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PubMed2005

Tongue base suspension combined with UPPP in severe OSA patients.

OBJECTIVE: Tongue base surgery in the severe OSA patients may improve the success of uvulopalatopharyngoplasty (UPPP) as the collapse is multilevel. The aim of this study was to evaluate the long-term objective and subjective effectiveness of the minimally invasive tongue base suspension combined with UPPP in severe OSA patients. STUDY DESIGN AND SETTING: We conducted a retrospective analysis of 22 OSA patients undergoing UPPP and the tongue base suspension for the treatment of severe OSA. RESULTS: Twenty-two men who had their preoperative and postoperative polysomnography had a 54% reduction in the preoperative Respiratory Disturbance Index (RDI), from 47.50 +/- 15.74 to a level of 17.31 +/- 14.17. The standard surgical cure rate which is a >50% reduction in the RDI and a postoperative RDI of <20 events/hour was 81.81%. All patients had some degree of subjective improvement in their snoring, daytime sleepiness, and the Epworth sleepiness scale. CONCLUSIONS: The tongue base suspension combined with UPPP has been shown to reduce RDI better than UPPP alone. This minimally invasive technique is highly successful at 81.81% when combined with UPPP in the severe OSA patients with multilevel airway collapse. SIGNIFICANCE: This study shows the benefits of minimally invasive tongue base suspension combined with UPPP in severe obstructive sleep apnea syndrome.

Adult↗

PubMed2006

A comparison of polysomnography and the SleepStrip in the diagnosis of OSA.

OBJECTIVE: To investigate the role of a portable screening device (SleepStrip) in the diagnosis of obstructive sleep apnea (OSA). METHODS AND MATERIALS: Prospective, nonrandomized double-blinded single cohort study at an academic health center. Patients with suspected OSA scheduled for an attended overnight Level I polysomnogram (PSG) and who consented to participate in the study wore the SleepStrip device at home the night after the PSG. The apnea-hypopnea index (AHI) determined by PSG was compared with the results of the SleepStrip recording. RESULTS: Thirty-seven patients with a mean age of 52.1 +/- 12.2 years and mean body mass index of 35.7 +/- 5.2 participated in the study. The overall agreement between the AHI and the SleepStrip results using Cohen's Kappa value was 0.139 (P = 0.19). The sensitivity and specificity of the SleepStrip for diagnosing severe OSA when the AHI was >40 were 33.3% and 95% (P = 0.05). When the AHI was >25, the SleepStrip sensitivity and specificity were 43.8% and 81.3% (P = 0.26). The sensitivity and specificity of the SleepStrip for diagnosing OSA in patients with an AHI >15 were 54.6% and 70%, respectively (P = 0.26). CONCLUSION: The SleepStrip has a low correlation with the AHI as measured by PSG. Further studies are needed before this device can be recommended as a screening tool for the diagnosis of OSA. EBM RATING: B-2b.

Adolescent↗

PubMed2004

Relative accuracy of algorithm-based prescription of nasal CPAP in OSA.

BACKGROUND: Patients with OSA on nasal continuous positive airway pressure (CPAP) have considerable night-to-night variation in their pressure requirements, suggesting that a one-night titration might not be very precise. This study investigates the likely error incurred using a one-night titration, and explores whether an algorithm-based approach to determine the pressure is as accurate. METHODS: Thirty patients with OSA used an autotitrating CPAP device for 28 nights and the average was regarded as the 'reference' pressure for that patient. Using estimates of precision and bias, this 'reference' pressure was compared with (1) an algorithm-derived pressure (based on neck circumference and OSA severity), (2) a one-night titration (using four alternative nights), and (3) a fixed pressure of 10 cmH2O. RESULTS: The mean 'reference' pressure for the group was 9.83 (SD 2.12) cmH2O. There was little bias from any of the alternatives. However, the precision varied between 1.65 and 2.45 cmH2O for the four one-night titrations, was 2.00 for the algorithm, and was 2.12 using a fixed pressure of 10 cmH2O. CONCLUSIONS: Considerable night-to-night variation means that a one-night titration is not very precise and is subject to random variation. A one-night titration has a similar inaccuracy to that resulting from using an algorithm, based on OSA severity and neck circumference. Setting all patients with OSA at 10 cmH2O is little worse.

Algorithms↗

PubMed2003

Complications of adenotonsillectomy in children with OSAS younger than 2 years of age.

The most common sleep disorder in children is obstructive sleep apnea syndrome (OSAS). The majority of children with OSAS improve following tonsillectomy and adenoidectomy (T&A). T&A as an outpatient procedure in children is very common. Young age in considered risk factors for postoperative respiratory complications. The purpose of this study is to analyze our experience with postoperative T&A complications in patients younger than 2 years of age. A total of 39 T&A were performed in children younger than 2 years of age. OSAS diagnosis was confirmed by overnight polysomnography (PSG). All the patients were hospitalized and monitored by overnight pulse oximetry monitoring. Post-operatively there was marked improvement in respiratory function in all the patients comparing pre- and post-operative nadir oxygen saturation (P<0.05). Complications were documented in seven patients (20%). Five of the complications occurred in children older than 1 year of age. Bleeding occurred in two patients (5.7%). Three patients (8.6%) had dehydration, one patient (2.9%) had hypercarbia and one patient had laryngospasm. In this study there was a low incidence of peri- and post- operative respiratory complications in children younger than 2 years of age who undergo T&A for OSAS. Identification of OSAS severity may be an important factor in determining the risk of T&A in a young child.

Adenoidectomy↗

PubMed2003

Cognitive dysfunction in patients with obstructive sleep apnea (OSA): partial reversibility after continuous positive airway pressure (CPAP).

The aims of this study were to assess cognitive function in obstructive sleep apnea (OSA) patients and to evaluate the effect of short- and long-term treatment with continuous positive airway pressure treatment (CPAP). A battery of neuropsychological tests, the Epworth Sleepiness Scale (ESS), and the Beck Inventory Scale were administered to 23 patients with severe OSA (age: 56.5+/-6.13; AHI: 54.9+/-13.37) and to 23 age- and education-matched controls. The OSA patients were evaluated in a baseline condition and in two follow-up treatment sessions (after 15 days and 4 months of CPAP, respectively). At baseline, OSA patients had a significant impairment, compared to controls, in tests of sustained attention, visuospatial learning, executive function, motor performance, and constructional abilities. The longitudinal evaluation showed that after a 15-days CPAP treatment attentive, visuospatial learning, and motor performances returned to normal levels. A 4-months CPAP treatment did not result in any further improvement in cognitive tests. Performance on tests evaluating executive functions and constructional abilities was not affected by short- and long-term treatment with CPAP. The findings of this study confirm the hypothesis of partial reversibility of cognitive dysfunction in OSA patients after CPAP.

Attention↗

PubMed2000

CPAP therapy in patients with mild OSA: implementation and treatment outcome.

Objectives: To determine continuous positive airway pressure (CPAP) treatment compliance and reversal of excessive daytime sleepiness in patients with mild OSA.Background: CPAP therapy is the most widely accepted and used intervention in patients with a diagnosis of obstructive sleep apnea (OSA). There are, however, no widely accepted protocols to help guide the rational use of CPAP therapy. Patients with mild OSA (respiratory event index (REI) >5 or </=25) represent a subset of the OSA population where CPAP implementation needs to be evaluated.Methods: This is a retrospective study of 740 consecutive patients evaluated for sleep apnea in 1996. Mild OSA was documented in 241 patients, of whom, 41 opted for CPAP therapy. Implementation of CPAP treatment included an education session and an overnight clinical polysomnography (CPSG) for titration purposes. Patients returned for follow-ups after 1 week and 1 year of CPAP use. During each appointment, compliance and response to treatment were evaluated.Results: Of the initial 41 patients nine were lost to follow-up, 16 discontinued CPAP use during the first week, and 16 were still using CPAP after 1 year. For the 16 still using CPAP after one year, hours of use the first week was correlated to hours of use the first year (r=0.81). Patients using CPAP more than 4 h/night experienced a marked improvement in daytime sleepiness after 1 year (P<0.01).Conclusions: Patients with mild OSA showed a high rate of CPAP discontinuation. Those patients who manifested good compliance during the first week of treatment continued using CPAP for the entire first year. These patients experienced improved alertness during the day. A 1 week trial on CPAP therapy is warranted to identify patients who benefit from this form of therapy.

Journal Article↗

PubMed2003

Sleep and respiratory stimulus specific dampening of cortical responsiveness in OSAS.

The application of inspiratory occlusion stimuli produces cortical responses called respiratory-related evoked potentials (RREPs). During wakefulness the RREP waveform consists of early P1 and Nf components, an N1 and a P300. During non-REM sleep the predominant component is an N550, best seen in the averages of elicited K-complexes. Obstructive sleep apnea syndrome (OSAS) patients have been previously shown to have a normal wake RREP but to have a reduced amplitude N550 and a smaller proportion of elicited K-complexes than controls. The present study tested the hypothesis that this reflects a sleep-specific dampening peculiar to inspiratory effort-related stimuli, by assessing both respiratory and auditory evoked potentials (AEPs) during wakefulness and non-REM sleep in OSAS patients and controls. Auditory tones were presented in an oddball sequence during wakefulness and as a monotonous series during stage 2 sleep. Inspiratory occlusions, delivered for 500 msec via an nCPAP mask were also presented during wakefulness and stage 2 sleep, every three to five breaths. Data were collected from ten OSAS patients and ten controls. There were no significant differences in the amplitudes of the auditory N1 and P3 or the respiratory P1, Nf, N1 or P3 components during wakefulness. The amplitude of the auditory N550 and the proportion of elicited K-complexes did not differ between groups for auditory stimuli presented during stage 2 sleep. The respiratory N550 and K-complex elicitation rate were both significantly reduced in the OSAS group, despite there being no differences in the mask occlusion pressure response to the occlusion. The results confirm a blunted cortical response to inspiratory occlusions that is specific to sleep. The absence of significant group differences in the responses to auditory stimuli highlight that the sleep-related differences seen in OSAS patients are specific to the processing of inspiratory effort related stimuli.

Acoustic Stimulation↗

PubMed2003

Chemoreflex control of ventilation is altered during wakefulness in humans with OSA.

We hypothesized that patients with obstructive sleep apnea (OSA) have a different awake ventilatory response to carbon dioxide above and below eupnea compared with normal. Eight male subjects with OSA and control subjects matched for gender, race, age, height and weight voluntarily hyperventilated during wakefulness to reduce the partial pressure of carbon dioxide (PET(CO2)) below 25 mmHg. Subjects were then switched into a rebreathing bag containing a normocapnic (42 mmHg) hypoxic [partial pressure of end tidal oxygen (PET(O2))=50 mmHg (H50)] or hyperoxic [PET(O2)=140 mmHg (H140)] gas mixture. During the trial PET(CO2) increased while PET(O2) was maintained at a constant level. The point at which ventilation and PET(CO2) increased linearly was considered to be the carbon dioxide ventilatory recruitment threshold (VRT(CO2)). Measurements of ventilation and its components (i.e. tidal volume and breathing frequency) were made below this threshold and the slope of the minute ventilation; tidal volume or breathing frequency response above the threshold was determined. Four trials for a given oxygen level were completed. The PET(CO2) that demarcated the VRT(CO2) was increased (H(50)=43.43+/-0.92 vs. 41.05+/-0.67; H(140)=47.65+/-0.80 vs. 45.28+/-0.75), as were measures of ventilation below the threshold (H(50)=18.50+/-2.11 vs. 13.44+/-1.43; H(140)=19.66+/-2.71 vs. 10.83+/-1.24) in the OSA subjects compared with control. In contrast the OSA and control subjects did not respond differently to changes in PET(CO2) above the threshold. We conclude that the PET(CO2) that delineates the VRT(CO2) and ventilation below this threshold is elevated in subjects with OSA.

Adult↗

PubMed1997

[Therapy with nasal CPAP (continuous positive airway pressure) in patients with obstructive sleep apnea syndrome (OSAS). I: Long-term acceptance of nasal CPAP].

BACKGROUND: Nocturnal ventilation with nCPAP has been established as the safest and most efficient nonsurgical treatment for OSAS. Long-term results, however, are determined by the patients' compliance with therapy. The aim of this study was the objective measurement of long-term acceptability of nCPAP therapy in all patients receiving this treatment in our sleep laboratory between January 1990 and March 1995. METHODS: We prospectively investigated 41 patients (36 male, 5 female) with moderate to severe OSAS who received nCPAP therapy. Mean time of follow-up was 20.6 months, ranging from 1.2 to 53.5 months. Therapy was indicated when OSAS was confirmed by cardiorespiratory polygraphy and either (1) the patient complained of daytime sleepiness or (2) the patient possessed an apnea-hypopnea index greater than 30/h or when the mean oxygen desaturation was below 80% regardless of the presenting symptoms. The compliance with treatment was defined as a mean rate of use of over 5 hours per night calculated from the time counter on the nCPAP machine. RESULTS: 33 patients (88.5%) have continued using nCPAP until the present time but only 24 patients (59%) met our criteria for long-term acceptance and this group was identified as responders. We found no significant differences in age, body mass index, apnea-hypopnea index, and nCPAP-pressure between responders and non-responders. CONCLUSION: Although nCPAP is the safest treatment for OSAS, there is still a large group of patients with moderate to severe OSAS who are not efficiently treated with nCPAP because of the low long-term acceptability of this therapy. With respect to this group of patients, surgical approaches have to be considered as an alternative therapy.

Adult↗

PubMed2005

Cortisol circadian rhythm and 24-hour Holter arterial pressure in OSAS patients.

Obstructive sleep apnea syndrome (OSAS) is a syndrome in which the principal symptom is apnea during sleep. Hypoxia in OSAS is a stress condition, which when prolonged in time, could alter hypothalamo-hypophysial-suprarenal control and the cortisol cicadian rhythm. We studied 28 patients with OSAS (30-60 years old), 20 female and 8 male. We calculated the OSAS class according to the Simmons classification. Twenty of the 28 patients maintained unmodified cortisol circadian rhythms, while 8 had cortisol levels more elevated in late and nocturnal hours. Holter monitoring showed arterial hypertension in 8 of the 28 patients (the same patients with cortisol circadian rhythm alteration). Our data seem to indicate that when the OSAS patients lack cortisol circadian rhythm they are having arterial hypertension.

Adult↗

PubMed1995

Neuropsychological function in obstructive sleep apnea syndrome (OSAS) compared to chronic obstructive pulmonary disease (COPD).

Forty-nine men, 25 with obstructive sleep apnea syndrome (OSAS) and 24 with chronic obstructive pulmonary disease (COPD), were evaluated with a standard 8-hour nocturnal polysomnogram, multiple sleep latency test the following day and a neuropsychological test battery. The OSAS patients had more respiratory disturbances per hour of sleep, more stage 1 sleep and greater daytime sleepiness than COPD patients. The OSAS patients were as impaired as the COPD patients in neuropsychological test functioning, with the pattern of impairment nonspecific as to hypoxemic-sensitive versus sleepiness-sensitive tasks, with two exceptions. The OSAS patients performed more poorly on a test requiring sustained attention and considered sensitive to sleepiness, whereas the COPD patients performed more poorly on a test requiring motor skills and sensitive to hypoxemia. These deficits in psychomotor and attention appear to be specifically related to patients group (OSAS vs. COPD), but the other deficits found in complex reasoning and memory are nonspecific.

Attention↗

PubMed2000

Osa-containing Brahma chromatin remodeling complexes are required for the repression of wingless target genes.

The Wingless signaling pathway directs many developmental processes in Drosophila by regulating the expression of specific downstream target genes. We report here that the product of the trithorax group gene osa is required to repress such genes in the absence of the Wingless signal. The Wingless-regulated genes nubbin, Distal-less, and decapentaplegic and a minimal enhancer from the Ultrabithorax gene are misexpressed in osa mutants and repressed by ectopic Osa. Osa-mediated repression occurs downstream of the up-regulation of Armadillo but is sensitive both to the relative levels of activating Armadillo/Pangolin and repressing Groucho/Pangolin complexes present and to the responsiveness of the promoter to Wingless. Osa functions as a component of the Brahma chromatin-remodeling complex; other components of this complex are likewise required to repress Wingless target genes. These results suggest that altering the conformation of chromatin is an important mechanism by which Wingless signaling activates gene expression.

Animals↗

PubMed1995

Daytime waking autonomic function and vascular control in OSA.

This paper deals with the potential role of two blood pressure regulatory systems in the development of hypertension in obstructive sleep apnoea (OSA). Beside the acute and long-term sympathoexcitation documented in this disease, there seems to be an impaired endothelium-dependent vascular relaxation. In particular, nitric oxide (NO)-mediated vasodilatation was impaired in patients with OSA. Both these changes act to increase blood pressure during physiological conditions. However, they may not be determinants for hypertension development in OSA as no differences between normo- and hypertensive patients with OSA were detected. Nevertheless, an altered balance between the vasoconstrictive influence of the sympathoadrenergic system and the vasodilatory action of NO-dependent vascular relaxation may be of importance in the development of sustained hypertension in OSA.

Journal Article↗

PubMed2003

Awake negative pressure reflex response of the genioglossus in OSA patients and normal subjects.

We hypothesized that the response of the genioglossus to negative pressure during wakefulness should be intact in obstructive sleep apnea (OSA) patients despite published evidence showing impairment of the response of palatal muscles (Mortimore IL and Douglas NJ. Am J Respir Crit Care Med 156: 867-873, 1997). Thus the response of the genioglossus to brief nasal negative pressure applications (NPAs) in early inspiration was compared between OSA patients and an age-matched group of normal subjects at two study sites (n = 11 per group in Long Beach, n = 14 per group in Boston). Subjects were studied in the sitting (Long Beach) or supine (Boston) posture, and the genioglossus electromyogram (EMGgg) was measured with an intraoral surface electrode (Long Beach) or intramuscular electrode (Boston). The response of the EMGgg was expressed as the percent change from baseline where the baseline EMGgg was the value at the onset of the NPA. In Long Beach, the EMGgg response was significantly higher in the OSA patients at a lower suction pressure of approximately 10 cmH(2)O (75.2 +/- 8.4 vs. 37.4 +/- 4.0% increase; P < 0.001) but not at a higher suction pressure of approximately 20 cmH(2)O. In Boston, the response in the OSA patients was also greater (107.2 +/- 25.9 vs. 46.3 +/- 8.3%; P < 0.05) at a suction pressure of approximately 13 cmH(2)O. We conclude that the response of the genioglossus to NPA during wakefulness is not impaired in OSA patients compared with normal subjects and is greater at low suction pressures.

Adult↗

PubMed2002

Mechanisms of sympathoexcitation: single-unit analysis of muscle vasoconstrictor neurons in awake OSAS subjects.

In congestive heart failure (CHF), muscle sympathetic activity (MSNA) is greatly elevated, but our laboratory has shown that single muscle vasoconstrictor neurons primarily fire only once per cardiac interval, as in normal subjects (Elam M and Macefield VG. J Appl Physiol 91: 717-724, 2001; Macefield VG, Rundqvist B, Sverrisdottir YB, Wallin BG, and Elam M. Circulation 100: 1708-1713, 1999). In this study, we used patients with obstructive sleep apnea syndrome (OSAS) to test the hypothesis that this firing pattern is maintained in other states of sympathoexcitation. Unitary recordings were made from muscle vasoconstrictor neurons in eight awake OSAS patients. The average firing frequency of 12 units was 0.96 Hz and the firing probability 51%, similar to previous observations in CHF patients (0.98 Hz, 55%) but higher than in healthy subjects (0.40 Hz, 31%). However, the percentages of cardiac intervals in which neurons generated one, two, three, or four spikes were 59, 27, 10, and 3% in OSAS, compared with 71, 18, 7, and 2% in CHF and 73, 18, 5, and 3% in healthy subjects. Thus the firing pattern is different in OSAS and CHF, leading to rejection of the hypothesis: although in both conditions individual neurons show an increase in firing probability, in OSAS patients they also fire more often within a cardiac interval. It is likely that differences may also be apparent in other states of sympathoexcitation.

Aged↗

PubMed1992

MESAM 4: an ambulatory device for the detection of patients at risk for obstructive sleep apnea syndrome (OSAS).

A validation study was performed on the MESAM 4, a digital recording device developed to monitor oxygen saturation, heart rate (HR), snoring, and body position in order to screen subjects for obstructive sleep apnea syndrome (OSAS). MESAM 4 recordings were scored with the computer-based automatic scoring system provided with the equipment. Nocturnal polysomnography (PSG) and MESAM 4 recordings were run simultaneously on 56 subjects presenting with any type of sleep complaint, including those secondary to OSAS. Patients were assigned to one room by hospital administration and were monitored consecutively. The polygraphic equipment and MESAM 4 equipment were placed on the subjects by separate teams. Records of PSG and MESAM 4 were analyzed in double-blind fashion. With the MESAM 4 computerized analysis, three indices based on SaO2 (ODI), on heart rate (HVI), and on snoring (ISI) were obtained, and the number of abnormal respiratory events occurring during the time selected for analysis (TAT) were determined. Polysomnographic records were scored by 30-s epochs following the American Sleep Disorders Association standards for sleep states and stages and for sleep-related events, including sleep apneas, hypopneas, and periodic leg movements. Following independent scoring, 26 subjects were identified with OSAS by PSG, while MESAM 4 identified 25 subjects with OSAS using oxygen algorithm; all had a respiratory disturbance index greater than or equal to 10 with PSG. Results of each polysomnogram and each MESAM 4 analysis were compared. With the polysomnogram used as a standard, the degree of error for each variable with the MESAM 4 was calculated. Specificity and sensitivity of the most accurate index of the MESAM 4, the ODI, were 97 percent and 92 percent, respectively. The other two indices, HVI and ISI, were less accurate: specificity and sensitivity were 32 percent and 58 percent for HVI and 27 percent and 96 percent for ISI. Nevertheless, a combination of all three indices (ODI, HVI, ISI) would have prevented the two false-positive cases we observed. The results of this validation study show that MESAM 4 can be helpful to general practitioners, clinicians, and epidemiologists as a low-cost screening device for subjects with OSAS and habitual snoring.

Female↗

PubMedDate not supplied

Pulmonary haemodynamics in patients with OSAS or an overlap syndrome.

BACKGROUND: Alveolar hypoxia is the most important mechanism leading to pulmonary arterial vasoconstriction, remodelling and pulmonary hypertension. Patients with Obstructive Sleep Apnoea Syndrome (OSAS) experience multiple short periods of alveolar hypoxia during apnoeic episodes. However, the question as to whether these hypoxic episodes are responsible for the development of permanent pulmonary hypertension is still debatable. We aimed to investigate the relationship between the episodes of nocturnal desaturation and pulmonary haemodynamics in two distinct group patients: with pure OSAS or an overlap syndrome. METHODS: We studied 67 patients with severe OSAS (means: age 45+/-8 years, AHI 62+/-22, FEV1 3.6+/-0.8 L = 97+/-16% of predicted PaO2 72+/-10 mmHg, PaCO2 40+/-4 mmHg) and 17 patients with an overlap syndrome (OS), means: age 51+/-5 years, AHI 64+/-19, FEV1 1.5+/-0.7 = 43+/-16% of predicted PaO2 57+/-9 mmHg). All subjects underwent pulmonary artery catheterisation with pressure and flow recordings and an overnight full sleep study. RESULTS: On average patients with OSAS had nocturnal desaturation (mean overnight SaO2 = 87+/-5%) and normal PPA (15.8+/-4.6 mmHg). Only 11 out of 67 subjects (16%) presented with pulmonary hypertension. Patients with OS had nocturnal desaturation (mean overnight SaO2 = 80.2+/-8.5%) and mild pulmonary hypertension (PPA 24.2+/-7.4 mmHg). Only three out of 17 patients had normal pulmonary arterial pressure. CONCLUSIONS: In patients with severe OSAS, pulmonary hypertension is rare (16%) and is related best to the severity of the disease and to obesity. In OS patients diurnal pulmonary hypertension is frequent but does not correlate with the severity of nocturnal desaturation.

Adult↗

PubMed2001

[The relationship between content of substance P, VIP in pharyngeal tissue and narrow pharyngeal cavity of patients with OSAS].

OBJECTIVE: To investigate the relationship between content of substance P, VIP in the pharyngeal tissue and narrow pharyngeal cavity of patients with OSAS. METHOD: By using semi-quantitative immunohistochemical method, resected pharyngeal tissue from 30 patients with OSAS and 12 normal health adult controls were investigated with rabbit anti-substance P and rabbit anti-VIP. RESULT: SP and VIP were detected in tribution within the epithelium or between epithelium cells, around the pharyngeal glands and gland ducts, around endothelium cells and smooth muscle of blood vessels. SP and VIP levels in pharyngeal tissue of the patients with OSAS were increased than those of the controls. CONCLUSION: Narrow of pharyngeal cavity with OSAS was relative to edema of pharyngeal tissue induced by increased SP and VIP in pharyngeal tissue. A neurogenic inflammation was one of the factors of OSAS.

Adult↗