Machado CC, Haddad FLM
61
REVIEW ARTICLE
The role of the nose in obstructive sleep apnea
O papel do nariz na síndrome da apneia obstrutiva do sono
Carolina Cozzi Machado1, Fernanda Louise Martinho Haddad1
ABSTRACT
To evaluate the relationships between nasal obstruction and obstructive sleep apnea syndrome (OSAS), this report provides a simple review of the literature relating to this subject. Patients with
OSA have exhibited a higher frequency of nasal abnormalities compared to controls, suggesting that these alterations play some role
in the physiopathology of this disease. However, clinical or surgical
treatment of these abnormalities has been shown to be limited in
controlling OSAS. Nevertheless, nasal surgeries are capable of reducing therapeutic pressure levels for positive airway pressure devices; the real benefit of the nose procedures on the use of positive
airway pressure devices in the long term must be further assessed.
Nasal evaluation in patients who are candidates for the use of an
intraoral device is seldom discussed in the literature, and only one
study has reported a positive finding, opening the way for new studies with this focus. Thus, the nose takes on an important role in
OSAS; however, some aspects of its impact in the clinical and surgical treatment of OSAS still remain controversial.
Keywords: obstructive sleep apnea, nose, nasal obstruction.
RESUMO
Para avaliar a relação da obstrução nasal e a Síndrome da apneia
obstrutiva do sono (SAOS), foi realizada uma revisão simples da literatura acerca deste tema. Pacientes com SAOS apresentam maior
frequência de alterações nasais quando comparados a controles, sugerindo que esta exerça algum papel na fisiopatologia desta doença.
Porém, o tratamento clínico ou cirúrgico dessas alterações tem se
mostrado limitado no controle da mesma. Entretanto, as cirurgias
nasais são capazes de reduzir os níveis pressóricos terapêuticos do
aparelho de pressão aérea positiva, mas o real benefício na adesão
ao aparelho de pressão aérea positiva em longo prazo necessita ser
mais bem estudado. Já a avaliação nasal em pacientes candidatos a
uso de AIO é um assunto remoto na literatura e, apenas um trabalho nos mostrou um achado positivo, abrindo as portas para novos
estudos com esse enfoque. Como podemos ver, o nariz assume
um papel extenso na SAOS; porém, alguns aspectos de seu impacto no tratamento clínico e cirúrgico da SAOS ainda permanecem
controversos.
Descritores: apnéia do sono tipo obstrutiva, nariz, obstrução nasal.
INTRODUCTION
Obstructive sleep apnea syndrome (OSAS) is characterized by repeated episodes of reduced or complete
cessation of air flow during sleep, stemming from the
narrowing or the collapse of the pharynx, and is usually
associated with fragmentation of sleep and reduction in
oxy-hemoglobin saturation. OSAS affects approximately
2-4% of men and 1-2% of women in middle age(1-4).
However, the most recent epidemiological study
performed in the adult population of the city of São Paulo
showed a prevalence of OSAS of 32.9%(5). Young et al.(6)
reported that the prevalences of mild to moderate OSAS
are even higher, estimating that up to 26% of middle-aged
men show a minimally symptomatic form of the disorder.
Among other factors, the fragmentation of sleep
and the reduced saturation of oxy-hemoglobin associated
with these respiratory events contribute to the elevated
risk of developing high blood pressure and other cardiovascular diseases(7-9).
Risk factors for OSAS in adults include obesity,
masculine gender, craniofacial dysmorphism, hypothyroidism, and nasal obstruction(1,10-12).
According to Suman et al.(13), deviation of the nasal
septum and turbinate hypertrophy were the most commonly identified abnormalities in nasal anatomy, occurring in 78% and 28% of cases with OSAS and 73% and
45% of patients with primary snoring, respectively.
Various studies in the literature have correlated
chronic nasal obstruction and OSAS(11,12,14), but the role
of the nose in the physiopathology of OSAS is still a controversial topic in the literature. The aim of this report is
to evaluate the role of the nose in OSAS through a simple
review of the literature regarding this subject.
The role of the nose in the physiopathology of OSAS
The three main factors that contribute to the development of OSAS are the reduction of the strength of the
muscles responsible for dilating the pharynx, the negative
inspiratory pressure generated by the diaphragm, and the
anatomical alteration of the upper airway (UA)(15).
Nasal obstruction increases the negative inspiratory pressure and causes an alteration in the functional
dynamic of the UA due to the consequent oral respiration(15,16). This increase in the inspiratory pressure causes
the narrowing of the pharynx, which results in episodes
of apnea and hypoxia(15), indicating that the UA is similar
to the resistance model of Starling with a collapsible segment at the oropharynx(17).
Compared to oral respiration, nasal respiration is
more efficient because the nasal cavity possesses a resistance, which is almost constant, and the stimulation of the
Work done at Universidade Federal de São Paulo – UNIFESP, São Paulo (SP), Brazil.
1
Universidade Federal de São Paulo – UNIFESP, São Paulo (SP), Brazil.
Corresponding author: Fernanda Louise Martinho Haddad. Rua Dr. Diogo de Faria, 508. Tel.: 38152116 / 83542450. E-mail: [email protected]
Received: 11/04/2011. Accepted: 12/10/2011.
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The role of the nose in obstructive sleep apnea
nasal receptors by air influx activates the dilating muscles
of the pharynx (nasopharyngeal reflex)(18).
The most frequent etiologies for nasal obstruction
are septal deviation, turbinate hypertrophy, nasal polyps,
and nasal valve insufficiency.
According to the literature from epidemiological
studies, nasal congestion contributes to the pathogenesis
of OSA(4,16). However, when considering randomized and
controlled studies, it was not possible to establish a positive correlation between nasal obstruction and OSAS(4).
Various studies have shown that patients with
OSAS had higher frequencies of nasal alteration compared to controls(19). However, despite these studies, the
role of the nose in the physiopathology of OSAS is still a
matter of controversy(4).
THE IMPACT OF NASAL TREATMENT IN THE
TREATMENT OF OSAS
There are various procedures for the correction
of nasal obstruction: septoplasty, turbinectomy, polypectomy, radiofrequency ablation/cauterization of the turbinates, and, in cases of nasal valve insufficiency, nasal alar
reconstruction.
The use of nasal dilators, topical corticosteroids,
and nasal decongestants to reduce nasal resistance has
yielded only a small improvement in the symptoms and
severity of OSA(4).
In general, nasal surgeries are not curative, but they
are able to improve snoring and quality of sleep and to
reduce daytime sleepiness; additionally, they are frequently
used to address multiple obstruction sites(2,20).
However, in the absence of other significant anatomical abnormalities, the patients who most benefit from
correction of nasal obstruction as a single intervention are
likely those with mild forms of respiratory sleep disturbances, those with a low BMI, and those who are younger(2,18,20).
THE ROLE OF THE NOSE IN THE USE OF
POSITIVE AIRWAY PRESSURE DEVICES
The gold-standard treatment for OSAS is the use
of positive airway pressure devices; CPAP (continuous positive airway pressure) devices are the most frequently used.
A CPAP device consists of a continuous airflow
generator, which is connected to a nasal or oronasal mask
by a flexible tube and is tightly adjusted to the face. The
pressure generated in the mask is transmitted to the UA
of the patient, creating a pneumatic cushion in its interior that increases its latero-lateral diameter and dislocates
the soft palate in the direction of the base of the tongue,
which increases the sectional area of the pharynx(21).
Low compliance of patients to the use of positive
airway pressure devices has been the chief factor in the
lack of success with this type of device. When evaluated
subjectively, compliance to a CPAP device varies from
60% to 90%(22); however, when measured objectively using a device that measures the hours of use with pressure
in the mask (i.e., a pressure horimeter), this rate reaches
30% - 60%(23,24).
Because the interface between the positive airway
pressure device and the patient takes place through nasal and oronasal masks, the presence of nasal anatomical abnormalities can make use of the mask difficult. This
difficulty may be due to increased resistance to the passage of air, so that these patients need higher therapeutic
pressures, which are thus more uncomfortable. Alternatively, the difficulty may be because the patient breathes
predominantly through the mouth, with consequent leaks
of air, leading to removal of the device. Moreover, during
episodes of nasal obstruction, the pressure may become
subtherapeutic with residual symptoms. These factors can
all be disincentives for use of the device(25-28).
Nasal resistance caused by obstruction of the airway is reduced significantly by surgical treatment(20). Thus,
it is believed that with surgical correction of the nasal obstruction, the OSAS patient will have better compliance
to positive pressure therapy, whether because its use becomes more comfortable or because of a reduction in the
necessary level of pressure(2,20,29).
Some studies have shown that nasal surgery is capable of reducing therapeutic levels for a CPAP device(29-32);
Nakata et al.(31) reported a reduction in the therapeutic
pressure of the CPAP device from 16.8 ± 1.1 to 12.0 ± 1.9
cm H2O. However, only a single 11-patient study objectively evaluated compliance to CPAP treatment; it showed
an average increase of 48.6 minutes/night in the use of
the CPAP device after surgery(30).
The clinical studies that have used acoustic rhinometry and/or rhinomanometry to evaluate the noses of patients with OSAS and that have indicated treatment with
a positive airway pressure device are controversial with
respect to compliance. Some studies have found an association between area and nasal resistance and compliance
to CPAP treatment(26,27), and others have not(25). Haddad(33)
evaluated the nose through subjective measures (questionnaires), anatomical measures (rhinoscopy, nasofibroscopy,
and acoustic rhinometry), and functional measures (nasal
peak inspiratory flow) and did not identify an association
between these parameters and compliance to CPAP treatment over a six-month tracking period.
Although nasal surgery may be useful in the reduction of therapeutic pressure in patients who cannot tolerate the use of positive airway pressure devices, the existing
controversy between clinical studies suggests that the nose
is perhaps only a co-factor in the compliance to CPAP
treatment; thus, it is likely that the sum of these co-factors
is the determinant in compliance to treatment.
THE ROLE OF THE NOSE IN COADJUVANT
TREATMENT WITH INTRAORAL DEVICES
The use of intraoral devices for the treatment of
OSA has been shown to be another possible therapeutic
modality and is indicated principally for mild to moderate
cases of the disease, with an evidence level of I(2,34).
Various predictors of the success of the use of intaoral devices have been reported, such as age, sex, OSAS
related to sleeping in the supine position, the basal index
of apnea and hypopnea, abnormalities in the curve of
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Machado CC, Haddad FLM
flow and volume, and a series of craniofacial characteristics, such as long jaw, short soft palate, and reduced distance between the hyoid bone and the mandibular plane.
Because elevated nasal resistance may exacerbate or even
induce apnea in patients with OSAS, it is plausible that the
same elevated nasal resistance can negatively affect compliance to treatment with an intraoral devices. Further, elevated nasal resistance is associated with oral respiration,
which potentially limits the beneficial effects of treatment
with this devices(35).
Only one study in the literature has used rhinomanometry to evaluate the nasal cavity in patients using intraoral devices. Zeng et al.(35) showed that only the BMI
and the nasal resistance were significant predictors of success for the use of intraoral devices for advancing the jaw,
suggesting that the nose can interfere with the success of
this type of therapy. Moreover, there are no studies in the
literature that have studied the relationship between nasal
abnormalities and compliance to the use of intraoral devices(36-38).
Thus, this is area deserves further study, and as yet,
no conclusions can be made regarding this subject.
FINAL COMMENTS
Clearly, the nose plays an important role in OSAS,
whether in the physiopathology of the disease or in the
treatment, and the nose can work to attenuate the disease
or to facilitate the use of positive airway pressure devices
and intraoral devices.
In fact, patients with OSAS have higher frequencies
of nasal abnormalities compared to controls, suggesting
that these abnormalities play some role in the physiopathology of the disease. However, the clinical or surgical
treatment of these alterations has been shown to be of
limited use in the control of OSAS.
The nose is the point of entry for the upper airway
and serves as the interface between patients and positive
airway pressure devices, which is the principal modality
for the treatment of moderate and severe OSAS. Thus,
abnormalities in the nose can impede compliance to these
devices. Surgical studies have shown that it is possible to
attenuate therapeutic pressure levels for positive airway
pressure devices, which can make their use more comfortable, but studies that measure long-term compliance
are lacking. Further, the results studies performing nasal
evaluations for patients who were candidates for the use
of positive airway pressure devices are not conclusive.
Thus, we are only able to conclude that nasal surgeries can
reduce therapeutic pressure levels for positive airway pressure devices, but the real benefit for compliance to this
modality of treatment over the long term must be further
evaluated.
Nasal assessment in patients who are candidates for
intraoral devices is a topic rarely addressed in the literature;
only one study reported a positive finding, which demonstrates the need for new studies with this focus. This topic
is the most insufficiently studied line of research among
all of those that involve the nose and OSAS.
63
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