The role of nasal pathologies in Obstructive Sleep Apnea Syndrome
By: Alberto Caranti
Tags: Surgery, Health, Medicine, Osa, Doctors

The role of nasal pathologies in Obstructive Sleep Apnea Syndrome

Obstructive Sleep Apnea Syndrome (OSAS) is a pathological condition for which the patient, during sleep, accuses episodes of apnea or hypopnea due to the collapse of the pathways upper airways, with repercussions on sleep quality, which induce daytime sleepiness, increased cardiovascular risk, cognitive deficits, increased medical care and increased car accidents.

Speaking of the upper airways, it is then instinctive, of course, to think at the nose, our olfactory pyramid through which, in health and well-being, we perform peaceful breathing. The nose is the physiological entrance port of the inspired air and the nasal cavities fulfill the natural role of the upper respiratory tract. When the nose is blocked it becomes necessary to breathe through the mouth, with an impact on the stability of the upper airways and a possible role in the pathogenesis of OSAS.

Although it is still a debated topic, several authors argue that being forced to breathe through the mouth, patients suffering from nasal obstruction can go to improperly stress the tissues of the upper airways, such as the palatine veil or the mucous membrane of the pharynx, with mechanical stimuli that would destabilize these ways, generating first snoring and then the actual obstruction, with the resulting apnoic episodes.

An established method for assessing when the nasal cavities are blocked is nasal manometry (or rhinomanometry), a study that allows to evaluate the air resistance present within the same airways. If the pressure normally in force is between 0.1 and 0.3 Pa / cm2/ s, when higher than 0.3 it is considered frankly pathological

What are the causes that can lead to nasal respiratory obstruction? They are basically three:

1. Anatomical conditions: deviation of the nose, hypertrophic inferior turbinates;

2. Chronic rhinosinusitis: condition that must comply with the EPOS classification, i.e. the presence of two or more symptoms including a sensation of bilateral nasal obstruction, nasal secretions, pain in the face or head, subjective olfactory dysfunction, for at least 12 consecutive weeks without ever having a complete resolution of the picture;

3. Nasal inflammations: where we mean allergic and non-allergic conditions such as NAR pathologies (non-allergic cell rhinitis).

A recent prospective study conducted between the Morgagni Pierantoni Hospital in Forlì and the Sapienza University of Rome has sought to better understand the correlations between nasal obstructions and OSAS. The study carried out showed that about 80% of patients suffering from sleep apnea are also affected by nasal obstructions: 30% anatomical conditions, 6% chronic rhinosinusitis, 18% allergic rhinitis and 26% NARs.

It is even more interesting to evaluate how in the case of patients suffering from obstruction attributable to anatomical defects they experience a sense of nocturnal obstruction in 50–60% of cases, in the case of obstructions from inflammatory rhinitis the percentage rises to about 95% of cases . This is justifiable if you think that in these contexts, the body releases inflammatory and interleukin mediators in large quantities, as well as patients who, due to inflammation and vascular congestion of the mucous membrane, are very affected by the position of decubitus.

One fact that is unsettling is that there is no significant difference between patients with obstruction of the nasal passages and patients without in terms of AHI (main reference value for calculating the severity of the syndrome). These data do not yet find a complete agreement in the literature.

In conclusion, given the high incidence of nasal obstructions in OSAS patients, a rhinological evaluation should always be carried out in these patients, carefully distinguishing patients suffering from inflammatory pathology from those with anatomical anomalies. Resolving the rhinological problems in these patients appropriately could in fact improve their subjective symptoms as well as compliance with therapies such as c-PAP.

REFERENCES:

Magliulo G. et al. – Nasal pathologies in patients with obstructive sleep apnoea – Acta otorhinolaryngologica italica 2019, 25: 1–6