Sleep Apnea Syndrome Treated by Repair of Deviated Nasal Septum

Sleep

Apnea

Deviated

Dov

Heimer,

and

Peretz

Syndrome

Treated

Nasal Septum*

M.D.;

Steven Ph.D.

Lavie,

M. Scharf

M.D.;

Alberto

by Repair

Lieberman,

M.D.;

Sleep apnea syndrome (SAS) often presents a difficult therapeutic problem to the clinician since many of the accepted modes of therapy are associated with only partial success or with a number of long-term complications. We

deviated

nasal

associated

with

present

dra-

cation,

we propose

of a

further

evaluated

three

matic

S

patients

clinical

leep

improvement

apnea

apnea

SAS

in whom

occurred

following

repair

(SAS) during

112 in non-REM

than sleep

obstructive

syndrome

recurrent

stages

with

is

characterized

sleep,

sleep.

by

primarily

The

apnea

during lasts

more

10 seconds and occurs more than 30 times per period.’ Clinically, there is heavy snoring during

sleep,

excessive

lectual

daytime

capacity,

obesity. which

and

There are all breathing

somnolence,

decreased

in approximately three eflbrts

types cease;

intel-

cases, central, in in which

breathing efforts continue, but air flow ceases as a result ofupper airway obstruction; and mixed, in which central-type apnea evolve into the obstructive type. The

apneic

emia weight

episodes

are

often

associated

with

and

respiratory

and

gesterone,4

stimulants

protryptyline.’

such

However,

poor

patient

fraught only

cooperation.

Long-term

with

complications,6

partially

successful.4”

therapy must We present whom

dramatic repair

was and

standard

night

gram,

and

scored

Fmm

the

and

Throat,

Sciences, Laboratory, Manuscript

184

Variables

sleep

by the

of

SAS

in

follow-

This

clinical

a decrease

episodes

measured

recordings measured

ofa

Division

Soroka

study.

in a

were

criteria.7

strain

ofLung

gauge Diseases,

Medical

from

seven

hours.

electrooculo-

the

sternocleido-

Sleep

stages

movements belt

and Department

tied

around ofEar

The

in

that

repair

of a deviated

as a mode

nasal

of therapy

septum

be

for this condition.

thorax, and air flow at the nose and mouth was detected by use of nasal and oral thermistors. Each patient underwent a complete ear, nose, and throat examination. The extent ofobstruction to the nares was estimated clinically. Nasal

septal

performed

repair under

ments

was local

done

underwent

of forced

by

lung

expiratory

responsiveness

a standard

submucosal

function

flows,

testing

lung

including

volumes,

measure-

and

ventilatory

to CO,.

1

CASE

A 56-year-old pulmonary

man

clinic

of European

because

extraction

ofcontinually

deviated

septum,

function

testing

episodes

imately

and was

a normal

A sleep

with

of the

asleep

system.

study

an average apneas

revealed

duration

were

to the

at his job

and

revealed: weight-.ll0 of the right nostril by a

cardiopulmonary

normal.

of apnea

60 percent

was referred

falling

loud snoring at night. Physical examination kg, approximately 80 percent obstruction

300

resection

anesthesia.

Pulmonary approximately

of 25 sec. Approx-

peripheral.

The

patient

was

unable to follow a weight reduction diet. A six-week trial of therapy with medroxyprogesterone acetate (80 mg a day in four divided doses)failed tolead to clinical improvement. Fullpatencyofthe right nostril

was

patient

noticed

restored

almost

complete

following

a marked

repair

clinical

disappearance

septum.

The

improvement

of the

deviated

in his symptoms

with

of his daytime

somnolence.

Repeat

sleep study

eight weeks fullowing surgery showed that the number of apneas was now 106 per sleep period with an average duration of 15 sec. At the time of his sleep study he was receiving no medication and his weight was unchanged. 2

A 44-year-old man of North pulmonary service complaining of the

frequent

napping,

worker.

impotence.

Physical

obstruction

ofthe

African origin presented to the of excessive daytime sleepiness.

He

he was

also

had

examination left nostril,

forced

loud

revealed: and

a normal

to quit

his job

nightime

snoring,

weight-119

kg,

as a

and

complete

cardiopulmonary

system.

function testing was normal. The patient could not follow adiet, and an eight-week trial ofmedroxyprogesterone(80 mg/day in four divided doses) failed to lead to clinical improvement. Sleep study revealed 290 apneas per sleep period with an average duration Pulmonary

EEG,

Respiratory respiratory

in the

septum.

a diminution

lower

construction

were performed

included

(recorded

periods

to standard use

sleep

CASE

in the

METHODS

AND

electromyogram

according

detected

is at best

occurred

obstructive

Because

polysomnographic

the

is

study.

way.

mastoid);

of

modes

documented

with

ofapneic

MATERIALS

conventional

therapy

septum.

associated

duration

sleep

Whole

with nasal

of therapy.

because

alternate

improvement

of a deviated

improvement number

and drug

clinical

are

tracheostomy

Thus,

be sought. three patients

as pro-

there

major difficulties with each ofthese modes Weight loss by diet is often unsuccessful

mg

hypox-

and arousals. ‘Theatment modalities include: loss,2 tracheostomy to bypass the upper airway

obstruction,’

subjective improvement was the number and duration of apnea episodes as observed during a standard Because ofits simplicity and low rate of compli-

All patients

half the

of apnea: peripheral,

of

were

were the Nose

Center, and Faculty of Health Ben Gurion University of Negev, Beersheba, and Sleep Technion, Haifa, Israel. received December 6; revision accepted March 28.

of 25

sec,

mucosal nearly

80

complete

of surgery,

of which of the

patient

A repeat that

the

number

Sleep Apnea

were

deviated

patency

the

somnolence. showed

percent

resection

ofthe noted sleep

left

peripheral.

septum, nasal

passage.

a marked study

ofapneas

Syndrome

done per

diminution six months sleep

and Deviated

Following

examination

period

Nasal

Within

two

of the following had

Septum

subrevealed weeks

daytime surgery

decreased

(Helmarat

to

a!)

40

with

an

resumed

average

duration

a normal

of 15 sec.

working

His

weight

tion

and he was taking

remained

By

that

life and his sexual

essentially

the

time,

function

same

the

patient

to apneas

had returned.

as at the

initial

examina-

no medications.

3

CASE

A 40-year-old

diabetic

man

ofNorth

African

origin

was

the pulmonary service because of severe nighttime excessive daytime sleepiness to the point ofinterfering as a glass

worker.

obstruction Sleep

ofthe

study

duration

showed

weeks

patient

all of which

sec,

study

were

71 kg and A further

of note

to be nasal

pattern

was

ofair

his

is that

in the

per

two to

septum,

the

somnolence. surgery

sleep

showed

period,

sleep

study,

most

of

his weight

no medication.

all

nasal

an average

daytime

repeat

on the

complete

Within

following

receiving

breathers

flow

ofthe

with

of the

40 apneas

time

patient

point

observed

only

At the

the

in

and

system.

peripheral.

resection

12 months

with

central.

period

were

diminution

performed

70 kg;

cardiopulmonary

sleep

submucosal

improvement

which

per

to

with his work

weight,

and a normal

apneas

dramatic

sleep

dramatic

the

350

following

noted

Repeat

revealed:

left nostril;

of 40-50

three

was

Examination

referred

snoring,

three

of these

sleep

and

patients

examination

mouth

were

as shown

by

thermistors.

three

SAS

patients

described

here

complained

ofobstructed

symptoms.

In

two,

breathing weight

or any

loss

and

other

disturbances

during

sleep.

sleep.8

Simons

et al9 described

with

nasal

which

nasal

three

septum

other

authors normal nares.

Zwillich

showed

an

complete

in the

nonapneic

subjects under same laboratory’3 sleep

the from

apneic

(nasal septal etc). Several

the repair

two possibilities:

upper

that

improvement following nasal

nasal airway

there

obstruction

in of

in symptoms septal repair. in SAS could

the case,

a nasal

as opposed to the

at least lead

then to oral

develop-

All three of our patients during their sleep stud-

of SAS be

is its very

low

performed

rate

under

of

local

even partial success may the need for other modes

evaluated

as a form

of symptomatic C, Ann

2 Fairman

sleep

‘fllkian

Rev

A,

Med

RP, Sugerman obesity.

nasal

be of

therefore, septum

oftherapy

apnea

Intern

Med

4 Sulton

FD,

patient

al.

in the

syndrome.

1981;

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The

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apnea

27:465-84

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B, MottaJ,

Obstructive

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125:108

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CurnmiskeyJ,

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and

Roskind

M,

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141:985

Zwillich

CW,

treatment

1975;

Rev

Simmons et

Dement

1976;

HJ. Gastroplasty

Am

J,

Creagh

CE.

of Pickwickian

Progesterone

syndrome.

for

Ann

out

Intern

Med

83:476-79

5 Conway

W,

airway

Roth

sleep

6 Conway

T, Zonick

apnea.

WA,

et al.

Victor

Adverse

F

Am

Rev

LD,

Donald

effect

Protryptyline

Respir

therapy

J,

for

1982; 125:102

Dis

J,

Magilligan

of tracheostomy

for

Fugita

SAS.

upper

(suppl) S, Zorick

JAMA

1981;

246:347 7 Rechtchaffen

A, Kales

techniques

and

Washington

1975; FB, FB,

and

prolonged

Rev

Respir

Lavie

14

and

Lavie

P, AIroy

Mathew pressure

J

AppI

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by

apnea.

upper

WC,

‘.fllkian

obstruction

airway

A, Hill

during

FN,

Weil

JV.

obstruction

J, Eliaschar

occlusion

breathing

in sleep.

G,

Halpern

Israel

OP, Abu-Osba Physiol

sleep

caused

Dement

airway

Hanson

N, Jomer

in sleep. changes

prolonged

N.

sleep.

Disturbed

in normal

sleep men.

Am

124:158

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(in press)

and

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Pickett

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Laryngoscope

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of standardized

for sleep

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(NIH

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10

A. Manual

scoring

DC

9 Simons

abnormality

are

to a greater

were

predispose

can

it

Furthermore, and obviate

syndrome.

physi-

of improvement septum,

lead

the

the presnegative

with direct mechanical effects of production of apneas. of repair of a deviated nasal

treatment and

be further

FJ,

Data from the in two-thirds

airway

that

airway and more

could

during sleep. nasal breathing

in the

upper

REFERENCES

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period

the

Ifthis

would

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in the

patients,

an upper

expected

Schroeder

hypertrophy of the adenoids, patients, ie, those suffering from

mechanism of the

septum

Several

an increase sleep

hypersomnolent

during sleep, study was noted

Regarding

and

possibly

increases become

This

ies, which is consistent as being the mechanism A potential advantage

of microarousals the

circumstances. demonstrated

revealed deviation, of these

during

of

closure.

pattern

ment of apnea demonstrated

in the number of apneic occlusion. Lavie et al” number

be

breathing

3 GuilleminaultC,

suc-

condition SAS.

a decrease

breathing time

these also

cal examination

hypopneas and sleep

nasal

of awake

would

it

sleep disturbances occur in temporary occlusion of the

and an increase

with

amount

of their

improve

et al” demonstrated

increase

associated

following

not

have found that subjects following

depth ofsleep episodes with

the

did

patients’#{176} suffering

for airway

morbid

cessfully treated with submucosal resection. However, data from a post-surgery sleep study were not provided. The same authors also reported that repair of the

to atmospheric.

treatment

was

mechanisms,

for airflow upper airway

tendency

of hypersomnia

deviation

obstruction

gradient within the

relative

should

Nasopharnygitis

a case

septal

sures

with

in children, for instance, is associated with an increase in the frequency and duration of apneic spells during associated

pressure

nasal

treatment

reflex

treatment. On the basis ofour observations, we recommend that repair of a deviated

medroxyprogesterone acetate was unsuccessful. There are a number of reports in the literature describing an association between upper airway obstruction and breathing

effects-with

anesthesia. worthwhile

responded

and objectively to repair of a deviated nasal It should be noted that none ofthese patients

clinically septum.

disturbed

complication

DISCUSSION

The

via

trigeminally or vagally mediated, which normally act to preserve airway patency in the presence of negative pressure in the upper airway;’4 and direct mechanical

on

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nasal Otolaryngol and

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and sleep

(Stockholm)

non-apneic

breathing

18:523-33

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muscle

ofpartial

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ofupper

respiratory

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I 84 I 2 I AUGUST,

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185