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PubMed2005

Genetic determinants of upper airway structures that predispose to obstructive sleep apnea.

Genetic factors are thought to play an important role in human development. Recent data indicate that obstructive sleep apnea may have a genetic basis. Sleep apnea is a very common disorder with significant cardiovascular and neurophysiologic morbidity. The pathogenesis of sleep apnea is related to a reduction in the size of the upper airway. The reduction in airway size is secondary to increased adipose tissue (enlargement of the parapharyngeal fat pads), alterations in craniofacial structure (reduction in mandibular size) and enlargement of the surrounding soft tissue structures (tongue, lateral pharyngeal walls). Genetic factors are one of the factors that have been proposed to mediate the size of each of these anatomic risk factors for sleep apnea. Recent evidence is accumulating about the genetic loci for these structural risk factors that predispose to the development of obstructive sleep apnea.

Animals↗
PubMed1986

Three-dimensional CT reconstructions of tongue and airway in adult subjects with obstructive sleep apnea.

The interaction between airway and tongue structures in a sample of 25 adult men with obstructive sleep apnea was quantified on the basis of a series of preoperative CT slices obtained for each subject. Tracings were completed for tongue, and right and left nasal, nasopharynx, oropharynx, and hypopharynx structures; computer graphics were used to obtain superior and lateral three-dimensional reconstructions of all structures for each subject. In addition, cross-sectional areas of specific sites of airway constriction, surface area, volume, and ratio calculations were completed. The majority of the constrictions occurred in the oropharynx (0.52 +/- 0.18 cm2), but six subjects had two constrictions--one in the oropharynx and one in the hypopharynx. The airway had a mean volume of 13.89 +/- 5.33 cm3, whereas tongue volume ranged from 44.03 to 99.56 cm3 with a mean of 71.96 +/- 13.41 cm3. Subjects with more severe obstructive sleep apnea tended to have larger tongue and smaller airway volumes. The more obese subjects showed larger tongue surface areas and smaller airway surface areas. To determine the structural relationships between airway and tongue variables, a series of logarithmic plots was determined. An isometric relationship characterized tongue surface area and tongue volume. A logarithmic plot of oropharyngeal airway vs. tongue volume showed a negative allometric relationship. Tongue volume increased more rapidly than airway volume in subjects with obstructive sleep apnea. Subjects with large tongue volumes were observed to experience significant complications at the time of surgical treatment. Quantification of the volume of the oropharynx and its relationship to tongue volume provide an overview of the interaction between these structures.

Adult↗
PubMed2004

Rapid maxillary expansion in children with obstructive sleep apnea syndrome.

OBJECTIVE: To evaluate the effect of rapid maxillary expansion on children with nasal breathing and obstructive sleep apnea syndrome. METHOD: Recruitment of children with maxillary contraction, without of adenoid hypertrophy, with a body mass index < 24 kg/m2, with obstructive sleep apnea syndrome demonstrated by polysomnography, and whose parents signed informed consent. Otolaryngologic and orthognathic-odontologic evaluation with clinical evaluation, anterior rhinometry and nasal fibroscopy, panoramic radiographs, anteroposterior and laterolateral telecephalometry were performed at entry and follow-up. INTERVENTION: Rapid maxillary expansion (ie, active phase of treatment) was performed for 10 to 20 days; maintenance of device (for consolidation) and orthodontic treatment on teeth lasted 6 to 12 months. RESULTS: 31 children (19 boys), mean age 8.7 years, participated in the study. The mean apnea-hypopnea index was 12.2 events per hour. At the 4-month follow-up, the anterior rhinometry was normal, and all children had an apnea-hypopnea index < 1 event per hour. The mean cross-sectional expansion of the maxilla was 4.32 +/- 0.7 mm. There was a mean increase of the pyriform opening of 1.3 +/- 0.3 mm. CONCLUSION: Rapid maxillary expansion may be a useful approach in dealing with abnormal breathing during sleep.

Body Mass Index↗
PubMed2001

A protocol for uvulopalatopharyngoplasty, mortised genioplasty, and maxillomandibular advancement in patients with obstructive sleep apnea: an analysis of 40 cases.

PURPOSE: This study evaluated the effectiveness of uvulopalatopharyngoplasty (UPPP) with mortised genioplasty and maxillomandibular advancement (MMA) for the treatment of patients with obstructive sleep apnea not controllable with appliances or continuous positive airway pressure. METHODS: Forty patients with obstructive sleep apnea were evaluated retrospectively. Thirty-three patients underwent combined UPPP and a modified mortised genioglossus advancement. Patients who had specific indications for MMA underwent combined procedures, eliminating staging of multiple surgeries. Seven patients were in this group. All patients were evaluated preoperatively and postoperatively with polysomnography to evaluate the efficacy of the treatment. RESULTS: Mean respiratory distress indices (RDI) and nadir oxyhemoglobin desaturation values were significantly improved with each of the therapies despite many patients having body mass indices significantly greater than the average quoted in other studies. Patients with moderate sleep apnea (RDI, 21 to 40) who underwent UPPP/genioglossus advancement did very well, with 86% of patients achieving success. Patients who underwent MMA all decreased their RDI by at least 56% and had an average improvement of 86%. CONCLUSIONS: The UPPP/mortised genioglossus advancement is effective for the treatment of obstructive sleep apnea. Maxillomandibular advancement is effective for treating severe sleep apnea and may, in some cases, be indicated in combination with UPPP/mortised genioglossus advancement to avoid multiple procedures. Surgical reconstruction of the upper airway is a reasonable approach to the treatment of patients with obstructive sleep apnea, and can be approached more directly to minimize repeated surgical intervention.

Adult↗
PubMedDate not supplied

Increased prevalence of perennial allergic rhinitis in patients with obstructive sleep apnea.

BACKGROUND: Impaired nasal breathing is a risk factor for obstructive sleep apnea syndrome (OSAS). OBJECTIVES: The aim of this study was to determine whether atopy to perennial allergens and existence of perennial allergic rhinitis was a risk factor for OSAS. METHODS: In a case-control study, we compared the proportions of OSAS patients with atopy to perennial allergens and perennial allergic rhinitis to the proportions in patients with chronic obstructive pulmonary disease (COPD). Seventy-two OSAS patients (mean age 60.7 years; 79.4% male) and 44 COPD patients (mean age 63.6 years; 88.6% male) were selected from a hospital outpatients' clinic in Switzerland. All patients completed a respiratory symptom questionnaire, performed spirometry and had a skin prick test for atopy. RESULTS: OSAS patients were significantly heavier than COPD patients (BMI 32.4 +/- (SD) 6.6 vs. 29.2 +/- 6.6 kg/m2, p = 0.04) and had a better lung function than COPD patients (FEV1% predicted 91.3 +/- 19.2 vs. 51.6 +/- 18.9%, p < 0.001). Patients with OSAS were more likely to be sensitized to perennial allergens such as house dust mite (23.6 vs. 4.5%, p = 0.009) and dog (18 vs. 4.5%, p = 0.04) than the COPD patients. Perennial allergic rhinitis (having nose problems [nasal obstruction and/or runny nose and/or sneezing] all year and being atopic to at least one perennial allergen) was reported in 11% of OSAS patients but in only 2.3% of COPD patients (p = 0.15). CONCLUSION: We conclude that subjects with OSAS may have an increased risk of being allergic to perennial allergens and suffer from perennial rhinitis. Awareness of this risk may have important consideration in the clinical situation.

Administration, Intranasal↗
PubMed2004

Using a wrist-worn device based on peripheral arterial tonometry to diagnose obstructive sleep apnea: in-laboratory and ambulatory validation.

STUDY OBJECTIVES: To assess the accuracy of a wrist-worn device (Watch_PAT 100) to diagnose obstructive sleep apnea in the home. DESIGN: Participants completed 2 overnight diagnostic studies with the test device: 1 night in the laboratory with concurrent polysomnography and 1 night in the home with only the Watch_PAT. The order of the laboratory and home study nights was random. The frequency of respiratory events on the PSG was quantified using indexes based on 2 definitions of hypopnea: the respiratory disturbance index (RDI) using American Academy of Sleep Medicine Task Force criteria for clinical research, also referred to as the Chicago criteria (RDI.C), and the Medicare guidelines (RDI.M). The Watch_PAT RDI (PAT RDI) and oxygen desaturation index (PAT ODI) were then evaluated against the polysomnography RDI.C and RDI.M, respectively, for both Watch_PAT diagnostic nights, yielding IN-LAB and HOME-LAB comparisons. SETTING: Sleep laboratory affiliated with a tertiary-care academic medical center. PATIENTS: 30 patients referred with suspected OSA. INTERVENTIONS: N/A. MEASUREMENTS AND RESULTS: The polysomnography and PAT measures were compared using the mean [2 SD] of the differences and the intra-class correlation coefficient (ICC). The receiver-operator characteristic curve was used to assess optimum sensitivity and specificity and calculate likelihood ratios. For the IN-LAB comparison, there was high concordance between RDI.C and PAT RDI (ICC = 0.88, mean difference 2.5 [18.9] events per hour); RDI.M and PAT ODI (ICC = 0.95, mean difference 1.4 [12.9] events per hour; and sleep time (ICC = 0.70, mean difference 7.0 [93.1] minutes) between the test device and PSG. For the HOME-LAB comparison, there was good concordance between RDI.C and PAT RDI (ICC = 0.72, mean difference 1.4 [30.1] events per hour) and RDI.M and PAT ODI (ICC = 0.80, mean difference 1.6 [26.4] events per hour) for the test device and PSG. Home studies were performed with no technical failures. CONCLUSIONS: In a population of patients suspected of having obstructive sleep apnea, the Watch_PAT can quantify an ODI that compares very well with Medicare criteria for defining respiratory events and an RDI that compares favorably with Chicago criteria for defining respiratory events. The device can be used with a low failure rate for single use in the lab and home for self-administered testing.

Adult↗
PubMed2005

The interaction between changes in upright mandibular position and supine airway size in patients with obstructive sleep apnea.

INTRODUCTION: The purpose of this study was to investigate the interaction between upright mandibular position change and supine upper airway size in men with obstructive sleep apnea fitted with titratable oral appliances. METHODS: Baseline supine cephalometry before placement of the oral appliance and after titration with the oral appliance in place were undertaken in 14 patients, and upright mandibular position change was evaluated with and without the titrated oral appliance in place with a DigiGraph workstation (Dolphin Imaging Systems, Valencia, Calif). RESULTS: The apnea-hypopnea index was significantly reduced after titration of the oral appliance (P < .01). Upright mandibular position change was associated with significant vertical (P < .01) and horizontal (P < .01) mandibular repositioning. The size of the supine velopharynx (P < .05), but not the supine oropharynx, was significantly enlarged at the titrated mandibular position. The supine oropharyngeal size change was correlated with the upright horizontal repositioning of the mandible (r = 0.69, P < .01). CONCLUSIONS: Evaluation of upright mandibular position changes with the DigiGraph workstation enables one to predict supine oropharyngeal enlargement with oral appliance therapy. Dose-dependent effects of the horizontal component of upright mandibular protrusion on supine oropharyngeal size in addition to velopharyngeal enlargement might contribute to oral appliance effectiveness in obstructive sleep apnea patients.

Adult↗
PubMed1998

Edema in the upper airway in patients with obstructive sleep apnea syndrome.

OBJECTIVE: The purpose of this study was to investigate the histologic alterations in the upper airway in patients with obstructive sleep apnea syndrome. STUDY DESIGN: Surgical specimens were obtained during non-laser-assisted uvulopalatopharyngoplasty from 5 adult patients (4 male and 1 female) with polysomnographically confirmed obstructive sleep apnea syndrome. RESULTS: In all of the specimens, interstitial edema was present with mild inflammatory reaction. Fat was not at all prominent. CONCLUSIONS: It is confirmed histologically that there is edema present in the upper airway in patients with obstructive sleep apnea syndrome. It is uncertain whether this edema is one of the causative mechanisms of the obstruction or a consequence of the syndrome.

Adult↗
PubMed1991

[A case of malignant rheumatoid arthritis associated with obstructive sleep apnea due to mandibular lesions].

A 55 year old man with malignant rheumatoid arthritis (MRA) was admitted because of severe snoring during sleep and hypersomnolence in the day time. The patient developed an episode of respiratory distress and cardiac arrest, which responded rapidly to tracheal intubation and mechanical ventilation. He could be easily weaned from ventilator after 3 days. Polysomnography showed that the patient had an obstructive sleep apnea syndrome. Lateral view of cranial radiography revealed acquired micrognathia and destruction of the temporomandibular joints caused by RA, which induced obstructive sleep apnea. It is important to consider that obstructive sleep apnea can occur in RA patients showing snoring, hypersomnolence and disordered sleep behavior.

Arthritis, Rheumatoid↗
PubMed1995

Obstructive sleep apnea: a mandibular positioning device for treatment and diagnosis of an obstruction site.

Obstructive sleep apnea (OSA) is a common condition with serious health and social consequences for millions of people. If untreated, it has significant effects on mortality, particularly by contributing to the rate of hypertension, stroke, and cardiac pathology. Standard therapy involves the use of a nasal continuous positive airway pressure device during sleep. This keeps the upper airway from collapsing, avoiding the cause of apneas and hypopneas. The inconvenience and side effects of the device make compliance with its use less than ideal. There are several surgical techniques that have been developed to correct OSA. These techniques have had variable success rates and are accompanied by some morbidity and mortality. Intraoral devices that position the mandible forward show promise for increasing the hypopharyngeal airway. A technique for physiologically determining an effective jaw relationship is described, as is a design for a device that maximizes nighttime retention. Radiographic analyses in the upright and supine positions are used to determine adequate airway improvement. The intraoral device can be used as a diagnostic tool to select patients who will most likely benefit from surgery.

Airway Obstruction↗
PubMed1983

Computerized tomography in obstructive sleep apnea. Correlation of airway size with physiology during sleep and wakefulness.

Pathophysiologic changes during sleep in patients with obstructive apnea are often associated with alterations in upper airway function during awake periods. To determine whether these functional changes are related to abnormal airway structure, we performed computerized tomography (CT) in 20 awake patients with obstructive apnea and in 10 control subjects. The CT scan measurements of cross-sectional areas of the nasopharynx, oropharynx, and hypopharynx in apneic patients were significantly reduced (p less than 0.05) compared with those in the control subjects. Sites of obstruction varied, and apparent airway occlusion occurred in 6 patients. Reduced pharyngeal size correlated with increased sleep-disordered breathing rates (p less than 0.05), more severe nocturnal oxygen desaturation (p less than 0.05), and the presence of a saw-tooth pattern of flow-volume curves obtained during awake periods (p less than 0.05). Structural upper airway narrowing is detectable with CT in awake patients with obstructive sleep apnea.

Adult↗
PubMed2003

Recent developments in the treatment of obstructive sleep apnea.

Modern sleep medicine has been in existence for only 20 years and therefore has to be regarded as a comparatively recent field of specialization. For this reason it is not surprising that there are numerous new trends and developments concerning the treatment of sleep-related breathing disorders. This review focuses on developments in the treatment of obstructive sleep apnea (OSA) over the last 5 years.The review is based on a Medline bibliographic search using the key words 'treatment', 'obstructive sleep apnea' and 'sleep-related breathing disorders' and covers papers published since 1997, including references in these articles. In respect to conservative treatments the following important developments were found. Oral devices were shown to be effective in about 50-70% of patients with OSA, but at this stage it is not possible to predict in which patients successful treatment can be expected. As subjective compliance averages only about 50%, thermoplastic devices used as trial devices provide a reasonable alternative to reduce costs. Automatic continuous positive airway pressure (CPAP) units have been shown to cut costs when used for pressure titration in severe sleep apneics during the day or when used in so-called split-night procedures in appropriate cases. Nasal CPAP has proven to be effective in children, showing higher compliance rates than in adults. The development of mouth-pieces provides the possibility of using CPAP orally, e.g. after nasal surgery. Electrical stimulation of the tongue muscles shows promising preliminary results. Nevertheless, further research in this field is necessary. In the field of surgery, the most valuable development has been tissue reduction using radiofrequency energy, which has been shown to be effective and minimally invasive. Other fundamentally new surgical techniques have not been attempted within the last 5 years; instead, development in this area appears to be defined by a combination of previously known methods (so-called multilevel surgery) and optimized methods of patient selection. Such combined surgical procedures has achieved success rates of about 70%. Taking all these developments into account, CPAP therapy remains the gold standard for treatment of patients with OSA; yet the low long-term compliance rates of 60-70% have to be regarded as a major challenge warranting further effort.

Adolescent↗
PubMed2004

Effects of long-term nasal continuous positive airway pressure therapy on morphology, function, and mucociliary clearance of nasal epithelium in patients with obstructive sleep apnea syndrome.

OBJECTIVES/HYPOTHESIS: The objective was to investigate the possible modification of nasal mucosa function and mucociliary clearance in a group of patients with severe obstructive sleep apnea syndrome receiving mechanical ventilation with long-term nasal continuous positive airway pressure (n-CPAP), without nasal diseases. STUDY DESIGN: The study design was experimental. Eight (six male and two female) nonsmoker patients were selected on the basis of two sleep questionnaires, were identified as needing n-CPAP therapy, and showed normal values of mucociliary transport time, ciliary beat frequency, and anterior rhinomanometry. METHODS: After a full polysomnographic examination, the authors recorded respiratory disturbance index (RDI), apnea/hypopnea index, nadir arterial oxygen saturation, and sleep stage. Every patient underwent pulmonary function test; arterial blood gas analysis; chest radiography; electrocardiography; ear, nose, and throat evaluation with rhinoscopy; anterior rhinomanometry; a saccharine test to measure the mucociliary transport time; and a brushing of nasal epithelium for study of ciliary beat frequency. All patients underwent polysomnographic examination in basal condition with overnight n-CPAP (without humidifier) and repeated this examination after 1 and 6 months with Auto CPAP (Autoset Res Care, Sidney, Australia) to titrate n-CPAP pressure and measure the new respiratory disturbance index. RESULTS: The mean basal respiratory disturbance index (number of respiratory events during sleep per hour of recording time) was 53.7 +/- 21.5 events/h; after 6 months of n-CPAP therapy (mean value, 7.5 +/- 0.7 cm H2O) the respiratory disturbance index was 5.7 +/- 3.76 events/h. Values for nasal resistance, mucociliary transport time, and ciliary beat frequency were normal before and after the ventilatory treatment. CONCLUSION: In the study group of patients with severe obstructive sleep apnea syndrome, the nocturnal use of n-CPAP without humidifier did not modify the function and mucociliary clearance of nasal epithelium.

Adult↗
PubMed2002

Treatment of obstructive sleep apnea with the Karwetzky oral appliance.

The aims of this retrospective study were to assess the effect of a Karwetzky mandibular protrusion appliance for treating patients with mild, moderate, and severe obstructive sleep apnea. Eighty-one of 116 patients (69.8%) suffering from obstructive sleep apnea were treated with an activator model according to Karwetzky. After 4 months (SD 4.0 months) treatment outcome was controlled by polysomnography. Therapeutic outcome depended on the severity of obstructive sleep apnea. The median apnea-hypopnea index decreased from 10.6 events/h (range 2.0-14.9) to 5.8 events/h (range 0.2-17.3, P<0.01) in the mild group, from 21.7 events/h (range 17.3-28.4) to 7.7 events/h (range 1.0-30.1, P<0.001) in the moderate group, and from 42.1 events/h (range 33.2-64.9) to 18.1 events/h (range 2.4-48.8, P<0.001) in the severe group. Sleep variables did not show consistent improvement except for a trend towards more REM sleep and slow-wave sleep. The numbers of retentive teeth did not statistically influence treatment efficacy. Comparing the pre- and post-treatment polysomnographic variables, it was found that the respiratory events rather than sleep stages were significantly reduced by the Karwetzky appliance investigated.

Activator Appliances↗
PubMed2005

Development of a measure of knowledge and attitudes about obstructive sleep apnea in children (OSAKA-KIDS).

BACKGROUND: Primary care physicians play an important role in screening for childhood obstructive sleep apnea syndrome (OSAS) that, if untreated, can result in serious complications. OBJECTIVE: To describe the development of the Obstructive Sleep Apnea Knowledge and Attitudes in Children (OSAKA-KIDS) questionnaire for use in measuring physicians' knowledge and attitudes about childhood OSAS and its treatment. DESIGN: Cross-sectional survey to pilot administration of the 23-item OSAKA-KIDS questionnaire, mailed to 1195 community- and academic-based physicians in Louisville, Ky; Philadelphia, Pa; and St Louis, Mo. MAIN OUTCOME MEASURES: Analysis of variance measured differences in knowledge and attitudes between academic- and community-based physicians and between pediatricians and family practitioners. Using stepwise multiple linear regression, we analyzed the associations between various predictors (including specialty, practice setting, and years since medical school graduation) and each item of knowledge and attitudes. All tests were 2-tailed. RESULTS: Questionnaires for 497 respondents (44% female; mean [SD] age, 45.7 [10.5] years; and mean [SD] number of years since medical school graduation, 18.7 [11.0] years) were analyzed. The mean (SD) knowledge score (percentage of 18 possible) was 69.6% (14.6%). In regression analyses, more knowledge was associated with more positive attitudes overall and more recent graduation from medical school; having a more positive attitude was associated with having completed a pediatrics residency and more knowledge about OSAS. CONCLUSIONS: Deficits in basic knowledge about childhood OSAS were observed regardless of physician practice setting and specialty training. More education focusing on the diagnosis and treatment of childhood OSAS and identifying children at risk for OSAS is recommended.

Analysis of Variance↗
PubMedDate not supplied

Obstructive sleep apnea syndrome as first manifestation of pharyngeal non-Hodgkin's lymphoma.

Obstructive sleep apnea syndrome (OSAS) is characterized by repetitive episodes of upper airway obstruction during sleep that provoke an abnormal number of apneas and hypopneas, leading to arousals and, as a result, to an altered sleep architecture. Here we present a patient with clinical symptoms characteristic of OSAS. During follow-up, pharyngeal non-Hodgkin's lymphoma was diagnosed and treated, with a nearly complete normalization of polysomnography.

Antineoplastic Combined Chemotherapy Protocols↗
PubMed1998

Obstructive sleep apnea syndrome: evaluation of subcritical continuous positive airway pressure.

Twenty eight of 48 patients diagnosed of obstructive sleep apnea syndrome over a six month duration opted for CPAP therapy. Half of them were given critical CPAP (Group A) and other half were prescribed subcritical level of CPAP (Group B). Re-evaluation after 3 months revealed that side effects like headache and feeling of inconvenience were more in Group A, though beneficial effects were same in both groups. It is concluded that subcritical level of CPAP should be adopted to treat patients of obstructive sleep apnea syndrome.

Female↗