Is there a relationship between the degree of nasal obstruction and snoring?

Subjective nasal fullness and objective congestion

How well do subjective descriptions of the sensation of nasal closure or absence of nasal patency agree with objective measures of nasal geometry and airflow? Problems with this concept begin with terminology. "Congestion" has been applied to both the subjective and objective measures. Therefore, the term "fullness" will be used to describe perceptions of nasal mucosal heaviness or blockage that subjects with allergic rhinitis articulate. "Congestion" will refer to the objective measures used to assess patency. Sensations attributed to the nasal mucosa are highly integrated interpretations summed from multiple subsets of nociceptive and other neurons. Activation of sensor systems is required to depolarize afferent neurons. These sensors and other receptor proteins can be modulated by inflammation as part of the neural plasticity that leads to increased sensitivity to nasal stimuli. This plasticity and hyperalgesia may extend from the afferent neuron to spinal cord dorsal horn synapses, and regulatory and analytical regions of the brainstem and cerebrum. Although glandular hypersecretion can deliver obstructing material into the nasal cavities, the dilation of deep venous sinusoids is the strongest factor regulating nasal airspace volumes. There is a long history of attempts to correlate subjective sensations to objective measurements such as airflow resistance (rhinomanometry), nasal wall geometry (acoustic rhinometry), and peak nasal inspiratory flow. The medical evidence supporting each method has been analyzed on the basis of the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) system. These results provide a starting point for linking the outcomes of pathophysiological processes with a patient's psychometrically calibrated sensation of airflow.

The role of ENT surgeons in snoring assessment: some prospective preliminary evidence

OBJECTIVES

To determine (i) the prevalence of unsuspected upper aerodigestive tract disease in snorers, (ii) the diagnostic yield of routine flexible endoscopy and (iii) the relationship between symptoms of upper aerodigestive tract disease and examination findings in snorers.

DESIGN

Prospective analytical cohort study.

SETTING

Snoring clinic in Secondary Care Otolaryngology centre.

PARTICIPANTS

Ninety-three patients referred with disruptive snoring.

MAIN OUTCOME MEASURES

A structured history of upper aerodigestive tract symptoms was obtained by clinic interview. All patients underwent detailed ENT examination. Univariate analysis was undertaken on data collected.

RESULTS

The prevalence of oropharyngeal and laryngeal pathology in the cohort was 3%. No unsuspected upper aerodigestive tract pathology was found on routine flexible endoscopy. A history of Hard Nasal Symptoms was an accurate predictor of underlying nasal pathology.

CONCLUSION

The authors propose that the detailed examination of snorers by ENT specialists is unnecessary in the absence of Hard Nasal Symptoms, hoarseness or pain. We propose that a system of triage based on patient history could help identify the minority of snorers who require specialist assessment.

Effect of total nasal obstruction on nocturnal oxygen saturation

BACKGROUND

Nasal obstruction is considered a risk factor for sleep-disordered breathing (SDB), although the relationship has not been established clearly. This study explores the repercussion of total nasal packing on arterial oxygen saturation during the nocturnal resting hours and its implication in SDB.

METHODS

Forty patients were subjected to total nasal packing after nasal surgery or epistaxis. In all cases the oxygen desaturation index (ODI) was monitored with and without nasal packs, and the results were compared.

RESULTS

Thirty-seven patients (92.5%) showed poorer oxygen saturation after nasal occlusion. Of these, 19 patients (47.5%) reached pathological desaturation (ODI > or = 12). Desaturation was greater among obese subjects.

CONCLUSION

Total nasal packing causes significant nocturnal oxygen desaturation. This must be taken into account in the postoperative nasal packing of patients with respiratory failure, obesity, or SDB.

Nasal resistance and OSA

Letters regarding the paper “Epidemiological study of the structural alterations present in the nasal cavity associated to the obstructive sleep apnea syndrome (OSAS)”, published on the Brazilian Journal of Otorhinolaryngology 72 (4) July/August 2006. Paper available at: http://www.rborl.org.br/conteudo/acervo/acervo_english.asp?id=3258

[Adverse effects of continuous positive airway pressure therapy and its relation to the nose]

The main problem in the treatment of obstructive sleep apnea syndrome (OSAS) with nasal continuous airway pressure (nCPAP) is the lack of compliance. One of the most important reasons for no compliance is the adverse effects of this treatment. We analyse, prospectively, 182 patients treated with nCPAP in order to show the relationship between previous nasal problems and adverse effects of nCPAP. Sixty percent of the population developed one o more side effects. Of this group, 69% showed nasal septum deviation at first examination in front of 31% that did not showed this problem (p = 0.001). In the group of patients with nasal side effects we observed an increase of compliance in 80% of patients treated medically and in 89% of those treated by a septoplasty. We demonstrate that the adverse effects of nCPAP are related to previous nasal problems and, also, that treatment of those problems can achieve an increase in compliance to nCPAP therapy.

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.

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.

Systematic analysis of snoring in women

Nineteen percent of women are habitual snorers, yet most snoring studies report only on male snorers. The aim of this study was to identify the factors responsible for habitual snoring in women. Twenty-four snorers and 16 controls were studied prospectively in a special snoring clinic. Snorers were shorter (p = .005) and heavier (p = .001), and with greater body mass index (BMI: p < .001), collar size (p = .002), and submental skinfold thickness (p = .001) than controls. The area of the posterior pharyngeal wall visible on oral examination was smaller in snorers (p = .005). Acoustic rhinometry areas and volumes were similar in the two groups. Nasal flow-volume loops showed reduced expiratory (p = .01) and inspiratory (p = .07) flow in snorers. Inspiratory flow correlated inversely with nasal symptoms (p < .05). The factors that best predict habitual snoring in women are a high BMI, a high nasal symptom score, and heavy weight. Of these, BMI is the most powerful.