no patient characteristics were found indicating the position dependency. Overall AHI does not identify positional OSAS.     

Quantitative analysis of uvular muscles in cases of simple snoring and obstructive sleep apnea: an image analysis study

Studies on the histopathological changes of the palatine muscles in cases of obstructive sleep apnea (OSA) and simple snoring are controversial, while some authors confirm the presence of muscle hypertrophy and increase in total muscle bulk (obstructive theory), others deny this confirming the presence of muscle atrophy and decrease in the muscle bulk (neurogenic theory), but all these studies depended on subjective observer dependent methods to calculate the muscle bulk. We are carrying a unique study to calculate the muscle bulk in uvular specimens in ten cases of OSA comparing it to ten cases with simple snoring and controls using digital computer dependent software (image analysis). Cases of OSA are associated with definite increase in the total muscle bulk of the palatine muscles when compared to cases of simple snoring and controls. Uvular muscular hypertrophy and the obstructive theory seem to explain the pathophysiology of OSA.     

儿童阻塞性睡眠呼吸暂停低通气综合征240例的手术治疗

目的探讨手术治疗儿童阻塞性睡眠呼吸暂停低通气综合征(obstructive sleep apnea hy-popnea syndrome,OSAHS)的适应证、手术方法和疗效。方法回顾性总结了2 4 0例确诊为OSAHS需手术治疗病例,其中腺样体加扁桃体切除214例,单纯腺样体切除11例,单纯扁桃体切除15例。结果所有患者术后随访半年以上,175例(72.91%)痊愈,50例(20.83%)好转,15例(6.25%)无效。其中11例乳牙松动,3例乳牙脱落,8例术后24 h体温超过38℃;给予对症支持治疗后病情愈合。结论手术切除肥大的扁桃体和腺样体是治疗儿童OSAHS的主要治疗方法,但应根据不同的阻塞因素选择不同的手术方式。     

Changes in emotional state of snoring and obstructive sleep apnea patients following radiofrequency tissue ablation

A total of 37 primary snoring and obstructive sleep apnea hypopnea syndrome (OSAHS) patients were treated with two sessions of radiofrequency tissue ablation (RFTA) to assess the relationship among RFTA and sleepiness, anxiety and depression in patients with OSAHS. Patients’ sleepiness was rated according to the Epworth sleepiness scale (ESS), anxiety—on Spielberg’s trait-state anxiety inventory scale and depression degree—with Beck depression inventory-second edition scale and the patients’ major complaints were evaluated using visual analog scales before and after the treatment. A remarkable decrease in patients’ complaints, sleepiness and depression after RFTA was observed. The ESS mean score decreased from 9.3 ± 3.4 to 7.14 ± 3.2 points (P < 0.05) and Beck depression index mean value decreased from 14.2 ± 10.8 to 8.7 ± 7.6 points (P < 0.05), respectively. RFTA is a treatment of choice for snoring and mild to moderate OSAHS. Reduction of sleepiness and depression was statistically significant after RFTA.     

阻塞性睡眠呼吸暂停低通气综合征患者腭咽组织病理学观察

目的：观察阻塞性睡眠呼吸暂停低通气综合征（OSAHS）患者腭咽组织病理学变化特点，探讨腭咽组织中脂质异位积累在OSAHS发生、发展机制中的作用。方法：以OSAHS患者（OSAHS组）和无鼾症患者（对照组）各19例为研究对象，按体质指数（BMI）配对研究。取2组软腭及咽腭弓组织分别用苏木精-伊红及油红-O脂肪染色，镜下观察2组腭咽组织病理学特点及脂质异位积累情况。结果：OSAHS组腭咽组织中存在明显的脂质浸润，同时伴有小唾液腺类型改变，其超微结构呈现相应变化及细胞缺氧性改变；对照组腭咽组织无异常改变。结论：脂质在腭咽组织中的异位积累可能是导致OSAHS患者睡眠时咽部气道塌陷的重要原因，与OSAHS的发生、发展关系密切。     

男性阻塞性睡眠呼吸暂停低通气综合征患者血液学指标与睡眠呼吸暂停低通气指数的关系

目的 了解男性阻塞性睡眠呼吸暂停低通气综合征（OSAHS）患者的血液常规及生化指标和睡眠呼吸暂停低通气指数（AHI）的关系。方法 对2011年1月—2019年12月住院手术治疗且入院前整夜睡眠监测数据完整的474例成年男性患者进行回顾性研究。根据AHI将患者分为4组：A组（AHI<30次/h,56例）、B组（30次/h≤AHI<60次/h,162例）、C组（60次/h≤AHI<90次/h,217例）和D组（AHI≥90次/h,39例）。收集的数据包括睡眠参数、Epworth嗜睡量表评分（ESS）、血液常规及生化指标和人口统计学特征。结果 4组患者的红细胞计数、血小板计数、白细胞计数、中性粒细胞、谷丙转氨酶（ALT）、谷草转氨酶（AST）、AST/ALT、葡萄糖、尿酸、甘油三酯、高密度脂蛋白差异均具有统计学意义（P<0.05）;高密度脂蛋白和甘油三酯与AHI的线性相关性较好,且前者呈负相关,后者呈正相关（r=-0.252,r=0.192）;多元线性回归分析表明红细胞计数（β=0.140,P=0.004）和甘油三酯（β=0.122,P=0.017）与AHI独立相关,多个相关系数R²=0.332。结论 高密度脂蛋白、甘油三酯与AHI的线性相关性较好,且前者呈负相关（r=-0.252）,后者呈正相关（r=0.192）,红细胞计数、甘油三酯与AHI独立相关,有潜力成为判断经多导睡眠监测（PSG）检查后诊断为OSAHS患者综合严重程度的辅助指标。     

悬雍垂腭咽成形术后患者胰岛素抵抗观察

目的探讨阻塞性睡眠呼吸暂停低通气综合征(obstructivesleepapneahypopneasyndrome,OSAHS)患者采用悬雍垂腭咽成形术(uvulopalato-pharyngoplasty,UPPP)治疗前后胰岛素抵抗情况的变化。方法中及重度OSAHS43例,采用UPPP治疗,观察手术前后体重指数、血压、空腹血糖、空腹胰岛素、糖化血红蛋白、餐后2小时血糖、HOMA法胰岛素抵抗指数(HOMA-IR)的变化。结果UPPP治疗3个月后,血氧饱和度(oxygensaturation,SaO2)明显升高,睡眠呼吸暂停低通气指数(apneahypopneaindex,AHI)降低,收缩压明显下降,血糖、胰岛素抵抗指数轻度下降;OSAHS合并糖尿病患者胰岛素用量明显减少;体重指数无明显变化。结论OSAHS患者UPPP治疗后,从HOMA-IR、空腹胰岛素、空腹血糖、胰岛素用量、血压等多方面反应胰岛素抵抗好转。     

Single versus double suspension sutures for selected cases of obstructive sleep apnea

ObjectiveTo compare the results of expansion pharyngoplasty using bilateral single palatal suspension sutures (SSS) versus double suspension sutures (DSS) for the treatment of selected cases of obstructive sleep apnea (OSA) with retropalatal collapse.MethodsPatients were randomly categorized into two groups: the first group for whom bilateral SSS were performed and a second group for whom bilateral DSS were done. Snoring on the basis of the visual analog scale (VAS), Epworth Sleepiness Scale (ESS), apnea hypopnea index (AHI), lowest O₂ saturation were assessed preoperatively and 6 months postoperatively in all patients.ResultsDSS provided significantly more retroplatal space (p = 0.0137) and less snoring score (p = 0.0005). While no significance difference between SSS and DSS as regard inter pillar distance (p = 0.0985), AHI (p = 0.1677), ESS (p = 0.4094), and lowest O₂ saturation (p = 0.0839).ConclusionBoth SSS and DSS are simple, rapid, bloodless and effective procedures for treating OSA (in patients with retropalatal collapse) with no temporary or persistent postoperative complications. Adding the second suture in DSS could significantly enlarge more retropalatal space and reduce more snoring scale than SSS.