Nasopharyngeal symptoms in patients with obstructive sleep apnea syndrome. Effect of nasal CPAP treatment

Burden of obstructive sleep apnea and CPAP use on patients with chronic rhinosinusitis

OBJECTIVE

To evaluate the impact of obstructive sleep apnea (OSA) on the quality-of-life (QoL) of patients with chronic rhinosinusitis (CRS).

METHODS

Retrospective cohort study of all adult patients with CRS presenting to our rhinology clinic between August 2020 and February 2023 was performed. OSA was established based on positive polysomnography. Patients' characteristics, apnea-hypopnea index, comorbidities, endoscopy scores, and SNOT-22 scores were collected.

RESULTS

A total of 513 patients with CRS were included, 127 patients with OSA and 386 without OSA. CRS patients with OSA were older (p < 0.001), had higher BMI (p < 0.001), more likely to be males (p = 0.07), more likely to have asthma (p < 0.001), and more likely to have COPD (p = 0.001). Presence of nasal polyps did not differ between the two groups. Baseline SNOT-22 scores were worse in the OSA cohort (44.4 vs 40.5, p = 0.064) secondary to worse sleep (13.4 vs 11.1; p = 0.002) and psychological (14.2 vs 11.5; p = 0.002) domains. Worse SNOT scores were strongly associated with presence of OSA after adjusting for confounding variables, including age, gender, asthma, allergic rhinitis, nasal septal deviation, and smoking status.

CONCLUSION

OSA is an independent negative contributor to the disease specific QoL in patients with CRS. CPAP use does not seem to affect the QoL in CRS patients with OSA. Further research is warranted to explore the impact of OSA in the outcome of medical and surgical treatment of CRS patients.

Impact of posture and CPAP on nasal airflow

Obstructive sleep apnea (OSA) patients who use continuous positive airway pressure (CPAP) often complain of nasal dryness and nasal obstruction as side effects of CPAP. The physiological mechanisms by which CPAP may cause nasal dryness and nasal obstruction remain poorly understood. It has been hypothesized that CPAP interferes with the nasal cycle, abolishing the resting phase of the cycle and leading to nasal dryness. We performed rhinomanometry measurements in 31 OSA patients sitting, laid supine, and supine after 10 min of CPAP at 10 cmH2O. A posture change from sitting to supine led to more symmetric airflow partitioning between the left and right nostrils in the supine position. CPAP did not have a significant impact on nasal resistance, unilateral airflows, or airflow partitioning. Our results suggest that airflow partitioning becomes more symmetric immediately after changing to a supine position, while CPAP had no effect on nasal airflow, thus preserving the nearly symmetric airflow partitioning achieved after the posture change.

Seasonal influence on sleep apnoea recorded daily by pacemakers

PURPOSE

Obstructive sleep apnoea (OSA) and cardiac conduction disorders are pathologies with a rising prevalence due to increased life expectancy. Upper airway patency is affected by environmental factors that may be associated with seasonal periods. The ability to record the degree of nocturnal apnoea on a daily basis may provide a more accurate picture of seasonal variability.

METHODS

This study used an observational, cross-sectional design recruiting consecutive patients with Sorin/Livanova/Microport® pacemakers. The study assessed the seasonal influence on the daily degree of nocturnal apnoea over a minimum period of 180 days. The respiratory events were recorded using a pacemaker-integrated detection algorithm based on transthoracic impedance variation. A generalised linear repeated measure mixed model was used to study the seasonal effect.

RESULTS

A sample of 101 subjects with a mean of 227 valid nights was compiled. Summer was associated with higher RDI (respiratory disturbance index) values and winter with lower values. The mean daily RDI ratio in summer was 1.099 times higher than in winter.

CONCLUSIONS

Slight seasonal influences on the degree of nocturnal apnoea were detected through the daily observation of an unselected sample of pacemaker wearers. The degree of apnoea is higher in warmer months and lower in colder months.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Is maxillomandibular advancement an effective treatment for obstructive sleep apnea? Systematic literature review and meta-analysis

OBJECTIVES

To evaluate the effectiveness of maxillomandibular advancement surgery in the treatment of Obstructive Sleep Apnea by comparing the pre- and postoperative Apnea and Hypopnea Index, in addition to classifying the degree of evidence and risk of intervention bias.

METHODS

A systematic review of the literature was carried out in the PUBMED, LILACS, EMBASE, SCOPUS, WEB OF SCIENCE and COCHRANE platforms, including cohort studies with polysomnographic follow-up, without other associated pharyngeal or nasal surgical procedures. The risk of study bias was assessed using the Modified Delphi technique. Pre- and postoperative Apnea and Hypopnea Index data were plotted for meta-analysis, and the quality of evidence was assessed using the GRADE system.

RESULTS

Of 1882 references, 32 articles were selected for full-text reading, of which four studies were included, totaling 83 adults with obstructive sleep apnea who underwent maxillomandibular advancement. The meta-analysis was in favor of the intervention (DM = -33.36, 95% CI -41.43 to -25.29, p < 0.00001), with a mean percentage reduction in the Apnea and Hypopnea Index of 79.5% after surgery, even though the level of evidence was classified as very low quality by the GRADE system.

CONCLUSION

The meta-analysis was in favor of the intervention, characterizing maxillomandibular advancement surgery as an effective treatment for obstructive sleep apnea in adults.

Nasal function and CPAP use in patients with obstructive sleep apnoea: a systematic review

PURPOSE

This systematic review was conducted to answer the following 3 questions: 'Does nasal pathology affect CPAP use?', 'What is the effect of CPAP on the nose?' and 'Does treatment of nasal pathology affect CPAP use?'.

METHODS

Pubmed and Scopus databases were searched for articles relevant to the study questions up to October 2020.

RESULTS

Sixty-three articles were selected, of which a majority were observational studies. Most studies identified a correlation between larger nasal cross-sectional area or lower nasal resistance and higher CPAP compliance or lower CPAP pressures; however, nasal symptoms at baseline did not appear to affect CPAP use. The effect of CPAP on the nose remains uncertain: while most studies suggested increased mucosal inflammation with CPAP, those investigating symptoms presented contradictory results, with some reporting an increase and others an improvement in nasal symptoms. Evidence is clearer for nasal surgery leading to an increase in CPAP compliance and a decrease in CPAP pressures, whereas there is little evidence available for the use of topical nasal steroids.

CONCLUSION

There appears to be a link between nasal volumes or nasal resistance and CPAP compliance, an increase in nasal inflammation caused by CPAP and a beneficial effect of nasal surgery on CPAP usage, but no significant effect of CPAP on nasal patency or effect of topical steroids on CPAP compliance. Results are more mitigated with regard to the effect of nasal symptoms on CPAP use and vice versa, and further research in this area would help identify patients who may benefit from additional support or treatment alongside CPAP.

Variations in funding for treatment of obstructive sleep apnoea in England

OBJECTIVES

This study aimed to review the funding policies of clinical commissioning groups for treatment of obstructive sleep apnoea in England.

METHODS

Published policies from a randomly selected sample of 60 out of 190 clinical commissioning groups were reviewed.

RESULTS

Continuous positive airway pressure was funded based on a clinical assessment or according to criteria that were in line with national guidelines in most clinical commissioning groups (49 of 60), with 11 clinical commissioning groups offering no policy. Mandibular advancement devices, tonsillectomy and nasal surgery were funded based on a clinical assessment or certain criteria in 16, 25 and 16 clinical commissioning groups, respectively. In contrast, only one clinical commissioning group provided funding for soft palate, tongue base or mandibular surgery. Hypoglossal nerve stimulation was not mentioned in any clinical commissioning group's policy.

CONCLUSION

Although most clinical commissioning groups provide funding for the use of continuous positive airway pressure, the availability of funding for other obstructive sleep apnoea treatment modalities is heterogeneous, leaving continuous positive airway pressure intolerant patients with limited therapeutic options in some regions.

Seasonal effects on the continuous positive airway pressure adherence of patients with obstructive sleep apnea

OBJECTIVE

This study examined seasonal differences in continuous positive airway pressure (CPAP) therapy adherence among patients with obstructive sleep apnea (OSA).

METHODS

Patients aged ≥20 years with OSA who had used CPAP devices on the automatic setting for >12 consecutive months (n = 141) were included in this retrospective study from December 2015-2016. The information of CPAP use (pressure, hours of actual use) was extracted from database downloaded from patients' CPAP devices. Patients were divided into adherent and non-adherent groups using the cutoff point of 70% CPAP use for ≥4 h daily over the 1-year study period. CPAP use data were averaged for each season.

RESULTS

Patients in the adherent group were significantly older than those in the non-adherent group (p < 0.001). In the adherent group, the rate of ≥4 h daily CPAP use was significantly lower, the daily duration of CPAP use was significantly shorter, and the residual apnea-hypopnea index (AHI; events/hour) was significantly higher in summer than in other seasons (all p < 0.001). In the non-adherent group, the duration of daily CPAP use and the AHI differed significantly between winter and summer (p = 0.008 and p < 0.001, respectively).

CONCLUSIONS

Seasonal changes were associated with the CPAP adherence of patients with OSA. The study findings suggest that there is possibility of increasing the duration of CPAP use by adjusting the bedroom environment in hot and humid seasons.

Association of Allergic Rhinitis With Change in Nasal Congestion in New Continuous Positive Airway Pressure Users

Importance

Nasal congestion occurring after continuous positive airway pressure (CPAP) treatment initiation impairs CPAP adherence. Allergic rhinitis is associated with worsening nasal congestion in patients who are exposed to nonallergic triggers. Use of CPAP presents potential nonallergic triggers (eg, humidity, temperature, pressure, and airflow).

Objective

To compare nasal congestion among CPAP users with allergic rhinitis, nonallergic rhinitis, and no rhinitis. We hypothesize that CPAP patients with baseline allergic rhinitis are more likely to experience a worsening of nasal congestion (or less improvement in nasal congestion) compared with patients with no baseline rhinitis.

Design, Setting, and Participants

This prospective cohort study included consecutive patients newly diagnosed with obstructive sleep apnea in a tertiary sleep center who were using CPAP therapy 3 months after diagnosis. Baseline rhinitis status was assigned as allergic rhinitis, nonallergic rhinitis, or no rhinitis, based on questionnaire responses and past allergy testing. Data were collected from 2004 to 2008 and analyzed from July 2019 to February 2020.

Main Outcomes and Measures

At baseline before CPAP exposure and again 3 months later, subjective nasal congestion was measured with the Nasal Obstruction Symptom Evaluation (NOSE) scale and a visual analog scale (VAS), each scored from 0 to 100 (100 = worst congestion). Changes in nasal congestion were tested over 3 months for the whole cohort, within each rhinitis subgroup (paired t test), and between rhinitis subgroups (multivariate linear regression).

Results

The study cohort comprised 102 participants, of whom 61 (60%) were male and the mean (SD) age was 50 (13). The study included 23 (22.5%) participants with allergic rhinitis, 67 (65.7%) with nonallergic rhinitis, and 12 (11.8%) with no rhinitis. Nasal congestion improved from baseline to 3 months in the whole cohort (mean [SD] NOSE score, 38 [26] to 27 [23], mean [SD] change, -10 [23]; 95% CI, -15 to -6; mean [SD] VAS score, 41 [27] to 32 [28]; mean [SD] change, -10 [26]; 95% CI, [-15 to -4]) and in each rhinitis subgroup. Adjusted improvement in nasal congestion at 3 months was significantly less in the allergic rhinitis subgroup compared with the no rhinitis subgroup (positive difference means less improvement) compared with baseline: NOSE score 14 (95% CI, 1 to 28) and VAS score 15 (95% CI, 0 to 30).

Conclusions and Relevance

Initiation of CPAP was associated with improved subjective nasal congestion, but less improvement in patients with baseline allergic rhinitis. Baseline allergic rhinitis may predict which patients are more vulnerable to potential congestive effects of CPAP.

Improvement in Snoring-Related Quality-of-Life Outcomes After Functional Nasal Surgery

Importance: Sleep-disordered breathing (SDB) represents a spectrum of sleep-related disorders associated with significant medical comorbidities. Nasal airway surgery has been shown to improve SDB but no large-scale studies exist that describe the long-term impact of surgery on patient perception of snoring and nasal obstruction. Objective: To characterize longitudinal snoring symptoms and nasal obstruction after functional nasal surgery for patients with SDB, stratified by history of snoring or obstructive sleep apnea (OSA). Design, Setting, and Participants: In this prospective cohort study, patients undergoing nasal surgery between 2013 and 2017 at a tertiary academic center were surveyed using Snoring Outcome Survey (SOS) and Nasal Obstruction Symptom Evaluation (NOSE) questionnaires through 24 months postoperatively. Patient demographics, history of snoring, diagnosis of OSA, and prior nasal surgeries were analyzed. A total of 625 patients were recruited with 325 females (52.0%) and mean age of 36.3 years (SD 15.6), with 74.9% patients reported snoring (n = 468) and 10.7% patients (n = 67) with OSA. Patients undergoing dual functional and cosmetic septorhinoplasty with or without turbinate surgery were included. Those undergoing concomitant sinus surgery were excluded. Intervention: Functional nasal surgery. Main Outcomes and Measures: SOS and NOSE scores were collected at 2, 4, 6, 12, and 24 months postoperatively. Results: Patients undergoing nasal surgery had statistically and clinically significant improvement in NOSE score at 24 months (mean improvement 29.0 points, p < 0.0001). Patients with snoring history also had significant improvement in SOS score through 24 months (mean improvement 10.7 points, p < 0.0001). Nonsnorers demonstrated no significant change. OSA patients achieved clinically significant improvement in SOS scores through 24 months (mean improvement 31.9; p > 0.05, minimum clinically important difference = 7.6 points). Conclusions and Relevance: Nasal surgery improves long-term nasal obstruction as measured by NOSE score and, for those with comorbid snoring and OSA, can lead to a sustained improvement in snoring-related quality of life (QOL) based on SOS score. Nonsnorers did not have a significant change in snoring symptoms. SOS can be used as a practical and effective instrument to measure snoring-related QOL outcomes after nasal airway surgery. Future studies using objective measures of snoring are needed to quantify the physiologic change in snoring after treatment of nasal obstruction. Level of Evidence: 2c.

Clinical indication of nasal surgery for the CPAP intolerance in obstructive sleep apnea with nasal obstruction

OBJECTIVE

The role of isolated nasal surgery for obstructive sleep apnea (OSA) patients with nasal obstruction, especially for an intolerance for continuous positive airway pressure (CPAP), is unclear. The aim of this study was to assess the effects of surgery for OSA patients with symptomatic nasal obstruction and CPAP intolerance.

METHOD

Retrospectve comparative study.1037 OSA patients with apnea-hypopnea index (AHI) ≥ 20 were enrolled. Case-control study was performed between the male apnea patients undergoing nasal surgery: surgery group (n = 43) and the pair-matched apnea patients for age, sex, body mass index, and race: control group (n = 43). The surgery group suffering from nasal obstruction could not use continuous positive airway pressure, and the CPAP group free from nasal obstruction could use it successfully.

RESULTS

In surgery group, surgery significantly decreased the nasal resistance and Epworth sleepiness scale scores without changing the AHI. Surgery significantly increased the nadir of oxygen saturation and shortened the apnea-hypopnea duration. Although all of the surgery group failed to use positive airway pressure preoperatively, the 40 patients of the 43 CPAP intolerance patients were able to use CPAP postoperatively. The resting three patients were cured OSA or changed the treatment to oral appliance(OA). For both groups, the cutoff nasal resistance for differentiating the failure of positive airway pressure and its success was 0.31 Pa/cm³/s.

CONCLUSION

Isolated nasal surgery is effective for an intolerance of positive airway pressure in sleep apnea with nasal obstruction presumably by decreasing nasal resistance.

Randomised trial on performance, safety and clinical benefit of hyaluronic acid, hyaluronic acid plus dexpanthenol and isotonic saline nasal sprays in patients suffering from dry nose symptoms

OBJECTIVE

Limited data exist on the clinical benefits of nasal applications for moistening the nasal mucosa. We therefore investigated the effects of hyaluronic acid, hyaluronic acid plus dexpanthenol and isotonic saline nasal sprays in patients suffering from dry nose symptoms in an otorhinolaryngological outpatient setting.

METHODS

240 patients were randomised into this prospective, three-armed clinical trial with two assessment points (baseline and 4 weeks later). Patients received either hyaluronic acid, hyaluronic acid plus dexpanthenol or isotonic saline nasal spray over a period of four weeks. Rhinitis Sicca Symptom Score (RSSS) was assessed as primary endpoint, and individual symptoms and tolerability of all treatments as secondary endpoints. Patient perceptions after first application of the allocated nasal spray were recorded using the Nasal Spray Sensory Scale. Treatment effects were analysed for each study arm first and subsequently compared against each other.

RESULTS

RSSS (hyaluronic acid: mean difference = 8.90 [98.33% CI = 7.34/10.45]; hyaluronic acid plus dexpanthenol: mean difference = 8.42 [98.33% CI = 6.91/9.94]; isotonic saline: mean difference = 8.94 [98.33% CI = 7.33/10.54]), individual symptoms and Endoscopy Score improved significantly (p < 0.001) in all treatment arms. Tolerability was assessed as "flawless" in more than 85% of all treatments, which is reflected in overall high rankings in the Nasal Spray Sensory Scale. Perception of nasal moisturisation was reported to be significantly higher in patients receiving hyaluronic acid plus dexpanthenol as compared to patients receiving hyaluronic acid or isotonic saline. No further significant differences were observed between the three treatments.

CONCLUSION

All three tested sprays (hyaluronic acid, hyaluronic acid plus dexpanthenol and isotonic saline) proved to be suitable treatments for patients suffering from dry nose symptoms. (DRKS-ID: DRKS00013357).

An optimization method for surgical reduction of hypertrophied inferior turbinate

Surgical reductions of the hypertrophied inferior turbinate (HIT) can improve nasal obstruction. However, there is currently a lack of personalized and objective methods to guide surgical operations, which results in the excessive or inadequate resection of HIT. In this study, we proposed an optimizing method based on homotopy deformation to determine the resected amount and shape of the tissue by matching the flow resistance in the two nasal passageways. The simulation results obtained using computational fluid dynamics showed that after such an optimization procedure, the most obstructed nasal side could have a similar air flux as the less obstructed side. A 35% and a 56% less tissue resection in the optimizing operation compared to that in the total turbinectomy could well balance the air flow between the two nasal cavities in the simulations for patients 1 and 2 with unilateral nasal obstruction respectively. Compared with the optimization operation, the total turbinectomy made a more aggressive resection of HIT, which could worsen the air conditioning capacity of the nose. A sensitivity test indicated that in the optimization operation, the most constricted region in the nasal cavity should be adequately enlarged. However, more tissue resection than is required for the optimization operation did not improve the flow in the obstructed side strikingly. Simulations of the optimization operation in both nasal cavities for a patient with bilateral nasal obstruction were also performed. The flow rate could reach the normal level and be well balanced in the two sides after such an optimization procedure.

Establishing a Patent Nasal Passage in Obstructive Sleep Apnea

The role of the nose in the pathophysiology and treatment of sleep-disordered breathing (SDB) has not been fully understood and might have been underestimated. In the Staring resistor model, the nose is regarded as a passive and noncollapsible tube, but recent studies have shown that the nose might participate more in the pathophysiology of SDB as anatomic, neuromuscular, and respiratory factors than previously reported, which might imply the nose is an active noncollapsible tube. The roles of nasal treatments for OSA are not only the reduction of AHI, but also the improvement of subjective symptoms, sleep quality, and CPAP adherence.

Nasal function and CPAP compliance

OBJECTIVE

Continuous positive airway pressure (CPAP) is the mainstay therapy for patients with obstructive sleep apnea (OSA) however compliance with CPAP is variable. Nasal ailments, such as nasal congestion are frequently mentioned as a cause for CPAP non-compliance, and potentially could be addressed prior to CPAP initiation, however, no specific criteria or recommendations for the evaluation and management of these patients exist. The aim of this retrospective study is to evaluate the effects of nasal anatomic features and disease on adherence to CPAP therapy for patients with OSA and determine the indications for pre-CPAP nasal treatment by using data obtained at clinical examination.

METHODS

In total, 711 adult patients with initial diagnosis of OSA and an apnea-hypopnea index of ≥20 who were amenable to CPAP were included. We analyzed nasal parameters, past history of nasal disease, subjective symptoms, and disease severity in addition to whether CPAP therapy had been initiated, rate of CPAP therapy use (initial and 1year), treatment continuation rate at 2 months and 1year, and nasal treatments for all patients.

RESULTS

CPAP therapy was initiated in 543 of 711 patients. Nasal resistance was significantly higher in patients who discontinued therapy soon after CPAP initiation. Nasal disease and nasal parameters were not found to be predictors of treatment adherence at 1year. Allergic rhinitis, moderate to severe nasal congestion at bedtime, slight or extensive sinus opacification, and a high nasal septum deviation score were found to be independent predictors of nasal treatment, while strong awareness of nasal congestion, a past history of sinusitis, and a total nasal resistance (supine position) of ≥0.35Pa/cm³/s were independent predictors of surgical treatment.

CONCLUSION

Long-term CPAP therapy adherence in patients with OSA can be predicted from initial CPAP adherence. Nasal disease and nasal parameters are important factors for early CPAP therapy discontinuation and should be adequately treated before therapy initiation to ensure long-term adherence. Indications for pre-CPAP nasal treatment and nasal surgery for patients with OSA can be predicted from the data obtained at the first examination, and these patients should be treated differently from those without OSA.

PAP treatment in patients with OSA does not induce long-term nasal obstruction

We hypothesized that positive airway pressure treatment would induce nasal obstruction and decrease nasal cavity due to mucosal swelling. We further hypothesized that subjective and objective nasal obstruction at baseline would negatively affect positive airway pressure adherence. A total of 728 patients with sleep apnea were investigated in the Icelandic Sleep Apnea Cohort at baseline and 2 years after starting positive airway pressure. Patients underwent home sleep apnea testing at baseline. Questionnaires were answered and acoustic rhinometry was completed at baseline and follow‐up. The proportion of patients reporting subjective nocturnal nasal obstruction was reduced (baseline: 35% versus follow‐up: 24%; p < 0.001). Small interior nasal dimensions increased (p < 0.001) independent of adherence to treatment. Small nasal volume at baseline was a determinant for becoming a non‐user of positive airway pressure treatment (odds ratio 2.22, confidence interval 95% 1.35–3.67, p = 0.002). Subjective nasal obstruction decreased 2 years after initiating positive airway treatment in sleep apnea, and objectively small nasal dimensions increased. Small nasal volume at baseline was a negative predictor for positive airway pressure treatment adherence. Maybe most importantly, positive airway pressure treatment did not cause long‐term objective or subjective nasal obstruction.

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.

An unusual case of infective pneumocephalus: case report of pneumocephalus exacerbated by continuous positive airway pressure

Background

Pneumocephalus, illustrated by air in the cranial vault is relatively infrequent and generally associated with neurosurgery, trauma, meningitis and barotrauma. However cases of spontaneous non-traumatic pneumocephalus remain rare. While the relationship between continuous positive airway pressure (CPAP) and atraumatic pneumocephalus has been previously reported, to our knowledge the rare presentation associated with sinus wall osteomyelitis has never been described. We summarize here the case of a 67-year-old woman’s acute presentation of Streptococcus salvarius infection after a sudden drop in her consciousness.

Case presentation

The patient was brought to hospital by family reporting a one week history of sudden deterioration, cognitive decline, and lethargy. The patient presented with reduced arousal, cognitive function (Glasgow Coma Scale: 10, Abbreviated Mental Test Score:CS, 0 AMTS), and no history of trauma. Computed Tomography (CT) imaging was ordered and identified a significant pneumocephalus with no cranial defect. Further investigations acknowledged possible sinus or middle ear disease, which was highlighted by the discovery of S. salivarius by polymerase chain reaction (PCR) and potentially exacerbated by the use of nocturnal continuous positive airway pressure (CPAP). The patient made a complete recovery by eliminating likely causative factors and long term regimental antibiotics administration.

Conclusion

This case highlights a rare neurological presentation of S. salivarius infection with a mixed aetiology of spontaneous pneumocephalus. This case features an atypical complication associated with CPAP use, and to our knowledge is the first case to be associated with sinus wall osteomyelitis. Recognition of the clinical features and risk factors for spontaneous pneumocephalus –while rare—serve to broaden our clinical index of suspicion when presented with patients experiencing neurological deficit. Information from this case may also aid in improving prevention, early diagnosis, and future management.

Acute impact of continuous positive airway pressure on nasal patency

BACKGROUND

Continuous airflow in the upper airway can cause discomfort, leading to nasopharyngeal complaints. The aim of the present study is to evaluate the acute effects of continuous positive upper-airway pressure on nasal patency in awake normal subjects.

METHODS

Twenty-seven adults (17 men; 10 women; age range, 18 to 43 years) were exposed to continuous airway pressure (20 cmH₂ O) in the nasal cavity, delivered by a continuous positive airway pressure (CPAP) device through a nasal mask for 2 hours. Visual analogue scale (VAS) of nasal obstruction, Nasal Obstruction Symptom Evaluation (NOSE) modified scale, acoustic rhinometry (AR), and peak nasal inspiratory flow (PF) were measured before and after the use of CPAP.

RESULTS

There was an increase in nasal obstruction scores both on the VAS (p < 0.05) and on the NOSE scale (p < 0.05), as well as a reduction in nasal cavity volume on AR (p < 0.05) and a decline in PF (p < 0.05). Subjects were stratified into 2 groups: with and without symptoms of allergic rhinitis. Nasal parameters were significantly worse in the rhinitis group, with higher nasal obstruction scores on the VAS (p = 0.001) and NOSE scale (p < 0.001) and decreased PF (p < 0.001).

CONCLUSION

Acute exposure to positive pressure via CPAP is associated with subjective and objective reductions in nasal patency. In individuals with allergic nasal symptoms, deterioration is even more severe than in patients without these symptoms.

Treatment of Obstructive Sleep Apnea. Prospects for Personalized Combined Modality Therapy

Obstructive sleep apnea (OSA) is a common sleep disorder with serious associated morbidities. Although several treatment options are currently available, variable efficacy and adherence result in many patients either not being treated or receiving inadequate treatment long term. Personalized treatment based on relevant patient characteristics may improve adherence to treatment and long-term clinical outcomes. Four key traits of upper airway anatomy and neuromuscular control interact to varying degrees within individuals to cause OSA. These are: (1) the pharyngeal critical closing pressure, (2) the stability of ventilator chemoreflex feedback control (loop gain), (3) the negative intraesophageal pressure that triggers arousal (arousal threshold), and (4) the level of stimulus required to activated upper airway dilator muscles (upper airway recruitment threshold). Simplified diagnostic methods are being developed to assess these pathophysiological traits, potentially allowing prediction of which treatment would best suit each patient. In contrast to current practice of using various treatment modes alone, model predictions and pilot clinical trials show improved outcomes by combining several treatments targeted to each patient's pathophysiology profile. These developments could theoretically improve efficacy and adherence to treatment and in turn reduce the social and economic health burden of OSA and the associated life-threatening morbidities. This article reviews OSA pathophysiology and identifies currently available and investigational treatments that may be combined in the future to optimize therapy based on individual profiles of key patient pathophysiological traits.

Nasal Surgery for Obstructive Sleep Apnea Syndrome

Obstructive sleep apnea is a common condition, primarily caused by narrowing of the nasal and pharyngeal airway. Treatment with continuous positive airway pressure (CPAP) is considered the first line of therapy, but long-term compliance is only about 40%, often because of nasal obstruction. Any nasal obstruction can worsen CPAP compliance. Treatment of the nasal obstruction with topical nasal steroid sprays or nasal dilators has been shown to improve sleep disordered breathing. Surgical treatment of nasal obstruction, has been shown to improve sleep disordered breathing, as well as CPAP requirement and compliance with CPAP.

Surgical Approaches to Obstructive Sleep Apnea

Surgery in adult obstructive sleep apnea (OSA) has undergone significant advancement in recent years and continues to evolve. It is a modality of treatment used in the context of failed device use, specifically, failed continuous positive airway pressure or mandibular advancement splint. In this context, the role of surgery is either as salvage therapy or to facilitate better tolerance of device use. Other treatments such as weight loss, adjuvant nasal therapy (medical ± prephase nasal surgery) and positional devices may be combined with airway surgery. In general, patients with OSA are managed with in-hospital monitoring perioperatively.

Obstructive Sleep Apnea and the Subsequent Risk of Chronic Rhinosinusitis: A Population-Based Study

The relationship between obstructive sleep apnea (OSA) and chronic rhinosinusitis (CRS) still remains unclear. This retrospective cohort study aimed to investigate the relationship between OSA and subsequent CRS using a population-based dataset. The study used data from the Taiwan Longitudinal Health Insurance Database 2005. We selected 971 patients with OSA for the study cohort and 4855 patients without OSA for the comparison cohort. Each patient was tracked for 5 years to determine those who were subsequently diagnosed with CRS. Stratified Cox proportional hazard regression analyses were performed to examine the association of OSA with subsequent CRS. The results revealed that 161 (2.76%) of the total sampled patients were subsequently diagnosed with CRS. Subsequent incidences of CRS were found in 64 (6.59%) patients with OSA and 97 (2.00%) patients without OSA. The adjusted hazard ratio (HR) of subsequent CRS for patients with OSA was 3.18 (95% confidence interval: 2.27~4.45) compared to those without OSA. Furthermore, the HR for CRS was similar for subjects with OSA for both genders (with an adjusted HR of 3.44 for males and 2.63 for females). We concluded that patients with OSA had a higher risk of subsequent CRS compared to patients without OSA regardless of sex.

Inferior Turbinate Size and CPAP Titration Based Treatment Pressures: No Association Found among Patients Who Have Not Had Nasal Surgery

Objective. To evaluate the effect of turbinate sizes on the titrated continuous positive airway pressure (CPAP) therapeutic treatment pressures for patients with obstructive sleep apnea (OSA) who have not had nasal surgery. Study Design. Retrospective case series. Methods. A chart review was performed for 250 consecutive patients. Results. 45 patients met inclusion criteria. The mean ± standard deviation (M ± SD) for age was 54.6 ± 22.4 years and for body mass index was 28.5 ± 5.9 kg/m(2). The Spearman's rank correlation coefficient (r s ) between CPAP therapeutic treatment pressures and several variables were calculated and were weakly correlated (age r s = 0.29, nasal obstruction r s = -0.30), moderately correlated (body mass index r s = 0.42 and lowest oxygen saturation r s = -0.47), or strongly correlated (apnea-hypopnea index r s = 0.60 and oxygen desaturation index (r s = 0.62)). No statistical significance was found with one-way analysis of variance (ANOVA) between CPAP therapeutic treatment pressures and inferior turbinate size (right turbinates p value = 0.2012, left turbinate p value = 0.3064), nasal septal deviation (p value = 0.4979), or mask type (p value = 0.5136). Conclusion. In this study, CPAP titration based therapeutic treatment pressures were not found to be associated with inferior turbinate sizes; however, the CPAP therapeutic treatment pressures were strongly correlated with apnea-hypopnea index and oxygen desaturation index.

The effect of nasal surgery on continuous positive airway pressure device use and therapeutic treatment pressures: a systematic review and meta-analysis

BACKGROUND

The relationship between nasal surgery and its effect on continuous positive airway pressure (CPAP) device therapeutic treatment pressures and CPAP device use has not been previously systematically examined.

STUDY OBJECTIVES

To conduct a systematic review and meta-analysis evaluating the effect of isolated nasal surgery on therapeutic CPAP device pressures and use in adults with obstructive sleep apnea (OSA).

METHODS

MEDLINE, Scopus, Web of Science, and The Cochrane Library were searched through July 15, 2014. The MOOSE consensus statement and PRISMA statement were followed.

RESULTS

Eighteen studies (279 patients) reported CPAP data after isolated nasal surgery. Seven studies (82 patients) reported preoperative and postoperative mean therapeutic CPAP device pressures and standard deviations (SD), which reduced from 11.6 ± 2.2 to 9.5 ± 2.0 centimeters of water pressure (cwp) after nasal surgery. Pooled random effects analysis demonstrated a statistically significant pressure reduction, with a mean difference (MD) of -2.66 cwp (95% confidence interval (CI), -3.65 to -1.67); P < 0.00001. Eleven studies (153 patients) reported subjective, self-reported data for CPAP use; and a subgroup analysis demonstrated that 89.1% (57 of 64 patients) who were not using CPAP prior to nasal surgery subsequently accepted, adhered to, or tolerated it after nasal surgery. Objective, device meter-based hours of use increased in 33 patients from 3.0 ± 3.1 to 5.5 ± 2.0 h in the short term (<6 mo of follow-up).

CONCLUSION

Isolated nasal surgery in patients with OSA and nasal obstruction reduces therapeutic CPAP device pressures and the currently published literature's objective and subjective data consistently suggest that it also increases CPAP use in select patients.

Facial Pain Associated with CPAP Use: Intra-Sinusal Third Molar

Objective. This paper describes a patient with left hemifacial pain elicited by the use of a CPAP mask. Case Report. A 74-year-old man was referred with a history of pain in the left maxillary sinus related to the use of his CPAP interface, thereby prohibiting the use of the latter. Computed tomography revealed an intra-sinusal ectopic third molar in the left maxillary sinus floor corresponding to the painful area. After removal of the ectopic tooth under local anesthesia by a Caldwell-Luc approach, the patient was relieved of his symptoms. Conclusion. Although an ectopic tooth in the maxillary sinus is rare, this case points out the importance of actively looking for a regional problem if patients cannot tolerate the CPAP interface since this can lead to issues of incompliance and medical complications due to the untreated obstructive sleep apnoea syndrome.

Bilevel positive airway pressure for obstructive sleep apnea

For most patients with obstructive sleep apnea syndrome (OSA), continuous positive airway pressure (CPAP) is an effective therapy. However, for a subset of individuals, CPAP is either not effective or is poorly tolerated. Bilevel positive airway pressure (BPAP) is potentially capable of treating OSA at a lower mean pressure than CPAP and can help augment ventilation via pressure support. This review summarizes the evidence for the use of BPAP in spontaneous mode in the initial treatment of patients with OSA and in those who are poorly compliant with CPAP therapy. It also examines evidence regarding use of BPAP in OSA with associated hypoventilation, such as in chronic obstructive pulmonary disease or severe obesity. Finally, current clinical guidelines that help determine which patients would be candidates for a BPAP device and how to manually titrate BPAP to determine the optimal settings to be prescribed are also discussed.

Willingness score obtained after a short CPAP trial predicts CPAP use at 1 year

PURPOSE

To predict continuous positive airway pressure (CPAP) adherence at 1 year.

METHODS

We followed consecutive OSA patients scheduled for CPAP initiation for 1 year. Patients completed a self-efficacy questionnaire (5 = low, 25 = high score) before CPAP initiation. After CPAP initiation, we enquired about patients' satisfaction in CPAP trial and their eagerness and willingness to continue CPAP therapy (0 = unsatisfied, uneager, or refused CPAP; 100 = satisfied, eager, or willing to continue CPAP treatment).

RESULTS

Of the 580 patients we followed, 377 continued CPAP therapy beyond 1 year. A low willingness score (<50) was expressed by 77 patients but only 7 of them used CPAP >4 h daily at 1 year, yielding a specificity of 97 % in predicting CPAP failure. At 1 year, patients with a self-efficacy score >20, expressed prior to CPAP initiation, used CPAP more often than the patients with a score <20 (average use 4.4 ± 2.2 h vs. 3.7 ± 2.3 h, p<0.001).

CONCLUSIONS

A low score of willingness to continue CPAP therapy after a short trial predicts CPAP failure and poor CPAP adherence at 1 year.

Long-term continuous positive airway pressure therapy normalizes high exhaled nitric oxide levels in obstructive sleep apnea

STUDY OBJECTIVES

Upper airway inflammation and oxidative stress have been implicated in the pathogenesis of obstructive sleep apnea (OSA) and may be linked to cardiovascular consequences. We prospectively examined fraction of exhaled nitric oxide (FENO), a surrogate marker of upper airway inflammation using a portable nitric oxide analyzer (NIOX MINO).

DESIGN

In consecutive adult nonsmokers with suspected OSA, FENO was measured immediately before and after polysomnographic studies, and within 1-3 months following continuous positive airway pressure (CPAP) therapy.

MEASUREMENT AND RESULTS

FENO levels were increased in the 75 patients with OSA compared to the 29 controls, both before sleep (13.4 ± 6.5 ppb vs. 6.5 ± 3.5; p < 0.001) and after sleep (19.0 ± 7.7 ppb vs. 6.9 ± 3.7; p < 0.001). Furthermore, in patients with OSA, FENO levels were significantly higher post-sleep than pre-sleep (19.0 ± 7.7 ppb vs. 13.4 ± 6.5; p < 0.001), while there was no significant overnight change in patients without OSA. The rise in FENO correlated with the apnea-hypopnea index (r = 0.65, p < 0.001), nadir oxygen saturation (r = 0.54, p < 0.001), and arousal index (r = 0.52, p < 0.001). Thirty-seven of these patients underwent CPAP titration and treatment. Successful titration was associated with a lower overnight increase in FENO (7.2 ± 3.3 vs. 11.0 ± 4.3, p = 0.02). FENO levels declined after 1-3 months of CPAP therapy (11.7 ± 4.4 ppb, p < 0.001).

CONCLUSIONS

FENO levels are elevated in OSA, correlate with severity, and decrease after positive pressure therapy. This study supports the role of upper airway inflammation in OSA pathogenesis and a possible role for FENO in monitoring CPAP therapy.

The appearance of central sleep apnea after treatment of obstructive sleep apnea

Patients with a primary diagnosis of obstructive sleep apnea frequently demonstrate central sleep apnea that emerges during treatment with CPAP. Although a number of mechanisms for this finding have been hypothesized, the pathophysiology is not definitively known. Controversy exists as to whether the concomitant appearance of the two phenomena represents a distinct meaningful entity. Regardless, the coincidence of these diseases may have important clinical implications. Herein, we review the proposed mechanisms for obstructive sleep apnea complicated by central sleep apnea. Future research is needed to elucidate the relative importance and susceptibility to intervention of the various pathophysiologic mechanisms responsible for this phenomenon, and whether a treatment approach distinct from that of pure obstructive apnea is justified.

Regular CPAP utilization reduces nasal inflammation assessed by nasal cytology in obstructive sleep apnea syndrome

OBJECTIVES

To analyze nasal inflammation in a group of patients with obstructive sleep apnea syndrome (OSAS) by means of nasal cytology and to describe the changes induced by continuous positive air pressure (CPAP) treatment.

SUBJECTS AND METHODS

Thirty-two consecutive patients affected by OSAS (mean age 46.9 years) and 13 control subjects (mean age 49.1 years) were enrolled. Detailed clinical, laboratory, and polysomnographic studies were obtained in all participants and, in particular, nasal cytology was performed; inflammatory cells (neutrophils, eosinophils, mast cells, lymphocytes), bacteria, and spores were counted. A subgroup of 19 OSAS patients underwent regular nasal CPAP for eight weeks while the remaining 13 were noncompliant. Nasal cytology was repeated after eight weeks in all patients and controls.

RESULTS

All patients with OSAS were affected by some form of rhinopathy, mostly subclinical, which was not found to influence compliance to CPAP. Regular CPAP treatment induced a significant reduction of cell infiltration (neutrophils, eosinophils, lymphocytes, and muciparous cells), which was not seen in nontreated patients.

CONCLUSION

Nasal inflammation/infection is a very frequent finding in OSAS and can be reverted by the regular use of CPAP.

Upper airway symptoms in primary snoring and in sleep apnea

CONCLUSIONS

Upper airway symptoms were common in subjects referred for sleep study. In particular, nasal stuffiness and airway dryness already seemed to bother snorers before development of obstructive sleep apnea syndrome (OSAS). Mouth dryness increased with severity of obstructive sleep apnea (OSA).

OBJECTIVES

Upper airway symptoms are common in patients with OSAS. However, prevalence of these symptoms is unknown in primary snoring and mild OSA. We evaluated frequency of upper airway symptoms in a large group of patients referred for diagnostic sleep studies.

METHODS

We examined 524 consecutive subjects (69% men, mean ± SD age 51 ± 12 years, apnea-hypopnea index (AHI) 15 ± 21, body mass index 31 ± 6) by a questionnaire-based survey. The subjects filled in a questionnaire enquiring about current upper airway symptoms and history of nasal and pharyngeal disorders before the sleep study.

RESULTS

Frequent upper airway symptoms among study subjects were common: 56% of the patients reported throat dryness, 55% mouth dryness, 54% nasal stuffiness, 52% nose dryness, 33% sneezing, 33% postnasal drip, and 24% rhinorrhea. The patients with moderate or severe OSAS (AHI ≥15 and Epworth sleepiness score ≥10) suffered from mouth dryness more often (71% vs 40%, p < 0.01) than those with mild or no OSAS.

Short-term effects of air pollution from biomass burning in mucociliary clearance of Brazilian sugarcane cutters

Nasal mucociliary system is the first line of defense of the upper airways and may be affected acutely by exposure to particulate matter (PM) from biomass burning. Several epidemiologic studies have demonstrated a consistent association between levels of air pollution from biomass burning with increases in hospitalization for respiratory diseases and mortality. To determine the acute effects of exposure to particulate matter from biomass burning in nasal mucociliary transport by saccharin transit time (STT) test, we studied thirty-three non-smokers and twelve light smokers sugarcane cutters in two periods: pre-harvest season and 4 h after harvest at the first day after biomass burning. Lung function, exhaled carbon monoxide (CO), nasal symptoms questionnaire and mucociliary clearance (MC) were assessed. Exhaled CO was increased in smokers compared to non-smokers but did not change significantly after harvest. In contrast, STT was similar between smokers and non-smokers and decreased significantly after harvest in both groups (p < 0.001). Exposure to PM from biomass burning did not influence nasal symptoms. Our results suggest that acute exposure to particulate matter from sugarcane burned affects mucociliary clearance in smokers and non-smokers workers in the absence of symptoms.

Continuous positive airway pressure intolerance associated with elevated nasal resistance is possible mechanism of complex sleep apnea syndrome

PURPOSE

Complex sleep apnea syndrome (CompSAS) is diagnosed after an elimination of obstructive events with continuous positive airway pressure (CPAP), when a central apnea index ≥5/h or Cheyne-Stokes respiration pattern emerges in patients with obstructive sleep apnea syndrome (OSAS). However, the pathophysiology of CompSAS remains controversial.

METHODS

Of the 281 patients with suspected OSAS, all of whom underwent polysomnography conducted at Nagoya University Hospital, we enrolled 52 patients with apnea-hypopnea index ≥15/h (age 51.4 ± 13.3 years). The polysomnographic findings, left ventricular ejection fraction (LVEF), and nasal resistance were compared between the CompSAS patients and OSAS patients.

RESULTS

Forty-three patients were diagnosed with OSAS and nine patients with central sleep apnea syndrome by natural sleep PSG. Furthermore, 43 OSAS patients were classified into the OSAS patients (OSAS group, n = 38) and the CompSAS patients (CompSAS group, n = 5) by the night on CPAP PSG. The nasal resistance was significantly higher in CompSAS group than in OSAS group (0.30 ± 0.10 vs. 0.19 ± 0.07 Pa/cm(3)/s, P = 0.004). The arousal index, percentage of stage 1 sleep, and oxygen desaturation index were significantly decreased, and the percentage of stage REM sleep was significantly increased in the OSAS group with the initial CPAP treatment, but not in the CompSAS group. In addition, the patients with CompSAS showed normal LVEF.

CONCLUSION

CPAP intolerance secondary to an elevated nasal resistance might relate to frequent arousals, which could presumably contribute to an increase in central sleep apnea. Further evaluation in a large study is needed to clarify the mechanism of CompSAS.

Routine use of humidification with nasal continuous positive airway pressure

BACKGROUND

Heated humidification can reduce nasal symptoms caused by continuous positive airway pressure (CPAP) treatment, but its routine use has not been studied over the medium term in a randomized controlled trial. The aim of this study is to determine if heated humidification would reduce nasal symptoms and improve adherence with CPAP treatment in all patients with sleep apnoea irrespective of whether they had nasal symptoms initially.

METHODS

A randomized, parallel group design. Patients were treated for 3 months with a Fisher & Paykel HC201 pump with built-in heated humidification, or with the heater disabled and without water. Adherence was measured with a timer built into the pumps. Nasal symptoms were measured with a 10-cm visual analogue scale.

RESULTS

There were 25 in the humidification group and 29 in the non-humidification group. After 12 weeks mean (standard deviation) adherence with CPAP was 4.7 (2.4) and 4.5 (2.2) hours per night respectively. Nasal symptoms that were reduced were nose blocked* 6 (12), 18 (26); sneezing* 4 (8), 15 (25); dry nose* 8 (12), 24 (33); stuffy nose* 7 (14), 22(31); dry mouth* 13 (18), 33(36); and runny nose* 6 (17), 14 (29). Parameters marked with an asterisk '*' had P < 0.05 with t-tests.

CONCLUSION

The routine use of heated humidification with CPAP in all patients with sleep apnoea reduced nasal symptoms, but did not improve adherence.

Cerebrospinal fluid leak associated with nasal continuous positive airway pressure treatment for obstructive sleep apnoea

Clear rhinorrhoea is a common symptom in patients with obstructive sleep apnoea (OSA), which may worsen with nasal continuous positive airway pressure treatment (nCPAP). However, rhinorrhoea can also be the presenting symptom of cerebrospinal fluid (CSF) leak, which is due to a communication between the subarachnoid space and the nasal cavity or sinuses. We report another case of a patient with OSA in whom CSF leak developed following the initiation of nCPAP treatment.

Oroantral communication as an osteotome sinus elevation complication

The sinus elevation procedure is a predictable technique to allow for placement of dental implants in the posterior maxilla when the height of the alveolar ridge is limited. The sinus elevation can be performed by various techniques. In the crestal approach, bone graft is utilized to hydraulically elevate the sinus membrane through an osteotomy prepared in the alveolar crest. The implant can be placed either immediately or at a later surgery. This is a case report of an oroantral communication that developed as a complication to a sinus elevation surgery performed with the crestal approach. A 54-year-old female patient presented for dental implant treatment. The patient reported sleep apnea and smoking. Full-thickness flap was reflected in the posterior maxilla and using trephines, an osteotomy was prepared, 1 mm short of the sinus. The trephined core of bone was pushed into the sinus using osteotomes. Particulate bone graft was introduced through the osteotomy to elevate the sinus membrane, and a collagen membrane was used over the bone graft. Six days after surgery, the patient returned to the clinic with an oroantral communication. The patient reported that she was using a positive-pressure breathing mask at night because of sleep apnea. A flap was extended to the tuberosity area and was rotated palatally to achieve closure. The use of the pressure breathing mask was discontinued. The oroantral communication was successfully closed. Relatively few complications have been reported using the osteotome sinus elevation technique. The use of a positive pressure mask may have complicated a sinus elevation surgery. Other factors that may have contributed to this complication include smoking and delayed healing of the area.

Continuous positive airway pressure (CPAP) induces early nasal inflammation

STUDY OBJECTIVES

To assess whether noninvasive application of nCPAP is a mechanical stimulus inducing early nasal inflammation.

DESIGN

Prospective controlled animal study.

SETTING

University laboratory.

PATIENTS OR PARTICIPANTS

32 male Sprague-Dawley rats (250-300 g).

INTERVENTIONS

The rats were anesthetized and subjected to nCPAP=10 cm H2O and sham-CPAP through a mask for 3 h and 5 h (n=8 each).

MEASUREMENTS AND RESULTS

After nCPAP or sham, nasal scraping was carried out to detect neutrophils, and septum and dorsal nasal concha were excised to assess gene expression of inflammatory markers by real time PCR. Percentage of neutrophils in nucleated cells in the nasal scrapings was significantly (P = 0.006) higher after 5 h of nCPAP (3.51% +/- 0.73%; m +/- SEM) than in the sham group (1.12% +/- 0.39%). When compared with sham, the mRNA of macrophage inflammatory protein-2 (MIP-2) in nasal tissue was significantly overexpressed after both 3 h (2.28-fold +/- 0.43-fold; P = 0.034) and 5 h (5.56-fold +/-1.88-fold; P = 0.002) of nCPAP=10 cm H2O. No significant changes were found in the gene expressions of tumor necrosis factor-alpha, nerve growth factor and tachykinin-1 receptor.

CONCLUSIONS

The compression applied by nCPAP (10 cm H2O, 5 h) on the nasal wall of healthy rats is a mechanical stimulus that triggers an early inflammatory process mediated by MIP-2, resulting in neutrophil extravasation.

The acute impact of continuous positive airway pressure on nasal resistance: a randomized controlled comparison

Subjective nasal obstruction is common among users of continuous positive airway pressure (CPAP). The aim of this study was to measure the acute effect of CPAP on nasal resistance and nasal symptoms in awake normal subjects. Twenty-four healthy CPAP-naive adults [8 men, 16 women; mean age 30 yr (SD 14)] underwent a randomized controlled crossover study comparing nasal CPAP (8 cmH(2)O) for 6 h on one occasion and the control condition (nasal mask without CPAP) on the other. Nasal resistance measurements (posterior active rhinometry) before and after the test exposure were similar on both test days. Nasal resistance during CPAP exposure [2.04 cmH(2)O.l(-1).s (SD 0.72)] was significantly lower than that of the control [2.67 cmH(2)O.l(-1).s (SD 1.07)]: mean difference 0.66 cmH(2)O.l(-1).s, 95% confidence interval 0.19-1.13 cmH(2)O.l(-1).s. The gradient in pressure from CPAP mask to posterior naris during CPAP exposure varied from 1.6 to 2 cmH(2)O but was not significantly different between time points. Subjective nasal symptom scores and peak nasal inspiratory flow rates did not change significantly on either test day. We conclude that in awake CPAP-naive normal subjects, acute CPAP exposure is associated with a reduction in nasal resistance compared with the control condition, but it is not associated with an immediate post-CPAP change in subjective or objective nasal resistance.

Short-term effects of nCPAP on nasal mucociliary clearance and mucus transportability in healthy subjects

Nasal mucociliary clearance is a primary defense mechanism of the upper airways and may be acutely affected by nasal continuous positive airway pressure (nCPAP). nCPAP treatment is effective and safe. However, it can cause nasal side effects and contribute to a low compliance to the treatment. The aim of this study was to investigate the short-term effects of nCPAP on nasal mucociliary clearance and on mucus transportability of healthy subjects. Eleven healthy subjects were submitted to 20 min of nCPAP (10 cm H2O). Five subjects were also evaluated before and after 20 min of rest on the consecutive study day. Nasal mucociliary clearance was measured by the saccharin nasal transit time test and nasal mucus was collected for the in vitro study of mucus transportability by the frog palate model, both before and after the nCPAP challenge. Saccharin nasal transit time decreased significantly after nCPAP (9.29+/-6.06 min and 4.83+/-5.57 min; P=0.002 before and after nCPAP respectively). No significant changes were observed on the control day (11.66+/-7.57 min and 12.40+/-5.62 min; P=0.70). Mucus transportability was not significantly affected by nCPAP. Our results suggest that nCPAP can acutely increase nasal mucociliary clearance but does not affect in vitro mucus transportability in healthy subjects.

Drug therapy for obstructive sleep apnoea in adults

BACKGROUND

The treatment of choice for moderate to severe obstructive sleep apnoea (OSA) is continuous positive airways pressure (CPAP) via a mask during sleep. However this is not tolerated by all patients and its role in mild OSA is not proven. Drug therapy has been proposed as an alternative to CPAP in some patients with mild to moderate sleep apnoea and could be of value in patients intolerant of CPAP. A number of mechanisms have been proposed by which drugs could reduce the severity of OSA. These include an increase in tone in the upper airway dilator muscles, an increase in ventilatory drive, a reduction in the proportion of REM sleep, an increase in cholinergic tone during sleep, a reduction in airway resistance and a reduction in surface tension in the upper airway.

OBJECTIVES

To determine the efficacy of drug therapies in the treatment of sleep apnoea.

SEARCH STRATEGY

We carried out searches on the Cochrane Airways Group Specialised Register of trials. Searches were current as of July 2005.

SELECTION CRITERIA

Randomised, placebo controlled trials involving adult patients with confirmed OSA . We excluded trials if continuous positive airways pressure, mandibular devices or oxygen therapy were used. No restriction was placed upon publication language or trial duration.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed studies for inclusion, undertook data extraction according to pre-specified entry criteria, and quality assessment of studies. No response for further information was forthcoming from study authors. Results were expressed as mean differences and 95% Confidence Intervals (CI).

MAIN RESULTS

Twenty-six trials of 21 drugs, involving 394 participants contributed data to the review. Most of the studies were small and many trials had methodological limitations. Each of the studies states that the subjects had OSA but diagnostic criteria were not always explicit and it is possible that some patients with central apnoeas may have been recruited. Six drugs had some impact on OSA severity and two altered daytime symptoms. One study reported that apnoea hypopnea index (AHI) was lower following treatment with intranasal fluticasone compared with placebo (23.3 versus 30.3) in 24 participants with sleep apnoea and rhinitis. Subjective alertness in the daytime also improved. Physostigmine gave an AHI of 41 compared to 54 on placebo (10 participants) and in a similar study Mirtazipine 15 mg produced an AHI of 13 compared to 23.7 for placebo (10 participants). Topical nasal lubricant given twice overnight resulted in an AHI of 14 compared to 24 with placebo (10 participants). These three latter studies were of single night crossover design and so there are no data on the acceptability of these treatments or their effect on symptoms. Paroxetine was shown to reduce AHI to 23.3 compared to 30.3 for placebo, most of the 20 participants tolerated the treatment but there was no improvement in daytime symptoms. Acetazolamide also reduced the AHI (one crossover trial of nine patients, mean difference 24 (95% CI 4 to 44). However there was no symptomatic benefit from the drug and it was poorly tolerated in the long term. Protriptyline led to a symptomatic improvement (improved versus not improved) in two out of three crossover trials (13 participants, Peto Odds Ratio 29.2 (95% CI 2.8 to 301.1) but there was no change in the apnoea frequency. In one trial naltrexone did reduce AHI, but total sleep time favoured placebo. No significant beneficial effects were found for medroxy progesterone, clonidine, mibefradil, cilazapril, buspirone, aminophylline, theophylline doxapram, ondansetron or sabeluzole.

AUTHORS' CONCLUSIONS

There is insufficient evidence to recommend the use of drug therapy in the treatment of OSA. Small studies have reported positive effects of certain agents on short-term outcome. Certain agents have been shown to reduce the AHI in largely unselected populations with OSA by between 24 and 45%. For fluticasone, mirtazipine, physostigmine and nasal lubricant, studies of longer duration are required to establish whether this has an impact on daytime symptoms. Individual patients had more complete responses to particular drugs. It is likely that better matching of drugs to patients according to the dominant mechanism of their OSA will lead to better results and this also needs further study.

Patient- and bed partner-reported symptoms, smoking, and nasal resistance in sleep-disordered breathing

OBJECTIVES

Nocturnal and daytime symptoms are important determinants in clinical decision making in patients suspected of having sleep-disordered breathing (SDB). We compared patients' and bed partners' reporting of symptoms associated with SDB in a clinical sample of snoring men. The bed partners' view on snoring disturbance was assessed. The relationship between sleep parameters, anthropometric data, and selected subjective symptoms was assessed. Additionally, we evaluated the relationship between smoking, nasal resistance, and habitual snoring.

DESIGN

A cross-sectional, prospective study.

SETTING

University teaching hospital.

PATIENTS

Thirty-seven consecutive snoring men referred to ENT Hospital because of a snoring problem or suspicion of sleep apnea, and scheduled for surgical treatment of nasal obstruction.

INTERVENTIONS

The patients completed a sleep questionnaire, a questionnaire on nasal history, and the Epworth sleepiness scale. The bed partners were asked to complete a separate sleep questionnaire of the patient's daytime and nocturnal symptoms. Both patients and bed partners evaluated the intensity of snoring on a visual analog scale. The patients underwent polysomnography and anterior rhinomanometry.

RESULTS

Agreement of patients' and bed partners' reports on symptoms related to SDB was good in this material. One half of the bed partners were disturbed by snoring every night or almost every night, and one third of the bed partners reported disharmony in the relationship from time to time or repeatedly due to snoring. The combination of current smoking and total nasal resistance in a supine position higher than the median value in this patient sample was associated with history of habitual snoring.

CONCLUSIONS

Male patients and their bed partners seem to give congruent reports of snoring and symptoms related to SDB in a clinical population with mild SDB. One half of the bed partners found their sleep constantly disturbed. The combination of current smoking and high nasal resistance was related with habitual snoring.

Influence of nasal resistance on initial acceptance of continuous positive airway pressure in treatment for obstructive sleep apnea syndrome

BACKGROUND

Continuous positive airway pressure (CPAP) is considered as the standard therapy for obstructive sleep apnea syndrome (OSAS), but some patients with OSAS are unable to accept CPAP due to nasal obstruction and poor nasal airflow.

OBJECTIVES

We assessed the influence of nasal resistance before beginning CPAP treatment on the initial acceptance of CPAP in OSAS patients.

METHODS

The study subjects comprised 77 patients (74 males, 3 females) with primary OSAS, all of whom received CPAP treatment with nasal masks. Before trials, all subjects underwent overnight polysomnography, and nasal resistance was measured with active anterior rhinomanometry in the seated position on the first day of CPAP trial.

RESULTS

The CPAP treatment was accepted by 56 patients after the initial trials with overnight polysomnography. Body mass index, the number of apnea/hypopnea episodes per hour (apnea/hypopnea index; AHI), and the number of episodes per hour with an oxygen desaturation of >3% (oxygen desaturation index) were significantly higher (p<0.01) and nasal resistance was lower (p=0.003) in patients who accepted CPAP than in those who did not. Logistic regression analysis, with patient age, body mass index, Epworth sleepiness scale score, AHI, oxygen desaturation index, and nasal resistance before CPAP treatment as explanatory variables, showed that nasal resistance (OR+0.1 Pa/cm3/s: 1.48; p=0.002) and AHI (OR+1 event/h: 0.93; p=0.003) were significant factors for CPAP non-acceptance.

CONCLUSIONS

Nasal resistance before the beginning of CPAP treatment has a significant effect on the acceptance of CPAP in OSAS patients, and hence, could be a predictive parameter for the initial acceptance of CPAP.

Cerebrospinal Fluid Leak and Meningitis Associated With Nasal Continuous Positive Airway Pressure Therapy

Clear rhinorrhea is a common symptom in patients with obstructive sleep apnea (OSA) and may worsen with continuous positive airway pressure therapy. Clear rhinorrhea can also be the presenting symptom of cerebrospinal fluid (CSF) leak, which is evidence of a communication between the subarachnoid space and the nasal cavity or sinuses. While CSF leak has been reported to occur with nasal continuous positive airway pressure (nCPAP) therapy following trauma to the skull base, its association with OSA and nCPAP therapy in the absence of trauma has not been previously described. We report two patients with OSA in whom CSF leak developed following the institution of nCPAP therapy. In one patient, the rhinorrhea was complicated by meningitis. Both patients underwent successful repair of their defects. One patient successfully restarted nCPAP therapy, while the other refused it.

Efeitos da pressão positiva contínua em vias aéreas sobre os sintomas nasofaríngeos em pacientes com a síndrome da apnéia obstrutiva do sono

INTRODUÇÃO: Sintomas nasofaríngeos são comuns em pacientes com a síndrome da apnéia obstrutiva do sono (SAOS) em tratamento com pressão positiva contínua em vias aéreas (CPAP). No entanto, sintomas nasofaríngeos são também comuns em pacientes com SAOS antes do início do tratamento. OBJETIVO: Determinar o impacto do tratamento com CPAP nasal sobre os sintomas nasofaríngeos em pacientes com SAOS. MÉTODO: Foram avaliados 35 pacientes (28 homens), com idade de 54 ±10 anos portadores de SAOS moderada a grave diagnosticada através de polissonografia. Os sintomas nasofaríngeos (espirros, coriza, prurido, obstrução, sangramento e ressecamento nasal e de garganta) foram quantificados através de questionário aplicado antes e depois de pelo menos 3 meses de tratamento com CPAP nasal. RESULTADOS: O índice de apnéia + hipopnéia foi de 50±25 eventos por hora. Ao menos um sintoma nasofaríngeo estava presente em 26 pacientes (74%) antes do tratamento. A obstrução nasal foi o sintoma mais comum, presente em 18 pacientes (51%). Dentre os pacientes inicialmente assintomáticos (n = 9), 78% apresentaram alguma reação nasofaríngea adversa com o tratamento. Em contraste, nos pacientes inicialmente sintomáticos, houve redução significativa da intensidade da obstrução, do ressecamento nasal e de garganta e do sangramento nasal após o tratamento. CONCLUSÃO: Sintomas nasofaríngeos são freqüentes em pacientes com SAOS. O uso de CPAP pode tanto desencadear sintomas nasofaríngeos em pacientes assintomáticos, como reduzir sua intensidade nos pacientes com sintomas prévios.

Differential gene expression in the T-helper lymphocytes of obstructive sleep apnea patients treated with nasal continuous positive airway pressure (nCPAP)

Obstructive sleep apnea (OSA) is a disease with significant morbidity, increased risk of accidents attributed to daytime somnolence, and has been associated with cardiovascular complications. The treatment of choice for OSA is nasal continuous positive airway pressure (nCPAP). Some OSA patients, however, are unable to benefit from this therapy as they find nCPAP intolerable due to the related nasal inflammation. It is hypothesized that nCPAP may cause nasal inflammation in these patients by inducing changes in the expression of genes that encode interleukins (IL-3, IL-4, IL-6, IL-8, IL-13) or adhesion molecules (i.e., ICAM-1) in T-helper lymphocytes. An understanding of the underlying inflammatory mechanism could lead to specific interventions that render nCPAP therapy tolerable for these individuals.