A case of Arnold-Chiari Type I malformation presenting with dysrhythmic breathing during sleep

Treatment emergent obstructive sleep apnea after Chiari surgery: A case report

Patients with Chiari type I malformation may also present with sleep disordered breathing mainly central sleep apnea. Here, we report a patient with Chiari I malformation referred to our clinic because of snoring and sleep disordered breathing. He was a 28-year-old man referred to us for evaluation of snoring. An overnight polysomnography revealed central sleep apnea. On further evaluation of central sleep apnea, the patient found to have Chiari malformation type I on brain MRI. The patient developed obstructive sleep apnea after surgery for Chiari malformation. Accordingly, pap titration was performed for the patient's obstructive sleep apnea. In patients with central sleep apnea comprehensive evaluation of predisposing causes is required. Lesions of central nervous system including Chiari malformation should not be overlooked. Furthermore, after treatment of central sleep apnea follow up PSG is warranted to confirm newly emerged sleep breathing disorder such as obstructive sleep apnea.

Risk of tinnitus in patients with sleep apnea: A nationwide, population-based, case-control study

OBJECTIVE

To investigate the risk of tinnitus in patients with sleep disturbance or sleep apnea.

STUDY DESIGN

Case control study.

METHODS

We identified 21,798 middle-aged and elderly patients with otolaryngologist-diagnosed tinnitus between January 1, 2000, and December 31, 2012, from the Longitudinal Health Insurance Database 2000 of the Taiwan National Health Insurance Research Database. A total of 108,990 controls were also identified from the same database based on frequency-matching on 10-year age interval, sex, and year of index date of the cases. Diagnoses of sleep disturbance (International Classification of Diseases, 9th Revision, Clinical Modification [ICD-9-CM] codes 780.50, 780.52, 307.4) and sleep apnea (ICD-9-CM codes 780.51, 780.53, 780.57) in the cases and controls prior to the index date were assessed. The risks of tinnitus in patients with sleep disturbance and sleep apnea were separately evaluated with multivariate logistic regression analyses.

RESULTS

The mean age of the total 130,788 patients was 59.8 years, and 47% of them were males. The risk of tinnitus was higher in patients with sleep disturbance compared to those without the condition (adjusted odds ratio [OR] = 1.13, 95% confidence interval [CI] [95% CI] = 1.11-1.17), and the risk of tinnitus was higher in patients with sleep apnea compared to those without the condition (adjusted OR = 1.36, 95% CI = 1.16-1.60).

CONCLUSION

In this population-based, case-control study, the risk of tinnitus was found to be significantly higher among middle-aged and elderly Taiwanese patients with sleep disturbances, especially with sleep apnea.

LEVEL OF EVIDENCE

3b. Laryngoscope, 127:2171-2175, 2017.

The association between sleep-disordered breathing and magnetic resonance imaging findings in a pediatric cohort with Chiari 1 malformation

BACKGROUND

The prevalence of sleep-disordered breathing (SDB) reported in the literature for Chiari malformation type 1 (CM1) is uniformly high (24% to 70%). In Canada, there is limited access to pediatric polysomnography (PSG). Therefore, the identification of clinical features would be invaluable for triaging these children.

OBJECTIVE

To identify demographic features, clinical symptoms/signs and radiological findings associated with SDB in a large pediatric cohort with CM1.

METHODS

A retrospective review was conducted on children with CM1 who underwent baseline PSG. Data were collected on patient demographics (age, sex, weight, height, body mass index), clinical symptoms (chart review and clinical questionnaires), diagnostic imaging of the brain and cervicothoracic spine, and medical history at the time of referral.

RESULTS

A total of 68 children were included in the review. The mean (± SD) age of the children at the time of PSG was 7.33 ± 4.01 years; 56% (n=38) were male. There was a 49% prevalence of SDB in this cohort based on the overall apnea-hypopnea index. Obstructive sleep apnea was the predominant type of SDB. Tonsillar herniation was significantly correlated with obstructive apnea-hypopnea index (r=0.24; P=0.036).

CONCLUSIONS

A direct relationship between the degree of cerebellar tonsillar herniation and obstructive sleep apnea was demonstrated. However, further prospective studies that include neurophysiological assessment are needed to further translate the central nervous system imaging findings to predict the presence of SDB.

MRI findings and sleep apnea in children with Chiari I malformation

Chiari I malformation is characterized by downward herniation of the cerebellar tonsils through the foramen magnum. Scant data are available on the clinical course, relationship to the extent of herniation on magnetic resonance imaging in Chiari I malformation and the presence of sleep-disordered breathing on polysomnography. Retrospective analysis was performed looking at polysomnographic findings of children diagnosed with Chiari I malformation. Details on how Chiari I malformation was diagnosed, brainstem magnetic resonance imaging findings, and indications for obtaining the polysomnogram in these patients were reviewed. We also reviewed available data on children who had decompression surgery followed by postoperative polysomnography findings. Twenty-two children were identified in our study (11 males, median age 10 years, range 1 to 18). Three had central sleep apnea, five had obstructive sleep apnea, and one had both obstructive and central sleep apnea. Children with sleep-disordered breathing had excessive crowding of the brainstem structures at the foramen magnum and were more likely to have a greater length of herniation compared with those children without sleep-disordered breathing (P = 0.046). Patients with central sleep apneas received surgical decompression, and their conditions were significantly improved on follow-up polysomnography. These data suggest that imaging parameters may correlate with the presence of sleep-disordered breathing in children with Chiari I malformation.

Chiari malformation type I: related conditions

Chiari malformation type I (CMI) is a morphological diagnosis defined as the inferior displacement of the cerebellum through the foramen magnum. In parallel to this basic definition of CMI, there are diagnoses that co-exist with CMI in selected patients. In addition, there are specific constellations of clinical symptoms and signs reported in the literature that occur non-randomly in patients affected by CMI. There is no established system that categorizes these CMI-related conditions or even defines them as causes or consequences of CMI. Identifying the relationship between CMI and these associated disorders may allow greater understanding of CMI etiology and potentially inform CMI management.

Hindbrain-hernia-related syringomyelia without syringobulbia, complicated by permanent nocturnal central hypoventilation requiring non-invasive ventilation

INTRODUCTION

In the absence of syringobulbia, hindbrain hernia does not commonly cause permanent respiratory complications. We present two patients who developed permanent central nocturnal hypoventilation following acute deterioration of hindbrain-hernia-related syringomyelia despite successful surgery.

PATIENTS

Two children (one boy and one girl, aged 7 and 13 years, respectively) presented with acute neurological deterioration. The boy presented with a 6-week history of progressive tiredness and weakness and a short history of respiratory depression. The girl presented with a 2-year history of left hemiparesis and a short history of left hemiplegia and respiratory depression. On magnetic resonance scan, both had hindbrain hernia, hydrocephalus and cervical syringomyelia. Following cranio-vertebral decompression and, later, a ventriculoperitoneal shunt, the syringomyelia remained well controlled in both patients. In contrast, their respiratory depression improved minimally. Repeated multichannel respiratory monitoring revealed a persistently slow sleeping respiratory rate, with nocturnal hypercapnia and hypoxemia, managed successfully by night-time non-invasive ventilation. Neither the boy nor the girl, after 7 and 4 years, respectively, has developed any complications of nocturnal hypoventilation. When awake, both breathe normally.

RESULT

Both children appear to have suffered a permanent impairment of respiratory control, resulting in nocturnal hypoventilation. This is usually seen with brain stem lesions and is unexpected when syringomyelia does not extend above C2, in the absence of syringobulbia.

DISCUSSION

Central nocturnal hypoventilation is postulated to be due to permanent damage of central brain stem pathways controlling the respiratory muscles, due to local pressure at the cranio-cervical junction associated with acute deterioration of the hindbrain herniation.

CONCLUSION

Sudden deterioration of hindbrain hernia and cervical syringomyelia can rarely impair the central mechanisms of respiratory control, with long-term implications on quality of life.

Chiari Type I Malformation Presenting as Hemifacial Spasm: Case Report

OBJECTIVE AND IMPORTANCE:

We report on a patient with a Chiari I malformation presenting with right hemifacial spasm. Clinicians should consider the downward displacement of the hindbrain as a rare cause of hemifacial spasm in Chiari I malformation.

CLINICAL PRESENTATION:

An 18-year-old man was admitted with right hemifacial spasm. The results of the neurological examination were normal except for the facial spasm. Magnetic resonance imaging demonstrated a Chiari I malformation without syringomyelia. After surgery, the hemifacial spasm completely resolved.

INTERVENTION:

Posterior fossa decompression, C1 laminectomy, and duraplasty were performed.

CONCLUSION:

The hemifacial spasm could be attributed to compression and/or traction of the facial nerve because of downward displacement of the hindbrain in Chiari I malformation. Compression and/or traction might create irritation of the facial nerve that causes hemifacial spasm. Resolution of the hemifacial spasm after posterior fossa decompression could explain the facial nerve irritation in Chiari I malformation. Clinicians should consider Chiari malformation as a cause of hemifacial spasm and posterior fossa decompression as a potential treatment.

Cheyne-Stokes respiration, periodic circulation, and pulsus alternans in spinal cord injury patients

STUDY DESIGN

Case reports.

OBJECTIVES

To describe Cheyne-Stokes respiration (CSR) and associated circulatory abnormalities in three patients with spinal cord lesions.

SETTING

Veterans Administration Hospital, USA.

SUBJECTS

One paraplegic patient with coronary artery disease in congestive heart failure, one tetraplegic patient with alcoholic cardiomyopathy and postural hypotension, and one tetraplegic complete patient with cardiomegaly, severe aortic atherosclerosis, and postural hypotension.

METHODS

Breathing activity was measured with a nasal thermistor or abdominal stretch transducer. Cardiac activity was estimated with a photoelectric sensor for cutaneous blood flow placed on the forehead or a piezoelectric transducer for pressure positioned over an artery or the cardiac apex. Tracings were drawn on a strip chart recorder. The subjects were at rest in semireclining positions.

RESULTS

Survey times were 17-21 min, and cycling periods were 41-72 s. Periodic changes in the depth of breathing were accompanied by periodic changes in amplitude of forehead cutaneous pulse, blood pressure, or apical cardiac impulse in all patients. Peak circulation occurred at or following peak respiration. In addition, cyclical pulsus alternans occurred in two patients.

CONCLUSION

Three spinal cord injury patients sustained CSR and circulatory periodicity associated with cardiac disease and postural hypotension.

Adult Chiari malformation and sleep apnoea

Chiari malformation (CM) is primarily characterised by herniation of the cerebellar tonsils through the foramen magnum. Clinically, two main types of CM represent the vast majority of cases: type I (in adults) and type II (in infants). CM may result in neuronal impairment of the brainstem, upper spinal cord and cranial nerves. Part of the afferent and efferet systems and the central respiratory controlling system are located in the cranium-cervical transition and may be damaged in these pathologies, leading to respiratory disorders, such as respiratory failure and death. The ventilatory responses to exogenous and endogenous stimuli, such as responses to hypoxia and hypercapnia, are usually diminished, and apnea may be manifested and detected during sleep, allowing for the diagnosis. This study is a review of the relationship between sleep apnoea and adult CM.

Otorhinolaryngologic manifestations in Chiari malformation

The Chiari malformation causes herniation of the cerebellar amygdalae through the foramen magnum, resulting in the descent of the brain stem and/or traction on the lower cranial pairs. It is important for otolaryngologists to recognize Chiari malformations as part of the differential diagnosis of balance disorders, because patients may initially exhibit symptoms related to the vestibular system, including ataxia, nystagmus, or vertigo. We report 2 cases.