Improved nasal breathing reduces snoring and morning tiredness. A 6-month follow-up study

Snoring was related to self-reported daytime sleepiness and tiredness in young adults performing compulsory conscript service

STUDY OBJECTIVES

In young adults performing compulsory military service, fatigue and somnolence are common and presumably associated with objective or self-reported sleep deprivation. We aimed to find out whether objective sleep parameters from ambulatory polysomnography could explain their self-reported tiredness and sleepiness and whether habits were associated with sleep parameters or tiredness.

METHODS

Seventy (67 male, age 18-24 years) participants had their sleep assessed with polysomnography. Their self-reported symptoms and demographic data were obtained from online survey including Epworth Sleepiness Scale, Beck's Depression Inventory, items from Basic Nordic Sleep Questionnaire, Internet Addiction Scale, and lifestyle questions.

RESULTS

Snoring (audio recording, percentage of total sleep time) was associated with self-reported sleepiness (P = .010) and tiredness (P = .030) and snoring seemed to, partially, explain sleepiness (P = .029). Twenty-six percent of the conscripts had self-reported sleep deprivation (mismatch between reported need for sleep and reported sleep). Self-reported sleep deprivation was significantly associated with somnolence (P = .016) and fatigue (P = .026). Smartphone usage, both average time (P = .022) and frequency of usage (P = .0093) before bedtime, was associated with shorter total sleep time. On average, objective sleep time was rather short (7 hours, 6 minutes), sleep efficiency high (94.9%), proportion of N3 sleep high (27.7%), and sleep latency brief (9 minutes)-suggesting that many of the conscripts might have chronic partial sleep deprivation.

CONCLUSIONS

Snoring might predispose to tiredness in presumably healthy young adults. Conscripts may have partial sleep deprivation.

CITATION

Orjatsalo M, Toppila J, Heimola M, et al. Snoring was related to self-reported daytime sleepiness and tiredness in young adults performing compulsory conscript service. J Clin Sleep Med. 2023;19(2):243-251.

Non-Surgical Devices for Nasal Obstruction

Nasal obstruction is a common presenting complaint in most otolaryngology practices. A reduction of nasal airflow can contribute to exercise intolerance, snoring, obstructive sleep apnea (OSA), and an overall decreased in quality of life. When medical management for non-anatomic issues fail to resolve the obstruction, surgeries targeting nasal obstruction-- namely septorhinoplasty and/or inferior turbinate reduction are often considered. A frequently overlooked alternative for these patients is the wide array of non-surgical and minimally invasive appliances available to address nasal obstruction. This article attempts to provide a basic overview of these devices, benefits and limitations, and the evidence supporting their efficacy in alleviating nasal obstruction.

Considering the Role of Adherence in New and Emerging Sleep Treatments

There are several novel and emerging treatments for obstructive sleep apnea (OSA), including new devices and pharmacotherapies. Long-term efficacy and adherence data for these interventions in the sleep context are lacking. Future studies exploring the long-term adherence and efficacy in novel and emerging treatments of OSA are required to fully understand the place of these treatments in treatment hierarchies. Such research also should aim to evaluate the use of these novel therapies in real-world clinical settings, because many of the studies performed to date have been done under closely monitored research populations and relatively small sample sizes.

Special Considerations in the Treatment of Pregnancy Rhinitis

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

[Sk2 guidelines"diagnosis and therapy of snoring in adults" : compiled by the sleep medicine working group of the German Society of Otorhinolaryngology, Head and Neck Surgery]

These guidelines aim to facilitate high quality medical care of adults with snoring problems. The guidelines were devised for application in both in- and outpatient environments and are directed primarily at all those concerned with the diagnosis and therapy of snoring. According to the AWMF three-level concept, these represent S2k guidelines.A satisfactory definition of snoring does not currently exist. Snoring is the result of vibration of soft tissue structures in narrow regions of the upper airway during breathing while asleep. Ultimately, these vibrations are caused by the sleep-associated decrease in muscle tone in the area of the upper airway dilator muscles. A multitude of risk factors for snoring have been described and its occurrence is multifactorial. Data relating to the frequency of snoring vary widely, depending on the way in which the data are collected. Snoring is usually observed in middle-aged individuals and affected males predominate. Clinical diagnosis of snoring should comprise a free evaluation of the patient's medical history. Where possible this should also involve their bed partner and the case history can be complimented by questionnaires. To determine the airflow relevant structures, a clinical examination of the nose should be performed. This examination may also include nasal endoscopy. Examination of the oropharynx is particularly important and should be performed. The larynx and the hypopharynx should be examined. The size of the tongue and the condition of the mucous membranes should be recorded as part of the oral cavity examination, as should the results of a dental assessment. Facial skeleton morphology should be assessed for orientation purposes. Technical examinations may be advisable in individual cases. In the instance of suspected sleep-related breathing disorders, relevant comorbidities or where treatment for snoring has been requested, an objective sleep medicine examination should be performed. Snoring is not-at least as we currently understand it-a disease associated with a medical threat; therefore there is currently no medical necessity to treat the condition. All overweight patients with snoring problems should strive to lose weight. If snoring is associated with the supine position, positional therapy can be considered. Some cases of snoring can be appropriately treated using an intraoral device. Selected minimally invasive surgical procedures on the soft palate can be recommended to treat snoring, provided that examinations have revealed a suitable anatomy. The choice of technique is determined primarily by the individual anatomy. At an appropriate interval after the commencement or completion a therapeutic measure, a follow-up examination should be conducted to assess the success of the therapy and to aid in the planning of any further treatments.

Diagnosis and treatment of snoring in adults-S2k Guideline of the German Society of Otorhinolaryngology, Head and Neck Surgery

OBJECTIVES

This guideline aims to promote high-quality care by medical specialists for subjects who snore and is designed for everyone involved in the diagnosis and treatment of snoring in an in- or outpatient setting.

DISCUSSION

To date, a satisfactory definition of snoring is lacking. Snoring is caused by a vibration of soft tissue in the upper airway induced by respiration during sleep. It is triggered by relaxation of the upper airway dilator muscles that occurs during sleep. Multiple risk factors for snoring have been described and snoring is of multifactorial origin. The true incidence of snoring is not clear to date, as the incidence differs throughout literature. Snoring is more likely to appear in middle age, predominantly in males. Diagnostic measures should include a sleep medical history, preferably involving an interview with the bed partner, and may be completed with questionnaires. Clinical examination should include examination of the nose to evaluate the relevant structures for nasal breathing and may be completed with nasal endoscopy. Evaluation of the oropharynx, larynx, and hypopharynx should also be performed. Clinical assessment of the oral cavity should include the size of the tongue, the mucosa of the oral cavity, and the dental status. Furthermore, facial skeletal morphology should be evaluated. In select cases, technical diagnostic measures may be added. Further objective measures should be performed if the medical history and/or clinical examination suggest sleep-disordered breathing, if relevant comorbidities are present, and if the subject requests treatment for snoring. According to current knowledge, snoring is not associated with medical hazard, and generally, there is no medical indication for treatment. Weight reduction should be achieved in every overweight subject who snores. In snorers who snore only in the supine position, positional treatment can be considered. In suitable cases, snoring can be treated successfully with intraoral devices. Minimally invasive surgery of the soft palate can be considered as long as the individual anatomy appears suitable. Treatment selection should be based on individual anatomic findings. After a therapeutic intervention, follow-up visits should take place after an appropriate time frame to assess treatment success and to potentially indicate further intervention.

The importance of improved nasal breathing: a review of the Nozovent nostril dilator

The Nozovent nostril dilator improves nasal breathing to the same degree as topical decongestants and reduces mouth dryness at night in 51% of nocturnal mouth breathers. It does not help every snorer but reduces the snoring heard by the sleeping partner in about 50%, improves the respiratory disturbance index significantly in 19% and gives less morning and daytime tiredness in 40% of snorers. The medium CPAP pressure can be significantly reduced with the dilator.

Snoring is not relieved by nasal surgery despite improvement in nasal resistance

OBJECTIVES

In the present study, we evaluated the effect of nasal surgery on snoring time, snoring intensity, and sleep-disordered breathing. The role of abnormal cephalometry in treatment outcome was assessed.

DESIGN

A cross-sectional prospective study.

SETTING

University teaching hospital.

PATIENTS

Forty consecutive snoring men who were referred to ENT Hospital because of a snoring problem or suspicion of sleep apnea.

INTERVENTIONS

The patients underwent anterior rhinomanometry and polysomnography (PSG) with recording of snoring before and after operative treatment of nasal obstruction. Cephalometric radiographs were obtained before surgery.

RESULTS

Nasal resistance decreased significantly in the overall patient group. Snoring time, snoring intensity, nocturnal breathing, and sleep architecture did not change after nasal surgery. Cephalometry did not predict operative outcome in these patients. Snoring intensity was found to be significantly higher during non-rapid eye movement (NREM) sleep than during rapid eye movement sleep.

CONCLUSIONS

Operative treatment of mainly structural nasal obstruction did not seem to decrease snoring intensity, snoring time, or sleep-disordered breathing in an objective assessment by PSG performed after surgery. The effect of treating inflammatory nasal changes during nocturnal breathing, as well as the role of cephalometry in the prediction of treatment outcome will need further evaluation. Higher snoring intensity related to NREM sleep may add to the sleep disturbance of a bed partner in the evening.

Pregnancy Rhinitis

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

Clinical and pathogenetic characteristics of pregnancy rhinitis

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

Effect of nasal valve dilation on effective CPAP level in obstructive sleep apnea

Nasal problems are frequent at high continuous positive airway pressure (CPAP). We hypothesized that a reduction of the nasal resistance reduces CPAP and investigated the effect of a nasal valve dilator (Nozovent) on CPAP in patients with obstructive sleep apnea. In a randomized cross-over design Nozovent was inserted in 38 patients during one of two nights using AutoSet T. CPAP differences > 1 cm H2O were considered as clinically relevant. With Nozovent the median CPAP pressure was reduced from 8.6 cm H2O to 8.0 H2O (P = 0.023) in all patients, but the number of patients with a reduction of CPAP by 1 cm H2O was not significant. The median CPAP level among 20 patients requiring a CPAP level of above 9 cm H2O was reduced from 10.3 to 9.1 cm H2O, P < 0.05. A clinical improvement with Nozovent was seen in 10 of 20 patients requiring a pressure of above 9 cm H2O compared with 4 of 18 patients who needed lower pressures, P = 0.025. Nozovent reduces the CPAP level 1 cm H2O in 50% of patients requiring a high pressure (> 9 cm H2O). Future studies should identify possible patients benefiting from a nasal dilator during CPAP therapy.

Acoustic reflection: review and clinical applications for sleep-disordered breathing

Sleep-disordered breathing (SDB) affects more than 4% of the adult population with an even higher prevalence within high-risk groups. Nasal continuous positive air pressure, although considered the current gold standard treatment for SDB, demonstrates poor patient compliance. Alternative therapies, such as palatal surgeries and airway orthotics, lack validated candidacy selection protocols, resulting in varying success rates. Although much has been published over the last several years regarding the effect of these therapies on the upper airway, no publication has presented an accounting of the use of acoustic reflection (AR) to evaluate airway characteristics pre- and post-treatment with these alternative therapies. This article will review AR and our current knowledge base of the pathological airway characteristics that can be assessed through AR. It will include the advantages, limitations, and potential clinical usefulness of this diagnostic modality in the treatment of patients with SDB.

What are the nonsurgical treatment options for obstructive sleep apnea syndrome?

Obstructive sleep apnea (OSA) syndrome is now recognized as a relatively common cause of excessive daytime sleepiness, with resultant psychosocial impairment and motor vehicle accidents, and it likely contributes to premature cardiovascular disease. Treatment is naturally directed at the upper airway; however, it is also important to identify and correct significant risk factors, such as obesity and hypothyroidism, whenever possible. Oral appliances or nasal continuous positive airway pressure may immediately reverse symptoms caused by OSA and can be used either indefinitely or as a bridge to potentially definitive surgery.

Effect of nasal-valve dilation on obstructive sleep apnea

OBJECTIVE

Nasal-valve dilation reduces nasal resistance and increases air flow. It is possible that this mechanism prevents hypopharyngeal collapse and sleep apneas. We investigated the effect of a plastic device (Nozovent; Prevancure AB; Västra Frölunda, Sweden)-which dilates the nasal valve-on patients with obstructive sleep apnea (OSA).

DESIGN

Prospective interventional study.

SUBJECTS

Twenty-six consecutive patients with OSA were included (22 men; mean +/- SD age, 54.8+/-11.3 years; respiratory disturbance index [RDI], 34.4+/-18.5 events/h; body mass index, 31.6+/-5.7 kg/m(2)).

INTERVENTION

The nasal dilator was inserted during sleep into the nares and fitted to exert a dilating force on the nasal valves by means of its elasticity.

MEASUREMENTS

Polysomnographic studies were performed before and after 1 month of treatment. A responder is defined as one with a reduction in RDI to < 50% of the baseline value and RDI of < or =10 events/h during treatment.

RESULTS

Five patients dropped out. As a result, only 21 patients were analyzed. Four patients responded, and 17 patients were nonresponders. In the whole population, neither the mean values for respiration during sleep nor sleep staging changed significantly with the device.

CONCLUSIONS

The investigated nasal dilator had no effect on sleep-related breathing disorders in patients with moderate to severe OSA. The reduction in nasal resistance does not prevent hypopharyngeal obstruction.