Nocturnal nasal congestion and nasal resistance

Evaluation of Respiratory Resistance as a Predictor for Oral Appliance Treatment Response in Obstructive Sleep Apnea: A Pilot Study

The aim of this study was to determine the utility of respiratory resistance as a predictor of oral appliance (OA) response in obstructive sleep apnea (OSA). Twenty-seven patients with OSA (mean respiratory event index (REI): 17.5 ± 6.5 events/h) were recruited. At baseline, the respiratory resistance (R20) was measured by impulse oscillometry (IOS) with a fitted nasal mask in the supine position, and cephalometric radiographs were obtained to analyze the pharyngeal airway space (SPAS: superior posterior airway space, MAS: middle airway space, IAS: inferior airway space). The R20 and radiographs after the OA treatment were evaluated, and the changes from the baseline were analyzed. A sleep test with OA was carried out using a portable device. The subjects were divided into Responders and Non-responders based on an REI improvement ≥ 50% from the baseline, or REI < 5 after treatment, and the R20 reduction rate between the two groups were compared. The subjects comprised 20 responders and 7 non-responders. The R20 reduction rate with OA in responders was significantly greater than it was in non-responders (14.4 ± 7.9 % versus 2.4 ± 9.8 %, p < 0.05). In responders, SPAS, MAS, and IAS were significantly widened and R20 was significantly decreased with OA (p < 0.05). There was no significant difference in non-responders (p > 0.05). A logistic multiple regression analysis showed that the R20 reduction rate was predictive for OA treatment responses (2% incremental odds ratio (OR), 24.5; 95% CI, 21.5–28.0; p = 0.018). This pilot study confirmed that respiratory resistance may have significant clinical utility in predicting OA treatment responses.

The Recumbent Position Affects Nasal Resistance: A Systematic Review and Meta-Analysis

OBJECTIVE

Nasal diseases are among the main motives for the early discontinuation of continuous positive airway pressure therapy and for long-term therapeutic compliance with mandibular advancement device. Although our clinical experience leads us to the belief that recumbency impacts nasal airflow in some patient populations, there is no consensus regarding the magnitude of this effect and the specific group of patients who are the most affected by this condition. In this study, we conducted a meta-analysis to assess the effect of the recumbent position on nasal resistance and nasal airflow.

REVIEW METHODS

PubMed (Medline), Cochrane Library, EMBASE, Scopus, and SciELO databases were checked for relevant studies by two members of the YO-IFOS study group. The two authors extracted the data. The main outcome was expressed as the difference between nasal resistance and nasal airflow before and after recumbency.

RESULTS

Nine studies with a total population of 291 individuals were included in the meta-analysis for nasal resistance after recumbency. We found a statistically significant difference in nasal airway resistance of -0.18 Pa sec/cm³ as compared to before and after recumbency through rhinomanometry (RMM) analysis. A subgroup analysis revealed a variation of -0.20 Pa sec/cm³ for patients with snoring or sleep apnea and - 0.10 Pa sec/cm³ for healthy individuals. Regarding nasal airflow measured with RMM, three studies (n = 32) in asymptomatic controls revealed a statistically significant difference of 47.33 ml/sec.

CONCLUSIONS

Recumbency increases nasal resistance and diminishes nasal airflow. This finding is of utmost importance in snorers and sleep apnea patients. Laryngoscope, 2021.

Total nasal airway resistance while sitting predicts airway collapse when lying down

BACKGROUND

Nasal obstruction when lying down is a common complaint in patients with chronic nasal obstruction, but rhinomanometry is typically performed in the sitting position. This study aimed to analyse whether adding rhinomanometry in a supine position is a useful examination.

METHOD

A total of 41 patients with chronic nasal obstruction underwent rhinomanometry and acoustic rhinometry, sitting and supine, before and after decongestion, as well as an over-night polygraphy.

RESULTS

Total airway resistance was measurable in a supine position in 48 per cent (14 of 29) of the patients with total airway resistance of equal to or less than 0.3 Pa/cm3/second when sitting and in none (0 of 12) of the patients with total nasal airway resistance of more than 0.3 Pa/cm3/second when sitting. After decongestion, this increased to 83 per cent and 58 per cent, respectively.

CONCLUSION

Increased nasal resistance when sitting predicts nasal breathing problems when supine. Rhinomanometry in a supine position should be performed to diagnose upper airway collapse when supine.

Rhinosinusitis symptoms, smoking and COPD: Prevalence and associations

OBJECTIVE (S)

To estimate the prevalence and associations among rhinosinusitis symptoms, smoking and chronic obstructive pulmonary disease (COPD).

DESIGN

Cross-sectional study.

SETTING

Population-based.

PARTICIPANTS

All adults aged 40 years or more living in the selected households in the city of Florianópolis (Florianópolis, Santa Catarina, Brazil).

MAIN OUTCOME MEASURES

Assessment instruments comprised household interviews, anthropometric measurements and spirometry. Rhinosinusitis symptoms were based on the responses to the 22-item Sinonasal Outcome Test (SNOT-22) questionnaire; smoking status was defined by the criteria of the CDC, and the functional diagnosis of COPD was done by spirometry.

RESULTS

The prevalence (n = 1056) of rhinosinusitis symptoms, smoking and COPD was 14.7%, 17.9% and 8.7%, respectively. Multivariate analysis showed that, with the exception of COPD, all other clinical variables (smoking, previous diagnosis of rhinitis, previous diagnosis of gastritis/ulcer/gastroesophageal reflux, and symptoms of depression) remained associated with higher prevalence of rhinosinusitis symptoms.

CONCLUSIONS

Rhinosinusitis symptoms were common both in smokers and in patients with COPD. However, only tobacco was significantly associated with rhinosinusitis symptoms and can act as a cofounder in the association between COPD and rhinosinusitis symptoms.

Treatment Paradigm for Nasal Airway Obstruction

Nasal airway obstruction (NAO) is a common otolaryngic complaint with many potential causes, frequently structural or inflammatory in nature. Patients typically have multiple coexisting factors leading to symptoms. Good patient outcomes require careful preoperative evaluation, including nasal endoscopy, to accurately identify sources of obstruction and tailor intervention appropriately. Common structural causes of NAO include inferior turbinate hypertrophy, nasal septal deviation, and narrowing or collapse of the internal or external nasal valves. The internal nasal valve has the narrowest cross-sectional area within the nasal airway and is thus most sensitive to changes in dimension due to anatomic variation or surgical intervention.

Smoking and Improvement after Nasal Surgery in Snoring Men

Background

The aim of this study was to compare subgroups of smokers and nonsmokers undergoing nasal surgery and to evaluate improvement of nasal stuffiness, snoring, and symptoms related to sleep-disordered breathing after nasal surgery.

Methods

A cross-sectional prospective study was performed. The study population included 40 consecutive snoring men scheduled for surgical treatment of nasal obstruction. The patients completed nasal and sleep questionnaires, an Epworth sleepiness scale, and a visual analog scale of snoring intensity. They underwent polysomnography, anterior rhinomanometry, acoustic rhinometry, and cephalometric analysis.

Results

The smokers were younger, they snored longer and louder, and they had higher nasal resistance with decongestion and longer soft palates than the nonsmokers. Nasal stuffiness improved well after surgery, but a decrease of nasal resistance was not related to improvement of subjective snoring.

Conclusion

Smoking was associated with increased snoring, nasal obstruction, and pharyngeal soft tissue volume. Expectations of patients may influence subjective assessment of snoring after nasal surgery.

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis

BACKGROUND

Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR).

METHODS

Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR.

CONCLUSION

This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding.

Special Considerations in the Treatment of Pregnancy Rhinitis

Pregnancy rhinitis is a common condition that is not yet fully recognized by the public. This form of rhinitis affects approximately one in five pregnant women, can start in almost any gestational week, and disappears after delivery. However, as it reduces quality of life, and also possibly affects the fetus, treatment is often required. Saline irrigations, exercise and mechanical alar dilators are a safe and general means of relieving nasal congestion. Nasal corticosteroids have not been shown to be effective. As nasal decongestants provide good temporary relief, women tend to overuse them. Therefore, to avoid an additional rhinitis medicamentosa, nasal decongestants should be restricted to a few days use. Invasive methods of turbinate reduction may be effective, but are not recommended. The differential diagnosis towards sinusitis is often difficult. Antral irrigation is the ultimate diagnostic for purulent sinusitis and often needs to be repeated for therapeutic reasons. If β-lactam antibiotics are used, an increased dosage is required during pregnancy.

Neusverstopping

Acute neusverstopping is een frequente aandoening. Meestal is het geen geïsoleerd symptoom, maar treedt zij gecombineerd op met andere klachten van de neus. In overgrote meerderheid is de oorzaak een virale infectie die vanzelf overgaat, en heeft verdere diagnostiek geen consequenties voor de therapie. Bij chronische klachten is verdere diagnostiek wel zinvol; een allergie of hyperreactiviteit is het meest waarschijnlijk. Bij chronische neusverstopping is aandacht voor chronisch gebruik van decongestieve neusdruppels van belang. Persisterende eenzijdige neusverstopping, zeker wanneer dit gepaard gaat met bloederige afscheiding, is een alarmsymptoom.

14 Neusverstopping

Acute neusverstopping is een frequente aandoening. Meestal is het geen geïsoleerd symptoom, maar treedt zij gecombineerd op met andere klachten van de neus. In overgrote meerderheid is de oorzaak een virale infectie die vanzelf overgaat, en heeft verdere diagnostiek geen consequenties voor de therapie.

Bij chronische klachten is verdere diagnostiek wel zinvol; een allergie of hyperreactiviteit is het meest waarschijnlijk. Bij chronische neusverstopping is aandacht voor chronisch gebruik van decongestieve neusdruppels van belang. Persisterende eenzijdige neusverstopping, zeker wanneer dit gepaard gaat met bloederige afscheiding, is een alarmsymptoom.

Effect of weight reduction on rhinometric measurements in overweight patients with obstructive sleep apnea

BACKGROUND

Elevated nasal resistance and obesity predispose to obstructive sleep apnea (OSA). Weight loss has been shown to result in an alleviation of OSA, but its effect on nasal airflow has not been studied.

METHODS

This study was a prospective, randomized, controlled study with two parallel groups. A total of 52 adult overweight patients (body mass index [BMI], 28-40 kg/m2) with mild obstructive sleep apnea (apnea-hypopnea index (AHI), 5-15) were randomized into two study groups. The intervention group (n = 26) followed a very low calorie diet with a supervised lifestyle intervention while the control group (n = 26) received routine lifestyle counseling. The changes in BMI, total nasal resistance, total nasal volume, and quality of life scores (Mini Rhinoconjunctivitis Quality of Life Questionnaire, MiniRQLQ) were assessed at baseline and after the intervention at 3 months.

RESULTS

The reduction in BMI in the intervention group was significantly greater than that achieved by patients in the control group (5.4 kg/m2 versus 0.5 kg/m2). Accordingly, AHI was reduced by 3.2 events/hour in the intervention group and by 1.3 in the control group. However, there were no significant changes in rhinometric measurements despite significant weight loss. There was no correlation between the reduction of BMI and the change in nasal resistance or MiniRQLQ scores.

CONCLUSION

Weight reduction does not seem to have any effect on nasal resistance or volume in overweight patients with mild OSA. Patients with OSA and impaired nasal breathing need specific medical or surgical treatment to restore nasal airflow.

Pregnancy Rhinitis

Pregnancy rhinitis has gained attention as a defined clinical entity that is recognized increasingly by medical professionals and by the public. It affects one in five pregnant women, and as far as we know, it is not caused by one single factor. Pregnant women should be informed about this cause of nasal congestion, and how to handle it. There is no cure known, but symptomatic treatment may be needed, because impaired nasal breathing can reduce quality of life and possibly affect the fetus. Simple measures, such as elevated head end of the bed, physical exercise, nasal saline washings, and nasal alar dilation can improve nasal breathing.

Sleep, breathing and the nose

During sleep there is a discrete fall in minute ventilation and an associated increase in upper airway resistance. In normal subjects, the nasal part of the upper airway contributes only little to the elevation of the total resistance, which is mainly the consequence of pharyngeal narrowing. Yet, swelling of the nasal mucosa due to congestion of the submucosal capacitance vessels may significantly affect nasal airflow. In many healthy subjects an alternating pattern of congestion and decongestion of the nasal passages is observed. Some individuals demonstrate congestion of the ipsilateral half of the nasal cavity when lying down on the side. Nasal diseases, including structural anomalies and various forms of rhinitis, tend to increase nasal resistance, which typically impairs breathing via the nasal route in recumbency and during sleep. A role of nasal obstruction in the pathogenesis of sleep-disordered breathing has been implicated by many authors. While it proves difficult to show a relationship between the degree of nasal obstruction and the number of disturbed breathing events, the presence of nasal obstruction will most likely have an impact on the severity of sleep-disordered breathing. Identification of nasal obstruction is important in the diagnostic work-up of patients suffering from snoring and sleep apnea.

Clinical and pathogenetic characteristics of pregnancy rhinitis

Pregnancy rhinitis is a very common condition. Defined as "nasal congestion present during the last 6 or more weeks of pregnancy without other signs of respiratory tract infection, and with no known allergic cause, disappearing completely within 2 wk after delivery," it strikes one in five pregnant women, and it starts in almost any gestational week. The pathogenesis is not clear, but placental growth hormone is suggested to be involved. Smoking and sensitization to house dust mites are probable risk factors. It is often difficult to make a differential diagnosis from sinusitis, which may in pregnancy present with nasal congestion as the only symptom. Antral irrigation is diagnostic for purulent sinusitis and often needs to be repeated, as it should be treated intensively. Because of changes in pharmacokinetics, increased dosage of betalactam antibiotics is needed during pregnancy. As pregnancy rhinitis reduces quality of life and possibly also affects the fetus, there is often need for treatment. Nasal corticosteroid shave not been shown to be effective. Systemic administration should be avoided,but nasal corticosteroids could be used in pregnancy when indicated for other sorts of rhinitis. Nasal decongestants give good temporary relief, so pregnancy rhinitics tend to overuse them, giving an additional rhinitis medicamentosa. Therefore, use of nasal decongestants should be restricted to a few days. Invasive methods of turbinate reduction may be effective but are not recommendable in this self-limiting condition because of side effects. Nasal saline washings, exercise, and mechanical alar dilators are safe general means to relieve nasal congestion, but the ultimate treatment remains to be found.

Nasal obstruction and sleep-disordered breathing: the effect of supine body position on nasal measurements in snorers

OBJECTIVE

Nasal obstruction is considered to be a potential etiological factor in sleep-disordered breathing. However, a significant correlation between nasal measurements and obstructive sleep apnea has not been demonstrated so far. The aim of this study was to investigate the relationships between nasal resistance, nasal volumes and selected sleep parameters using nasal measurements performed in both seated and supine positions. We also investigated whether snoring patients in our clinical sample showed increased positional or decongestive nasal mucosal changes.

MATERIAL AND METHODS

Forty-one snoring men on a waiting list for correction of nasal obstruction underwent polysomnography, anterior rhinomanometry and acoustic rhinometry. Nineteen non-snoring control subjects were also recruited. Nasal measurements were performed in a seated position, after lying down in a supine position and, after decongestion of nasal mucosa, in a seated position again.

RESULTS

In the overall patient group, nasal volume at a distance 2-4 cm from the nares in the supine position correlated inversely with apnea-hypopnea index (AHI) (r = -0.32, p < 0.05) and oxygen desaturation index (ODI) (r = -0.49, p < 0.05). In the non-obese patients, total nasal resistance measured in a supine position correlated with AHI (r = 0.50, p < 0.05) and ODI (r = 0.58, p < 0.05) and supine nasal volumes were also inversely correlated with ODI. No significant correlations were found between baseline nasal measurements performed in a seated position and sleep parameters. Postural or decongestive changes in nasal measurements were not increased in snoring patients compared with control subjects.

CONCLUSION

The relationship found between nasal measurements and sleep parameters suggests that nasal obstruction does augment airway collapse.