Ambulatory office visits and medical comorbidities associated with obstructive sleep apnea

Prevalence of Laryngeal Muscle Tension in Patients With Obstructive Sleep Apnea

OBJECTIVE/HYPOTHESIS

To determine the prevalence of laryngeal muscle tension in patients with obstructive sleep apnea (OSA).

STUDY DESIGN

Retrospective case-control.

METHODS

A total of 75 patients were included in this study. These were divided into a study group with a history of OSA (n = 45), and a control group with no history of OSA matched according to age and gender (n = 30). The risk of OSA was assessed using the STOP-BANG questionnaire. Demographic data included age, gender, body mass index, smoking, history of snoring, history of use of continuous positive airway pressure, and history of reflux disease. Symptoms such as hoarseness, throat clearing/cough, and globus sensation were also noted. The video recordings of the flexible nasopharyngoscopy of both groups were analyzed for the presence or absence of four laryngeal muscle tension patterns (MTPs).

RESULTS

Twenty-five patients of the study group (55.6%) had signs of laryngeal muscle tension on laryngeal endoscopy compared to nine in the control patients (30%) (P = 0.029). The most common MTP observed in the study group was MTP III (n = 19), followed by MTP II (n = 17). Laryngeal muscle tension was more prevalent in patients of the intermediate and high-risk categories compared to those of the low-risk category (73.3% and 62.5% vs 28.6%, respectively) (P = 0.042). Patients with at least one MTP had more dysphonia and throat clearing than patients without any MTP.

CONCLUSION

Patients with a history of OSA have a higher prevalence of laryngeal muscle tension in comparison to subjects with no history of OSA. Moreover, patients at high risk of OSA have a higher prevalence of laryngeal muscle tension than those at low risk of OSA.

Clinical characterization of patients with bipolar disorder and a history of asthma: An exploratory study

INTRODUCTION

Bipolar disorder (BD) and asthma are leading causes of morbidity in the US and frequently co-occur.

OBJECTIVES

We evaluated the clinical features and comorbidities of patients with BD and a history of asthma.

METHODS

In a cross-sectional analysis from the Mayo Clinic Bipolar Biobank, we explored the clinical characteristics of the BD and an asthma phenotype and fitted a multivariable regression model to identify risk factors for asthma.

RESULTS

A total of 721 individuals with BD were included. From these, 140 (19%) had a history of asthma. In a multivariable model only sex and evening chronotype were significant predictors of asthma with the odds ratios and 95% confidence intervals being 1.65 (1.00, 2.72; p=0.05) and 1.99 (1.25, 3.17; p < 0.01), respectively. Individuals with asthma had higher odds of having other medical comorbidities after adjusting for age, sex, and site including hypertension (OR = 2.29 (95% CI 1.42, 3.71); p < 0.01), fibromyalgia (2.29 (1.16, 4.51); p=0.02), obstructive sleep apnea (2.03 (1.18, 3.50); p=0.01), migraine (1.98 (1.31, 3.00); p < 0.01), osteoarthritis (2.08 (1.20, 3.61); p < 0.01), and COPD (2.80 (1.14, 6.84); p=0.02). Finally, individuals currently on lithium were less likely to have a history of asthma (0.48 (0.32, 0.71); p < 0.01).

CONCLUSION

A history of asthma is common among patients with BD and is associated with being female and having an evening chronotype, as well as with increased odds of having other medical comorbidities. A lower likelihood of a history of asthma among those currently on lithium is an intriguing finding with potential clinical implications that warrants further study.

Sleep Medicine Evaluation in the Annual Patient Management Problem (PMP) Exam for Otolaryngology Residents

The sleep medicine has not been previously included in the patient management problem (PMP) exam for otolaryngology residents at Tehran University of Medical Sciences. The aim of this study, is to evaluate the results of this first implementation. This was a cross-sectional study. The examinees included all 62 residents from the 1st to 4th years of the Tehran University of Medical Sciences otolaryngology department. The resident scores obtained in this exam were evaluated and compared by residency year. The overall participant score was low for this part of the PMP. There was no score difference between years 1 and 3, but there was a significant positive change in year 4 (p = 0.007). This score pattern was not evident in other parts of the exam. Otolaryngology residents have insufficient knowledge toward the sleep medicine. The reasons for such scoring patterns may be due to the structure of sleep medicine training within the department which may lead to undesirable consequences.

Asthma and Three Colinear Comorbidities: Obesity, OSA, and GERD

Asthma is a complex disease with heterogeneous phenotypes and endotypes that are incompletely understood. Obesity, obstructive sleep apnea, and gastroesophageal reflux disease co-occur in patients with asthma at higher rates than in those without asthma. Although these diseases share risk factors, there are some data suggesting that these comorbidities have shared inflammatory pathways, drive the development of asthma, or worsen asthma control. This review discusses the epidemiology, pathophysiology, management recommendations, and key knowledge gaps of these common comorbidities.

Impact of obstructive sleep apnea on assisted ventilation in children with asthma exacerbation

OBJECTIVE

To determine the impact of obstructive sleep apnea (OSA) on asthma exacerbation severity in children hospitalized for asthma exacerbation.

HYPOTHESIS

OSA is associated with greater use of invasive mechanical ventilation (IMV) and noninvasive mechanical ventilation (NIMV) in children hospitalized for asthma exacerbation.

STUDY DESIGN

A retrospective cohort study.

PATIENT-SUBJECT SELECTION

Hospitalization records of children aged 2-18 years admitted for acute asthma exacerbation were obtained for 2000, 2003, 2006, 2009, and 2012 from the Kids' Inpatient Database.

METHODOLOGY

The primary exposure was OSA, the primary outcome was IMV, and secondary outcomes were NIMV, length of hospital stay (LOS), and inflation-adjusted cost of hospitalization. Multivariable logistic regression, negative binomial, and linear regression were conducted to ascertain the impact of OSA on primary and secondary outcomes. Exploratory analyses investigated the impact of obesity on primary and secondary outcomes.

RESULTS

Among 564,467 hospitalizations for acute asthma exacerbation, 4209 (0.75%) had OSA. Multivariable regression indicated that OSA was associated with IMV (adjusted odds ratio [OR], 5.33 [95% confidence interval, CI: 4.35-6.54], p < .0001), NIMV (adjusted OR, 8.30 [95% CI: 6.56-10.51], p < .0001), longer LOS (adjusted incidence rate ratio, 1.34 [95% CI 1.28-1.43], p < .0001), and greater inflation-adjusted cost of hospitalization (adjusted β, 0.38 [95% CI: 0.33-0.43], p < .0001). Obesity was also significantly associated IMV, NIMV, longer LOS, and greater inflation-adjusted cost of hospitalization. There was no interaction between OSA and obesity.

CONCLUSION

OSA is an independent risk factor for IMV, NIMV, longer LOS, and elevated inflation-adjusted costs of hospitalization in children hospitalized for asthma exacerbation.

Asthma and Obstructive Sleep Apnea Overlap: What Has the Evidence Taught Us?

Obstructive sleep apnea (OSA) and asthma are highly prevalent chronic respiratory disorders. Beyond their frequent coexistence arising from their high prevalence and shared risk factors, these disorders feature a reciprocal interaction whereby each disease impacts the severity of the other. Emerging evidence implicates airway and systemic inflammation, neuroimmune interactions, and effects of asthma-controlling medications (corticosteroids) as factors that predispose patients with asthma to OSA. Conversely, undiagnosed or inadequately treated OSA adversely affects asthma control, partly via effects of intermittent hypoxia on airway inflammation and tissue remodeling. In this article, we review multiple lines of recently published evidence supporting this interaction. We provide a set of recommendations for clinicians involved in the care of adults with asthma, and identify critical gaps in our knowledge about this overlap.

Pilot study of the potential of 3D ultrasound to measure tonsillar volume and hypertrophy

OBJECTIVE

Obstructive sleep apnea (OSA), results in approximately 4-5 million outpatient visits per year in the United States. In pediatric patients, OSA is primarily caused by adenotonsillar hypertrophy, and therefore, adenotonsillectomy remains an effective surgical treatment. We investigate whether 3D ultrasound (3DUS) imaging can accurately and objectively assess tonsillar hypertrophy for the potential identification and stratification of candidates for adenotonsillectomy.

METHODS

A prospective study was performed evaluating pediatric patients (N = 17) between the ages of 4-14 years who were undergoing adenotonsillectomy for OSA symptoms. On the day of surgery, tonsillar ultrasound was performed by a single attending radiologist. Tonsillectomy was performed and each tonsils' principal axes and physical volume by water submergence were measured. The findings were compared using paired T-test, Pearson correlation coefficient and Bland-Altman analysis.

RESULTS

The average tonsillar physical measurements of length, width and height were 1.54 ± 0.28, 2.0 ± 0.31 cm and 2.72 ± 0.41 cm, and 1.73 ± 0.17, 1.61 ± 0.21 mm and 2.98 ± 0.28 mm from physical and 3DUS estimations, respectively (P < 0.001 for all measurements). The average tonsillar volume was 3.84 ± 1.23 ml and 4.30 ± 1.15 ml from physical and 3DUS measurements, respectively (p = 0.04). The Bland-Altman mean difference ± 95% limit of agreement between length, width, height, and volume results from the two measurements were -0.186 ± 2.01 cm, -0.393 ± 6.33 cm, 0.25 ± 7.71 cm, and 0.45 ± 2.32 ml, respectively.

CONCLUSION

While 3DUS is feasible, it may not be an accurate estimate of tonsillar volume for assessing hypertrophy. A larger study will be required to establish the accuracy of 3DUS measurements of tonsillar volume.

Impact of self-reported symptoms of allergic rhinitis and asthma on sleep disordered breathing and sleep disturbances in the elderly with polysomnography study

BACKGROUND

Sleep disordered breathing (SDB) and sleep disturbances have been reported to be associated with allergic rhinitis and asthma. However, population-based studies of this issue in the elderly are rare.

OBJECTIVE

To investigate the impact of self-reported rhinitis and asthma on sleep apnea and sleep quality using polysomnography in an elderly Korean population.

METHODS

A total of 348 elderly subjects who underwent one-night polysomnography study among a randomly selected sample were enrolled. Study subjects underwent anthropometric and clinical evaluations. Simultaneously, the prevalence and co-morbid status of asthma and allergic rhinitis, and subjective sleep quality were evaluated using a self-reported questionnaire.

RESULTS

Ever-diagnosis of allergic rhinitis was significantly more prevalent in subjects with SDB compared with those without SDB. Subjects with an ever-diagnosis of allergic rhinitis showed a higher O2 desaturation index and mean apnea duration. Indices regarding sleep efficiency were affected in subjects with a recent treatment of allergic rhinitis or asthma. Waking after sleep onset was longer and sleep efficiency was lower in subjects who had received allergic rhinitis treatment within the past 12 months. Subjects who had received asthma treatment within the past 12 months showed significantly lower sleep efficiency than others.

CONCLUSION

Our study indicates that a history of allergic rhinitis is associated with increased risk of SDB in the elderly. Sleep disturbance and impaired sleep efficiency were found in the subjects who had received recent treatment of allergic rhinitis or asthma. Physicians should be aware of the high risk of sleep disorders in older patients with respiratory allergic diseases.

Obstructive Sleep Apnea and Gastroesophageal Reflux: A Multivariate Population-Level Analysis

OBJECTIVES

Previous studies investigating the relationship between gastroesophageal reflux (GER) and obstructive sleep apnea (OSA) demonstrate mixed results and have had limited capacity to control for concurrent confounders. Our objectives were to (1) determine if GER is significantly associated with OSA when simultaneously adjusting for the presence of other potentially confounding conditions and (2) quantify the magnitude of any such association that exists.

STUDY DESIGN

Cross-sectional analysis of the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, 2005-2010.

SETTING

Ambulatory visits in the United States.

SUBJECTS AND METHODS

Adults with a diagnosis of OSA or GER and potentially confounding conditions were identified. Univariate and multivariate logistic regression analyses were performed, as well as sensitivity analyses based on increasingly narrow diagnostic definitions.

RESULTS

A significant positive association between GER and OSA was observed, which persisted after adjustment for age, sex, race/ethnicity, sinonasal obstructive and inflammatory disorders, laryngopharyngeal obstructive and inflammatory disorders, obesity, asthma, and lung disorders. This positive association remained significant regardless of diagnostic criteria, whether broad (odds ratio: 1.94, 95% confidence interval: 1.07-3.54, P = .030) or narrow (odds ratio: 2.13, 95% confidence interval: 1.17-3.88, P = .014).

CONCLUSION

In this analysis of a national database defining the 3 most prioritized diagnoses, GER is independently associated with OSA, with double the odds of concurrent occurrence, even while controlling for potentially related conditions.

Risk of Cerebrovascular Diseases After Uvulopalatopharyngoplasty in Patients With Obstructive Sleep Apnea: A Nationwide Cohort Study

Little was known about the beneficial effects of uvulopalatopharyngoplasty (UPPP) on the outcomes after obstructive sleep apnea (OSA). The aim of this study is to investigate the effects of UPPP on reducing risk of cerebrovascular diseases in patients with OSA.Using Taiwan's National Health Insurance Research Database, we conducted a retrospective cohort study of 10,339 patients with new OSA between January 1, 2004, and December 31, 2009. The incident cerebrovascular disease was identified during the 1-year follow-up period in patients with and without receiving UPPP. The rate ratios (RRs) and 95% confidence intervals (CIs) of cerebrovascular disease associated with receiving UPPP in patients with OSA were calculated in multivariate Poisson regression.The 1-year incidences of cerebrovascular disease for OSA patients with and without UPPP were 1.06% and 5.14%, respectively. Patients with OSA receiving UPPP had lower risk of cerebrovascular disease compared with those without UPPP (RR, 0.45; 95% CI, 0.33-0.61). The decreased risk of cerebrovascular disease following UPPP was observed in both sexes and all age groups. In the stratified analysis of medical conditions, the RR of cerebrovascular disease associated with UPPP for patients with 0, 1, ≥ 2 medical conditions were 0.28 (95% CI 0.12-0.68), 0.39 (95% CI 0.21-0.73), and 0.63 (95% CI 0.43-0.93), respectively.Patients with OSA who received UPPP had lower risk of cerebrovascular disease within 1 year after surgery compared with patients not receiving UPPP. Clinical physicians could have more evidence to persuade patients to receive surgical intervention, especially those who have severe OSA symptoms or do not acquire adequate symptom relief under conservative treatments.

Obstructive sleep apnea in infancy: a 7-year experience at a pediatric sleep center

PURPOSE

To investigate the common indications for polysomnogram (PSG) associated co-morbid conditions, evaluation strategies, treatment options, and outcomes in a series of infants diagnosed with obstructive sleep apnea (OSA) by a PSG.

METHODS

Retrospective chart review of infants who underwent PSG over a 7-year period was done. Infants with PSG diagnosed OSA were included in this study.

RESULTS

A total of 97 infants (59 males, mean age 4.6 months, standard deviation 3.3 months) were diagnosed with OSA (AHI ≥ 1/hr) based on PSG. The most common indication for PSG in infants were excessive snoring (53%) followed by nocturnal desaturations (24%). Associated co-morbid conditions included gastro-esophageal reflux (30%), laryngomalacia (24%), and craniofacial abnormalities (16%). Genetic abnormalities were found in 53%, of which trisomy 21 was the most common. Surgical treatments were employed in 36% and oxygen therapy in 15%. Thirty-eight patients were followed up with a repeat sleep study after a median interval of 8 months (range 1-24 months), of whom 26/38 had resolution of symptoms. Twenty-seven patients (28%) were followed clinically after a mean interval of 5 months of intervention (range, 1-34.5 months), in whom the symptoms resolved in 23/27 patients. Seven patients were deceased at review. Causes of death included status epilepticus, respiratory failure, hepatic failure, kidney failure, or unknown causes.

CONCLUSION

The etiologies of OSA in infants are different when compared to older children. PSG is feasible and a valuable tool in the diagnosis of OSA in infants and may help determine timely and appropriate evaluation and interventions. Clinical improvement in symptoms and resolution of PSG parameters were noted following medical and/or surgical interventions. Prospective studies need to be done to ascertain the long-term outcome of infants diagnosed with OSA to assess the benefits of early intervention on their neurocognitive development.

Clinical Implications of Impaired Sleep

Despite its pervasiveness in primary care, deficient sleep often is underappreciated as a cue to other health risks. Accordingly, this review discusses contemporary evidence-based perspectives on impaired sleep and its associations with other lifestyle medicine concerns, including obesity, cardiovascular conditions, psychological problems, and health-compromising habits. The potential clinical benefits of promoting sleep health also will be considered.

Swallowing Disorders in the Ambulatory Medical Setting

Objectives

The aims of this cross-sectional study were to explore the nationwide number and demographics of patient visits due to dysphagia and to investigate potential differences in their management between otolaryngologists and other physicians in the outpatient setting.

Study Design

Cross-sectional.

Setting

National Ambulatory Medical Care Survey.

Subjects and Methods

The data sets from 2007 to 2010 were queried to extract all cases with dysphagia as a reason for visit. Data regarding demographics, imaging studies, nonmedication therapies, diagnoses, medications, and patient disposition were compared between otolaryngologists, primary care physicians, and other specialists.

Results

Annually, 1,875,187 (95% confidence interval [CI], 1,443,876-2,307,204) outpatient visits were due to dysphagia, comprising 0.19% of all visits (95% CI, 0.14%-0.23%) and 1.55% (95% CI, 1.10%-2.0%) of the visits to otolaryngologists. The visits were mostly distributed between primary care physicians and other specialists, while 16.4% (95% CI, 11.3%-21.6%) visited an otolaryngology office. Otolaryngologists, primary care physicians, and other specialists ordered imaging studies in 22.8%, 10.2%, and 24.0% ( P = .02); performed aerodigestive-specific procedures in 20.8%, 4.0%, and 36.2% ( P < .0001); and referred the patient to another physician in 5.8%, 14.8%, and 2.8% ( P = .003) of the visits, respectively.

Conclusions

Almost 0.2% of office visits to physicians have a complaint of dysphagia. Otolaryngologists are involved in the care of a minority of these visits. The differences in the management of dysphagic patients may be due to different etiologies of the disease.

Obstructive sleep apnea and asthma: associations and treatment implications

Obstructive sleep apnea (OSA) and asthma are highly prevalent respiratory disorders and are frequently co-morbid. Risk factors common to the two diseases include obesity, rhinitis, and gastroesophageal reflux (GER). Observational and experimental evidence implicates airways and systemic inflammation, neuromechanical effects of recurrent upper airway collapse, and asthma-controlling medications (corticosteroids) as additional explanatory factors. Therefore, undiagnosed or inadequately treated OSA may adversely affect control of asthma and vice versa. It is important for clinicians to be vigilant and specifically address weight-control, nasal obstruction, and GER in these populations. Utilizing validated screening instruments to affirm high risk of co-morbid OSA or asthma in persistently symptomatic patients will allow clinicians to cost-effectively test and treat appropriate patients, potentially improving outcomes. While non-invasive ventilation in acute asthma improves outcomes, the role of chronic continuous positive airway pressure (CPAP; the first-line treatment for OSA) in improving long-term asthma control is not known. Future research should focus on the impact of optimal CPAP therapy and adherence on asthma symptoms and outcomes.