Fernanda Louise Martinho Haddad

Use of Muller's maneuver in the evaluation of patients with sleep apnea: literature review

Sleep apnea-hypopnea syndrome was described twenty years ago, and since then there have been doubts and controversies regarding it. Fiberoptic nasopharyngosc...

Systematic Evaluation of the Upper Airway in the Adult Population of São Paulo, Brazil

Objectives. To study the prevalence of otorhinolaryngologic symptoms and findings of physical examination of the upper airway (UA) of a representative sample of the adult population of São Paulo, Brazil, and the association between these findings. Study Design. Cross-sectional survey. Setting. Population sample. Methods. A total of 1101 randomly selected volunteers representing the adult population of São Paulo according to sex, age, and socioeconomic class were included in this study. Otorhinolaryngological evaluation included investigation of nasal complaints, physical examination of the UA, and a facial inspection. Results. A total of 993 volunteers (53.9% women), with a mean age of 41.8 ± 0.89 years, underwent otorhinolaryngologic examination. The most prevalent symptoms were the following: symptoms suggestive of rhinitis (44.9%), snoring (42.8%), mouth breathing (39.3%), and nasal obstruction (33.3%). In physical examination, the most common findings were a web palate (redundant posterior pillar; 62.9%), septum deviation (56.9%), and inferior turbinate hypertrophy (37.7%). Significant associations were found between nasal obstruction and septum deviations, inferior turbinate hypertrophy, high-arched palate, and class II dental occlusion; between symptoms of rhinitis and inferior turbinate hypertrophy; and between snoring and obstructive deviated septum, modified Mallampatti grades III and IV, increased neck circumference, and age greater than or equal to 50 years. Conclusions. The prevalence of otorhinolaryngologic symptoms and alterations in physical examination of the UA were high in the adult population of São Paulo, Brazil. The snoring and nasal symptoms were significantly associated with findings from UA physical examination and inspection of the facial skeleton.

Systematic Evaluation of the Upper Airway in a Sample Population Factors Associated with Obstructive Sleep Apnea Syndrome

Objectives To investigate the anatomy of the upper airway (UA) of a representative sample of the adult population of São Paulo city, Brazil, and to identify factors associated with the presence of obstructive sleep apnea syndrome (OSAS), as confirmed using full-night polysomnography (PSG). Study Design Cross-sectional study. Setting Population-based sample. Methods A 3-stage sampling procedure was used to proportionally recruit adult residents of São Paulo city according to gender, age, and socioeconomic status. A complete evaluation was performed, including a systematic evaluation of the UA prior to conducting PSG. Results Nine-hundred ninety-three (90.2%) of the participants were seen by an ear, nose, and throat (ENT) specialist. Individuals who were diagnosed with OSAS (32.9%) presented a higher frequency of nasal symptoms and structural abnormalities (both nasal and oropharyngeal) compared with those without OSAS. No anatomical differences were observed in the facial skeleton. An abnormal nasal structure visible via anterior rhinoscopy was the only UA factor predicting OSAS after adjustments for the other common OSAS risk factors (male sex, aging, obesity, and increased neck circumference). Conclusion This is the first study in which a systematic evaluation of the UA was followed by a sleep study in a population-based sample. In a sample of the general population that had not previously been screened for OSAS, having an abnormal nasal structure was found to be a risk factor for OSAS, in conjunction with other well-established clinical and demographic factors, such as male gender, increased age, increased neck circumference, and body mass index.

Acute impact of continuous positive airway pressure on nasal patency: Acute impact of CPAP on nasal patency

Continuous airflow in the upper airway can cause discomfort, leading to nasopharyngeal complaints. The aim of the present study is to evaluate the acute effects of continuous positive upper‐airway pressure on nasal patency in awake normal subjects.

The influence of nasal abnormalities in adherence to continuous positive airway pressure device therapy in obstructive sleep apnea patients. What role does the nose play

The role of the nose in obstructive sleep apnea (OSA) is a controversial topic in the literature. The comments made regarding the pathophysiology that exists between the nose and OSA are relevant and important. However, prior research shows that the treatment of nasal abnormalities can improve sleep quality but has limited impact on improvement of OSA. With regard to adherence to air pressure devices, there is a consensus in the literature that nasal surgery is able to decrease therapeutic continuous positive airway pressure (CPAP) pressure [1–4], which could make its use more comfortable and improve adherence. But in fact, only one study showed a significant mean increase of 48.6 min in use of CPAP after surgery [4]. Studies following nasal surgery that measure mediumand long-term adherence are still needed. Another relevant point is that the role of the nose on adherence to CPAP is controversial in the literature. Tarrega et al. [5] found no association between the findings of rhinomanometry and adherence to CPAP, demonstrating results similar to those found by Haddad et al. [6]. On the other hand, Morris et al. [7] and Sugiura et al. [8] found associations between nasal findings and CPAP adherence. So et al. [9] found an association when evaluating patients with a lower apnea-hyponea index, but found no association for the whole group of study subjects. There are two main factors that limit the ability to demonstrate the role of the nose on adherence to CPAP. One is the difficulty in determining an ideal method for the evaluation of nasal function [10]. A second is the fact that adherence to CPAP is multifactorial and not solely dependent upon nasal matters. Further studies that evaluate the nasal function of patients who are non-adherent to CPAP are needed. Adherence to any kind of treatment depends on the sum of the individual approaches to many small factors, and the nose is one of them.

Clinical and polysomnographic predictors of laryngopharyngeal reflux in obstructive sleep apnea syndrome

INTRODUCTION Obstructive sleep apnea syndrome and laryngopharyngeal reflux are diseases with a high prevalence in the overall population; however, it remains unclear whether they are diseases with the same risk factors present in the same populations or if there is any association between them. OBJECTIVES To evaluate and determine the prevalence of laryngopharyngeal reflux in patients with moderate and severe obstructive apnea syndrome and also to determine its predictive factors. METHODS Historical cohort, cross-sectional study of patients aged 18-70 years, referred to a tertiary service Otorhinolaryngology outpatient clinic with a polysomnographic diagnosis of moderate or severe obstructive sleep apnea syndrome. The reflux symptom index questionnaire and the reflux finding score at indirect videolaryngoscopy were applied to the assessed population, considering the inclusion and exclusion criteria. RESULTS Fifty-six patients were evaluated, of which 64.3% had a positive laryngopharyngeal reflux (positive reflux symptom index and/or positive endolaryngeal reflux finding score). Body mass index was a predictor of reflux presence in this group of patients with moderate to severe obstructive sleep apnea syndrome. In patients with positive score for endoscopic findings and reflux symptom index (12.3%), there was a trend toward significance for a higher mean apnea-hypopnea index and a higher percentage of sleep time with oxyhemoglobin saturation below 90% (p=0.05). CONCLUSION The prevalence of laryngopharyngeal reflux was higher in this group of patients with moderate to severe obstructive sleep apnea syndrome, and the body mass index was a predictor of laryngopharyngeal reflux in these patients. There was a trend toward greater oxyhemoglobin desaturation in patients with a positive score for reflux symptoms index (RSI) and reflux finding score (RFS).

Impact of upper airway abnormalities on the success and adherence to mandibular advancement device treatment in patients with Obstructive Sleep Apnea Syndrome

INTRODUCTION The mandibular advancement device (MAD) is a option to treat patients with Obstructive Sleep Apnea Syndrome (OSAS). OBJECTIVE To assess the influence of upper airway abnormalities on the success of and adherence to MAD in patients with OSAS. METHODS Prospective study with 30 patients with mild to moderate OSAS and indications for MAD. The protocol included questionnaires addressing sleep and nasal complaints, polysomnography, and upper airway assessment. The analyzed parameters of patients who showed therapeutic success and failure and those who exhibited good and poor treatment adherence were compared. RESULTS 28 patients completed the protocol; 64.3% responded successfully to treatment with MAD, and 60.7% exhibited good adherence to treatment. Factors associated with greater success rates were younger age (p=0.02), smaller cervical circumference (p=0.05), and lower AHI at baseline (p=0.05). There was a predominance of patients without nasal abnormalities among patients treated successfully compared to those with treatment failure (p=0.04), which was not observed in relation to adherence. Neither pharyngeal nor facial skeletal abnormalities were significantly associated with either therapeutic success or adherence. CONCLUSION MAD treatment success was significantly lower among patients with nasal abnormalities; however, treatment adherence was not influenced by the presence of upper airway or facial skeletal abnormalities.

Clinicals And Upper Airway Characteristics in Obese Children with Obstructive Sleep Apnea

Introduction Obesity is a factor that is strongly related to the occurrence of obstructive sleep apnea (OSA) in adults, although this association remains controversial for children. Objective The aim of this study was to compare the clinical and upper airway charactheristics, obtained by questionnaires, physical examination and laboratory tests, among obese children with and without OSA. Method This was aprospective cohort study. 44 obese children (body mass index above the 95th percentile) were included in the study. Questionnaires, physical examination of the upper airway, nasofibrolaryngoscopy, polysomnography, and laboratory allergic tests were performed. Results There were 22 male patients (50%), and the mean age was 7.6±2.5 years. OSA was present in 19 (43%) patients. There were no statistically significant differences between the groups with and without OSA, in relation to clinical or laboratory allergic parameters. For the upper airway assessments, hypertrophy of the pharyngeal (p=0.001) and palatine (p=0.049) tonsils were the only parameters associated with OSA, and a modified Mallampati index of class III/IV also demonstrated a tendency towards being statistically associated with OSA (p=0.081). Moreover, these findings were confirmed to be factors associated with OSA in this group of children according to a logistic regression analysis. Conclusions The occurrence rate of OSA in this obese pediatric population was high. Adenotonsillar hypertrophy and a modified Mallampati index of class III/IV were the factors associated with OSA.

New clinical staging for pharyngeal surgery in obstructive sleep apnea patients

INTRODUCTION The success of pharyngeal surgery in the treatment of obstructive sleep apnea syndrome depends on the appropriate selection of patients. OBJECTIVE To propose a new staging for indication of pharyngeal surgery in obstructive sleep apnea syndrome. METHODS A total of 54 patients undergoing extended tonsillectomy were retrospectively included, divided into six stages. Stage I: patients with palatine tonsils grade 3/4 and modified Mallampati index 1/2; stage II: palatine tonsils 3/4 and modified Mallampati index 3/4; stage III: palatine tonsils 1/2 and modified Mallampati index 1/2; stage IV: palatine tonsils 1/2 and modified Mallampati index 3/4; stage V: body mass index ≥40 kg/m(2) with palatine tonsils 3/4 and modified Mallampati index 1, 2, 3, or 4. Stage VI: body mass index ≥40 with palatine tonsils 1/2 and modified Mallampati index 1, 2, 3, or 4. RESULTS The surgical success rates were 88.9%, 75.0%, 35.7%, 38.5%, and 100.0% in stages I-V. CONCLUSION The presence of hypertrophic palatine tonsils was the anatomical factor in common in the most successful stages (I, II, and V), regardless of body mass index. Although the modified Mallampati index classes 3 and 4 reduced the success rate of surgery in patients with hypertrophic tonsils (stage II), the presence of modified Mallampati index classes 1 and 2 did not favor surgical success in patients with normal tonsils (stage III).

Upper Airway in the Adult Population of São Paulo, Brazil

Objective: 1) Study the prevalence of otolaryngologic symptoms and findings of physical examination of upper airway of a representative sample of the adult population of São Paulo, Brazil. 2) Correlate subjective symptoms with physical findings. Method: A total of 1101 randomly selected volunteers representing the adult population of São Paulo according to gender, age, and socioeconomic class were included in this study. The sampling process was probabilistic, consisting of 3 stages. Otolaryngologic examination included investigation of nasal complaints, physical examination of the upper airway, and facial inspection. Results: A total of 993 volunteers (53.9% women) underwent otolaryngologic examination, with a mean age of 41.8 ± 0.89 years. The most prevalent symptoms were rhinitis (44.9%), snoring (42.8%), mouth breathing (39.3%), and nasal obstruction (33.3%). On physical examination, the most common findings were web palate (62.9%), septum deviation (56.9%), and inferior turbinate hypertrophy (37.7%). Significant correlations between symptoms and physical examination variables were nasal obstruction with septum deviation, inferior turbinate hypertrophy, high-arched palate, and class II dental occlusion; symptoms of rhinitis with inferior turbinate hypertrophy; and snoring with deviated septum obstruction, Mallampati III and IV, increased neck circumference, and age ≥ 50 years. Conclusion: The prevalence of otolaryngologic symptoms and changes in physical examination of the upper airway are high in the adult population of São Paulo, Brazil. There is a significant association between snoring and nasal obstruction with objective signs of physical examination of upper airway and inspection of the facial skeleton.