Nasal obstruction in sleep-disordered breathing

The use of CBCT in orthodontics with special focus on upper airway analysis in patients with sleep-disordered breathing

Applications of cone-beam CT (CBCT) in orthodontics have been increasingly discussed and evaluated in science and practice over the last two decades. The present work provides a comprehensive summary of current consolidated practice guidelines, cutting-edge innovative applications, and future outlooks about potential use of CBCT in orthodontics with a special focus on upper airway analysis in patients with sleep-disordered breathing. The present scoping review reveals that clinical applications of CBCT in orthodontics are broadly supported by evidence for the diagnosis of dental anomalies, temporomandibular joint disorders, and craniofacial malformations. On the other hand, CBCT imaging for upper airway analysis-including soft tissue diagnosis and airway morphology-needs further validation in order to provide better understanding regarding which diagnostic questions it can be expected to answer. Internationally recognized guidelines for CBCT use in orthodontics are existent, and similar ones should be developed to provide clear indications about the appropriate use of CBCT for upper airway assessment, including a list of specific clinical questions justifying its prescription.

Aerodynamics Analysis of the Impact of Nasal Surgery on Patients with Obstructive Sleep Apnea and Nasal Obstruction

OBJECTIVE

The purpose of this study was to evaluate the effects of nasal surgery on airflow characteristics in patients with obstructive sleep apnea (OSA) by comparing the alterations of airflow characteristics within the nasal and palatopharyngeal cavities.

METHODS

Thirty patients with OSA and nasal obstruction who underwent nasal surgery were enrolled. A pre- and postoperative 3-dimensional model was constructed, and alterations of airflow characteristics were assessed using the method of computational fluid dynamics. The other subjective and objective clinical indices were also assessed.

RESULTS

By comparison with the preoperative value, all postoperative subjective symptoms statistically improved (p < 0.05), while the Apnea-Hypopnea Index (AHI) changed little (p = 0.492); the postoperative airflow velocity and pressure in both nasal and palatopharyngeal cavities, nasal and palatopharyngeal pressure differences, and total upper airway resistance statistically decreased (all p < 0.01). A significant difference was derived for correlation between the alteration of simulation metrics with subjective improvements (p < 0.05), except with the AHI (p > 0.05).

CONCLUSION

Nasal surgery can decrease the total resistance of the upper airway and increase the nasal airflow volume and subjective sleep quality in patients with OSA and nasal obstruction. The altered airflow characteristics might contribute to the postoperative reduction of pharyngeal collapse in a subset of OSA patients.

Effects of intranasal mometasone furoate on blood pressure in patients with allergic rhinitis

Background: Nasal congestion as the main symptom in patients with allergic rhinitis can impair nasal breathing. It causes hypoxia and concomitant sympathetic system activation, which may also lead to increased blood pressure levels in these patients. Objective: We postulated that appropriate therapy, including intranasal steroids, decreases blood pressure levels in patients with allergic rhinitis. Methods: In our study, we investigated the effect of intranasal steroid (4 weeks of mometasone furoate) on blood pressure changes in 45 patients with allergic rhinitis whose main complaint was nasal congestion. We used ambulatory monitoring for determining blood pressure levels before and after intranasal steroid therapy. None of the patients had any other systemic diseases. Results: We found a significant decrease of daytime systolic and diastolic blood pressures and mean blood pressure values (daytime systolic blood pressure: 120 vs. 117 mmHg, p = 0.024; daytime diastolic blood pressure: 73 vs. 71 mmHg, p = 0.027; daytime mean blood pressure: 86 vs. 83 mmHg, p = 0.007). Although insignificant, we also found lower night-time systolic and mean blood pressure values (nighttime systolic blood pressure: 109 vs. 107 mmHg, p = 0.182; nighttime mean blood pressure 77 vs. 73 mmHg, p = 0.116). Conclusions: We found that post-treatment daytime average systolic, diastolic, and mean arterial blood pressure levels were significantly lower compared to values obtained during exacerbation of allergic rhinitis. Decrease in blood pressure with treatment of allergic rhinitis and nasal congestion suggests that nasal congestion and impaired nasal respiration may affect blood pressure and potentially cause serious problems in hypertensive patients with allergic rhinitis.

Association between allergic and nonallergic rhinitis and obstructive sleep apnea

PURPOSE OF REVIEW

Allergic rhinitis and nonallergic rhinitis (NAR) are common disorders, which have been considered as potential risk factors for obstructive sleep apnea (OSA). This review summarizes the proposed underlying pathophysiological mechanisms to provide a better understanding of the relationship between these conditions.

RECENT FINDINGS

In adults, allergic rhinitis and NAR may be considered as symptoms potentiating, rather than risk potentiating factors in the pathophysiology of OSA, whereas in children, these are considered to be independent predictors for sleep-disordered breathing (SDB) and failure of adeno-tonsillectomy, the recommended first-line therapy for children with OSA. Current advances suggest IL-6 may be important in regulating the sleep-wake cycle, and serum soluble IL-6 receptor (sIL-6R) levels may reflect the severity of OSA. Elevated Th17/Treg ratio correlates positively with apnea-hypopnea index of OSA patients, and Th17 and Treg imbalances caused by allergic rhinitis and OSA, respectively, may possibly promote each other, leading to further imbalance. Moreover, obesity is a strong risk factor for OSA, and leptin plays an important role in ventilatory function and upper airway obstruction. The variant trigeminocardiac reflex and nasotrigeminal reflex may also be involved in the association between rhinitis and OSA.

SUMMARY

Allergic rhinitis/NAR and OSA are closely associated, and each condition can be detrimental to the other. Thus, clinicians should pay attention to the potential presence of allergic rhinitis/NAR in OSA patients and vice versa.

Chronic Nasal Obstruction Causes Daytime Sleepiness and Decreased Quality of Life Even in the Absence of Snoring

Background

There has been a growing awareness that nasal obstruction may impair various daily and social activities. We performed a questionnaire survey in a working population to clarify the contribution made by snoring concomitant with nasal obstruction to daytime sleepiness and quality of life (QOL).

Methods

Seven thousand nine hundred eighty daytime workers were asked to complete questionnaires, 7702 responded, and the data from 3442 subjects were finally analyzed. Nasal obstruction and snoring were graded into three and four categories, respectively. Daytime sleepiness and QOL were assessed by the Epworth Sleepiness Scale (ESS) and the Medical Outcomes Study 36-Item Short-Form Health Survey, respectively.

Results

Subjects with chronic nasal obstruction, even if snoring was absent, reported significantly higher ESS scores and lower QOL scores than control subjects, and the presence of habitual snoring had an additive influence on these changes. The ESS and mental QOL scores adjusted for age, sex, and body mass index showed the same tendency.

Conclusion

Induction of sleep-disordered breathing (SDB) is a possible cause of excessive daytime sleepiness and impaired QOL in subjects with nasal obstruction. A variant of SDB such as silent upper respiratory resistance syndrome may participate in this phenomenon in the absence of snoring.

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 inpatients 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.

Craniofacial Deviations in the Children With Nasal Obstruction

Nasal obstruction mainly caused by adenoid hypertrophy in children affects the craniofacial growth and development process, and the craniofacial deviations and/or differences reported in the children are very similar to those in the adults with obstructive sleep apnea syndrome (OSAS). The authors aimed to look for relationships of the linear craniofacial dimensions in the children suffering from nasal obstruction with age, degree of clinical nasal obstruction score (CNOS), and relative size of the adenoid mass within the nasopharynx in their study.Fifty-five children suffering from nasal obstruction were retrospectively enrolled, and clinical data was used to calculate CNOS. On the lateral cephalometric radiographies, 9 linear variables were measured and adenoidal-nasopharyngeal ratio (ANR) was calculated.The data presented that, not CNOS, but ANR shown decrease by age, while many skeletal variables with exception of the nasopharyngeal and adenoidal postero-anterior dimensions were increased by age. Further, it was found that while CNOS were negatively correlated with the anterior cranial base length, anterior-superior facial height, and maxillary depth, ANR disclosed significant correlation only with the anteriorsuperior facial height. The authors' results support that nasal obstruction in the children was related not only to the adenoidal hypertrophy. Although relative size of the adenoidal mass in relation to the nasopharynx decreased by age, nasal obstruction was still present. Further, these results support that craniofacial deviations and/or differences in the children with nasal obstruction is similar to the adult OSAS patients. Smaller dimensions related to the naso-maxillary complex in the children with more severe nasal obstruction appear to be continuous by age. Hence, it could be said that narrow naso-maxillary complex could contribute to proceed nasal obstruction by age, which may contribute to OSAS in the adults.

Allergic and Non-Allergic Rhinitis Are Common in Obstructive Sleep Apnea but Not Associated With Disease Severity

STUDY OBJECTIVES

Several studies have suggested that rhinitis contributes to the pathogenesis of obstructive sleep apnea (OSA). We aimed to investigate the prevalence and influence of allergic rhinitis (AR) and non-allergic rhinitis (NAR) on severity of OSA.

METHODS

Two hundred forty patients with OSA confirmed by standardized polysomnography were assessed for presence of AR and NAR, using validated questionnaires and skin prick tests. Data comparison was carried out by using chi-square test, analysis of variance, and least significant difference test. Associations between severity of OSA and rhinitis, age, sex, and body mass index were assessed with ordinal logistic regression analysis.

RESULTS

The prevalence of AR and NAR among patients with OSA was 27.1% and 28.7%, respectively, with no significant differences in the severity of rhinitis. Ordinal logistic regression analysis showed AR and NAR were not the risk factors for severity of OSA. There were significant differences of polysomnography parameters in sleep efficiency (79.7 ± 2.0 versus 85.2 ± 1.4 between AR and NAR; 79.7 ± 2.0 versus 87.2 ± 1.4 between AR and no-rhinitis) and arousal index (36.8 ± 4.1 versus 24.7 ± 3.5 between AR and no-rhinitis). Patients with NAR had lower average arterial oxygen saturation (91.9 ± 0.6 versus 94.0 ± 0.6) and minimal arterial oxygen saturation (70.6 ± 1.7 versus 77.3 ± 1.8), compared with subjects categorized as no-rhinitis.

CONCLUSIONS

This study suggests that despite a comparatively high prevalence in patients with OSA, the presence or severity of AR or NAR does not influence the severity of OSA; however, rhinitis may significantly disturb sleep in patients with OSA.

Craniofacial changes and symptoms of sleep-disordered breathing in healthy children

INTRODUCTION:

The main cause of mouth breathing and sleep-disordered breathing (SDB) in childhood is associated with upper airway narrowing to varying degrees.

OBJECTIVE:

The aim of this study was to assess the prevalence of morphological and functional craniofacial changes and the main clinical symptoms of SDB in healthy children.

METHODS:

A cross-sectional observational study was conducted. A sample comprising 687 healthy schoolchildren, aged 7-12 years old and attending public schools, was assessed by medical history, clinical medical and dental examination, and respiratory tests. The self-perceived quality of life of mouth breathing children was obtained by a validated questionnaire.

RESULTS:

Out of the total sample, 520 children were nose breathers (NB) while 167 (24.3%) were mouth breathers (MB); 32.5% had severe hypertrophy of the palatine tonsils, 18% had a Mallampati score of III or IV, 26.1% had excessive overjet and 17.7% had anterior open bite malocclusion. Among the MB, 53.9% had atresic palate, 35.9% had lip incompetence, 33.5% reported sleepiness during the day, 32.2% often sneezed, 32.2% had a stuffy nose, 19.6% snored, and 9.4% reported having the feeling to stop breathing while asleep. However, the self-perception of their quality of life was considered good.

CONCLUSION:

High prevalence of facial changes as well as signs and symptoms of mouth breathing were found among health children, requiring early diagnosis and treatment to reduce the risk of SDB.

Orofacial-cervical alterations in individuals with upper airway resistance syndrome

INTRODUCTION

Studies that assess the upper airways in sleep-related breathing disorders have been performed only in patients with obstructive sleep apnea syndrome who seek medical attention. Therefore, in addition to the need for population studies, there are no data on the orofacial-cervical physical examination in subjects with upper airway resistance syndrome.

OBJECTIVES

To compare the orofacial-cervical examination between volunteers with upper airway resistance syndrome and without sleep-related breathing disorders.

METHODS

Through questionnaires, physical measurements, polysomnography, and otorhinolaryngological evaluation, this study compared the orofacial-cervical physical examination, through a systematic analysis of the facial skeleton, mouth, throat, and nose, between volunteers with upper airway resistance syndrome and volunteers without sleep-related breathing disorders in a representative sample of the adult population of the city of São Paulo.

RESULTS

There were 1042 volunteers evaluated; 49 subjects (5%) were excluded as they did not undergo otorhinolaryngological evaluation, 381 (36%) had apnea-hypopnea index>5 events/hour, and 131 (13%) had oxyhemoglobin saturation<90%. Among the remaining 481 subjects (46%), 30 (3%) met the criteria for the upper airway resistance syndrome definition and 53 (5%) met the control group criteria. At the clinical evaluation of nasal symptoms, the upper airway resistance syndrome group had more oropharyngeal dryness (17% vs. 29.6%; p=0.025) and septal deviation grades 1-3 (49.1% vs. 57.7%; p=0.025) when compared to controls. In the logistic regression model, it was found that individuals from the upper airway resistance syndrome group had 15.6-fold higher chance of having nose alterations, 11.2-fold higher chance of being hypertensive, and 7.6-fold higher chance of complaining of oropharyngeal dryness when compared to the control group.

CONCLUSION

Systematic evaluation of the facial skeleton, mouth, throat, and nose, between volunteers with upper airway resistance syndrome and volunteers without sleep-related breathing disorders, showed that the presence of upper airway resistance syndrome is mainly associated with nasal alterations and oropharyngeal dryness, in addition to the risk of hypertension, regardless of gender and obesity.

The relationship between structural/MHC changes in upper airway palatopharyngeal muscle morphology and obstructive sleep apnea/hypopnea syndrome

The aim of this study is to explore the relationship between structural/MHC changes in upper airway palatopharyngeal muscle morphology and obstructive sleep apnea/hypopnea syndrome. Palatopharyngeal muscle specimens were taken from 51 patients with obstructive sleep apnea hypopnea syndrome (OSAHS) who underwent uvulopalatopharyngoplasty (UPPP) resection. Patients were divided into light, medium and severe in terms of the severity of their OSAHS. There were 17 patients in each severity group. Palatopharyngeal muscle specimens were also taken from 17 patients suffering from chronic tonsillitis for comparison as the control group. All specimens were stained using Masson and observed for structural changes, especially in muscle fiber morphology, density and arrangement, as well as intermuscular connective tissues, under light microscopy. All specimens were also analyzed for MHC-I, MHC-IIa and MHC-IIb phenotype and protein expression differences using mRNA quantitative reverse transcription polymerase chain reaction (RT-PCR) and immunofluorescence staining. The results from each group were then statistically analyzed using semi-quantitative analysis. Light microscopy with Masson staining revealed that in the control group, the muscle fibers are closely connected and arranged neatly. In specimens from patients suffering from OSAHS, the palatopharyngeal muscle fibers are larger with obvious hypertrophy and there was an increase in elastic fibers. The mucosal lamina propria was thickened, and the density of muscle fibers was reduced. Muscle fibers are not neatly arranged and degeneration was observed. The amount of muscular pathology and fibrosis corresponds to the severity of disease in the patients. In patients with severe OSAHS, the proportion of collagen to muscle fibers was increased significantly. Immunofluorescence results reveal that there were significantly more fast muscle fibers and less slow muscle fibers in the study group than the control group. mRNA quantitative reverse transcription polymerase chain reaction (RT-PCR) revealed similar results, i.e., the proportion of MHC-II palatopharyngeal muscle fibers is higher in the study group than the control group, and increases with the severity of OSAHS. Pathological change occurs in both the collagen and muscle of OSAHS patients and corresponds to the degree of severity of OSAHS. Pathological change in palatopharyngeal muscle tissues is therefore, likely to be related to the occurrence and development of OSAHS. The increase in the proportion of the MHC-1I type fibers in OSAHS patients is likely to have an effect on the amount of airway support conferred by the muscle. This is likely the reason behind the lack of clinical improvement in some patients with severe OSAHS despite surgical treatment.

Current hypopnea scoring criteria underscore pediatric sleep disordered breathing

OBJECTIVE

This is a retrospective study comparing 2007 American Academy of Sleep Medicine (AASM) pediatric scoring criteria and Stanford scoring criteria of pediatric polysomnograms to characterize the impact different scoring systems have upon the diagnosis of sleep disordered breathing in children.

METHODS

The diagnostic and post-treatment nocturnal polysomnograms (PSGs) of children (age 2-18 years) consecutively referred to an academic sleep clinic for evaluation of suspected sleep disordered breathing (SDB) for 1 year were independently analyzed by a single researcher using AASM and Stanford scoring criteria in a blinded fashion.

RESULTS

A total of 209 (83 girls) children with suspected SDB underwent clinical evaluation and diagnostic PSG. Analysis of the diagnostic PSGs using the Stanford and AASM criteria classified 207 and 39 studies as abnormal, respectively. The AASM scoring criteria classified 19% of subjects as having obstructive sleep apnea (OSA) while the Stanford criteria diagnosed 99% of the subjects with OSA who were referred for evaluation of suspected sleep disordered breathing. There was a positive correlation between SDB-related clinical symptoms and anatomic risk factors for SDB. Scatter-plot analyses showed that the AASM apnea hypopnea index (AHI) was not only significantly lower compared to the Stanford AHI but also skewed in distribution. Ninety-nine children were restudied with PSG (9 were initially diagnosed with SDB with AASM criteria, whereas all 99 were diagnosed with SDB with Stanford criteria). All 99 children had been treated and had a post-treatment clinical evaluation and post-treatment PSG during the study period. All 99 children evaluated after treatment showed improvement in clinical presentation, Stanford AHI, and oxygen saturation during sleep.

CONCLUSION

The AASM scoring criteria classified 19% of subjects as having OSA while the Stanford criteria diagnosed 99% of the subjects with OSA who were referred for evaluation of suspected sleep disordered breathing. The primary factor differentiating the AASM and Stanford criteria was the scoring of hypopneas. The AASM definition of hypopnea may be detrimental to the recognition of SDB in children.

Surgical options for the treatment of obstructive sleep apnea

Obstructive sleep apnea (OSA) is a prevalent condition characterized by repetitive airway obstruction during sleep with associated increased morbidity and mortality. Although CPAP is the preferred treatment, poor compliance is common. Patients intolerant of conventional OSA medical treatment may benefit from surgical therapy to alleviate pharyngeal obstruction. Case series suggest that maxillomandibular advancement has the highest surgical efficacy (86%) and cure rate (43%). Soft palate surgical techniques are less successful, with uvulopalatopharyngoplasty having an OSA surgical success rate of 50% and cure rate of 16%. Further research is needed to more thoroughly assess clinical outcomes (eg, quality of life, morbidity), better identify key preoperative patient and clinical characteristics that predict success, and confirm long-term effectiveness of surgical modalities to treat OSA.

Evaluation of airway obstruction by nasopharyngoscopy: comparison of the Müller maneuver versus induced sleep

The use of nasopharyngoscopy during the application of intrathoracic pressure (Müller maneuver) is frequently employed to establish the site of upper airway obstruction. The Müller maneuver, however, is used when the patient is awake and therefore may not correlate with obstruction occurring during sleep. Aim: to compare the degree of pharyngeal obstruction in the retropalatal and retroglossal regions during the Müller maneuver versus induced sleep using nasopharyngoscopy. Study design: A prospective, case series study. Material and methods: Eight patients (three males, five females), with a mean age of 48.6 +/- 9,2 year, underwent nasopharyngoscopy to assess airway anatomy and funciton during the Müller maneuver while awake and during sleep induced by drip infusion of Midazolam. Results: Retropalatal obstruction was similar during the Müller maneuver and sleep (mean + standard deviation = 3.13 +/- 0.99 and 2.75 +/- 0.46, p= 0.234). Retroglossal obstruction was significantly lower during Müller maneuver compared to sleep (mean + standard deviation 0.63 +/- 1.06 and 2.63 +/- 1.30, respectively, p= 0.005). Conclusion: The sleep inducing method was safe under the monitored conditions of this study, and detected more retroglossal obstruction than the Müller maneuver.

Sleep impairment in allergic rhinitis, rhinosinusitis, and nasal polyposis

Sleep impairment is a significant problem for patients with inflammatory disorders of the upper respiratory tract, such as allergic rhinitis, rhinosinusitis, and nasal polyposis. Nasal congestion, one of the most common and bothersome symptoms of these conditions, is associated with sleep-disordered breathing and is thought to be a key cause of sleep impairment. This review examines sleep impairment associated with allergic rhinitis, rhinosinusitis, and nasal polyposis. It explores the adverse effects of disturbed sleep on patients' quality of life and how these inflammatory nasal conditions can be reduced by therapies that address the underlying problems affecting sleep. Treatment with intranasal corticosteroids has been shown to reduce nasal congestion in inflammatory disorders of the upper respiratory tract. Data on sleep-related end points from clinical trials of intranasal corticosteroids indicate that this reduction is associated with improved sleep, reduced daytime fatigue, and improved quality of life. Further research using measures of sleep as primary end points is warranted, based on the potential of these agents to improve sleep and quality of life in patients with allergic rhinitis, acute rhinosinusitis, and nasal polyposis. Such trials will help to identify the most effective therapies for sleep impairment in these 3 nasal conditions.

Avaliação da obstrução da via aérea superior através da videonasofaringoscopia: comparação da manobra de Müller com o sono induzido

A nasofaringoscopia com realização de Manobra de Müller é freqüentemente utilizada para determinar o local da obstrução na via aérea superior. No entanto, sua utilidade é controversa, uma vez que é realizada com o paciente acordado e pode não reproduzir os fenômenos obstrutivos que ocorrem durante o sono. OBJETIVOS: Comparar o grau de obstrução faríngea nas regiões retropalatal e retrolingual que ocorrem durante a manobra de Müller com aquelas que ocorrem durante o sono induzido. MATERIAL E MÉTODOS: Estudo prospectivo de 8 pacientes (3 homens e 5 mulheres) com idade (média ±desvio padrão) de 48,6 ± 9,2 anos de idade através de videonasofaringoscopia durante a manobra de Müller e durante o sono induzido por midazolam endovenoso. RESULTADOS: Observamos obstrução retropalatal similar durante a manobra de Müller e sono induzido (média + desvio padrão 3,13 + 0,99 e 2,75 + 0,46, respectivamente, p= 0,234). Em contraste, a obstrução retrolingual foi significantemente menor durante a manobra de Müller (média + desvio padrão 0,63 + 1,06 e 2,63 + 1,30, respectivamente, p= 0,005). CONCLUSÃO: O método do sono induzido foi seguro sob as condições de monitorização adotadas, tendo detectado maior ocorrência de colapso retrolingual do que a manobra de Müller.

Therapeutic options for reducing sleep impairment in allergic rhinitis, rhinosinusitis, and nasal polyposis

BACKGROUND

Patients with inflammatory disorders of the upper airways, such as allergic rhinitis, rhinosinusitis, and nasal polyposis, often have significant sleep disturbances. Poor sleep can lead to fatigue, daytime somnolence, impaired daytime functioning as reflected in lower levels of productivity at work or school, and a reduced quality of life. Although the exact mechanisms by which these inflammatory nasal conditions disturb sleep is not fully understood, congestion appears to be a key factor and is generally the most common and bothersome symptom for patients with these conditions. Successful therapy should improve patients' sleep and well-being without introducing any negative effects on sleep. SCOPE OF LITERATURE SEARCH: Literature searches of Medline, Embase, and abstracts from medical/scientific conferences were conducted for the period of 1995 through mid-2006 for primary and review articles and conference presentations about sleep disturbance related to allergic rhinitis, rhinosinusitis, and nasal polyposis. These searches also sought to identify articles examining how treatments for those diseases improved sleep and, consequently, patients' quality of life. Surveys of the impact of congestion on patients' quality of life and their sleep also were consulted. Clinical studies were selected for discussion if they were randomized, double-blind, and placebo-controlled. Limitations of this review include the absence of any direct comparisons of the effectiveness of different drugs on improving sleep and shortcomings in the statistical methods of the patient surveys.

FINDINGS

Intranasal corticosteroids (INSs) are the most effective medication for reducing congestion in patients with inflammatory nasal conditions. There is a growing amount of evidence that a reduction in congestion with INSs is associated with improved sleep, reduced daytime sleepiness, and enhanced patient quality of life.

CONCLUSION

Relief of sleep impairment associated with inflammatory disorders of the nose and sinuses can be addressed with INS therapy.

Adenoid hypertrophy presenting with systemic hypertension

A two and half year old male child was seen with systemic hypertension, left ventricular dysfunction, mitral regurgitation and congestive cardiac failure. Examination revealed adenoid hypertrophy. He was also suffering from obstructive sleep apnea. He was being treated with anti-hypertensive and anti-failure drugs. Adenoidectomy was performed following which obstructive sleep apnea symptoms disappeared and his cardiac status improved markedly. Subsequently he was weaned off anti-hypertensive and anti-failure therapy.

Allergic rhinitis and its effect on sleep, fatigue, and daytime somnolence

OBJECTIVE

To examine the adverse effects of sleep impairment on the quality of life of patients with the disorder and how these effects can be treated with therapies targeted at the underlying problems that influence sleep.

DATA SOURCES

Medline and Ovid search for sleep and rhinitis.

STUDY SELECTION

All literature on this topic were reviewed, and, if significant, were incorporated into this review.

RESULTS

Intranasal corticosteroids used as treatment for allergic rhinitis have been shown to reduce the nasal congestion characteristic of the disorder. Data on sleep-related end points from clinical trials on intranasal corticosteroids also reveal that the treatment's effectiveness in alleviating nasal congestion leads to better sleep, reduced daytime somnolence, and improved quality of life.

CONCLUSION

Further research, specifically using sleep measurements as primary end points, is needed to definitively show that intranasal corticosteroids reduce nasal congestion, thereby improving sleep and, consequently, quality of life in patients with allergic rhinitis. These future trials will serve to identify the most effective therapies that target the adverse effects of sleep impairment in this disorder.

Bibliography. Current world literature. Nose and paranasal sinuses

PURPOSE OF REVIEW

Patients with advanced head and neck cancer are being treated with chemo-radiotherapy, and life is being prolonged, with or without persistent disease, for longer than was previously. Hypercalcaemia may present in patients with advanced or disseminated head and neck cancer, and, as such, these patients may present to a larger variety of clinicians for advice concerning their symptoms and illness. Modes of presentation of hypercalcaemia and treatment strategies are reviewed.

RECENT FINDINGS

There were previously few large series of head and neck cancer patients diagnosed with hypercalcaemia, which may or may not have been related to their cancer being treated. Investigations, by way of blood/serum calcium level, may identify such patients. Patients with cancer-related hypercalcaemia have a poor prognosis, but many may respond temporarily to treatment when offered, with an improvement of their quality of life and death.

SUMMARY

Hypercalcaemia should and must be considered in all patients who have or possibly have a diagnosis of a head and neck cancer and who present unwell with symptoms of fatigue, lethargy and somnolence. Investigation must include serum calcium (corrected for serum albumin binding) and parathyroid hormone level. Patients may be treated by a combination of rehydration and bisulphonate therapy until the serum calcium is reduced to a level below 3 mmol/l. The majority of patients diagnosed with hypercalcaemia due to head and neck malignancy die of their diseases in the short term, but some may enjoy a prolongation of life with reasonable quality if diagnosed and treated aggressively.

Upper airway resistance syndrome--one decade later

PURPOSE OF REVIEW

The term upper airway resistance syndrome (UARS) was coined to describe a group of patients who did not meet the criteria for diagnosis of obstructive apnea-hypopnea syndrome and thus were left untreated. Today, most of the patients with UARS remain undiagnosed and are left untreated.

RECENT FINDINGS

Today, the clinical picture of UARS is better defined. We have learned that patients usually seek treatment with a somatic functional syndrome rather than sleep-disordered breathing or even a disorder of excessive daytime sleepiness. Therefore, most of these patients are seen by psychiatrists. In addition, recent technologic advances have allowed a better recognition of the problem. We have learned that obstructive apnea-hypopnea syndrome is associated with a local neurologic impairment that is responsible for the occurrence of the hypopnea and apneas. In contrast, patients with UARS have an intact local neurologic system and have the ability to respond to minor changes in upper airway dimension and resistance to airflow. New treatment options including internal jaw distraction osteogenesis are used and are promising for treatment of patients with UARS.

SUMMARY

The clinical presentation of patients with UARS is similar to the presentation of subjects with functional somatic syndrome. To diagnose UARS, nocturnal polysomnography should include additional measurement channels.

Rhinitis and sleep apnea

The nose and pharynx begin the upper airway system and represent a continuum. This is the biologic basis for the mutual influences of rhinitis and obstructive sleep apnea (OSA). Sleep-disordered breathing has a large differential diagnosis that includes snoring, upper airway resistance syndrome, and severe OSA. Nasal obstruction is an independent risk factor for OSA, but there is no correlation of daytime nasal resistance with the severity of OSA. However, nasal resistance was an independent predictor of apnea-hypopnea index in a recent study of nonobese OSA patients. Rhinitis alone is associated with mild OSA, but commonly causes microarousals and sleep fragmentation. Reduction of nasal inflammation with topical treatment improves sleep quality and subsequent daytime sleepiness and fatigue. Patient compliance with the nasal continuous positive airway pressure (nCPAP) device is relatively low, in part due to adverse nasal effects.