Cases reported "Sleep Apnea Syndromes"

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1/139. Successful treatment of obstructive sleep apnea with use of nasal continuous positive airway pressure in three patients with mucosal hemangiomas of the oral cavity.

    cysts and benign tumors are uncommon causes of obstructive sleep apnea (OSA), and surgical removal is usually favored. In patients in whom an operation poses a high risk, however, nasal continuous positive airway pressure (CPAP) may prove beneficial. We describe three patients with hemangiomas of the oral cavity in whom polysomnography revealed moderate to severe OSA. In all three patients, nasal CPAP effectively decreased sleep-related disordered breathing events and dramatically improved their sleep. To our knowledge, this is the first report of OSA associated with hemangiomas involving the upper airway. Our experience suggests that nasal CPAP therapy is effective and well tolerated in such patients.
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2/139. Pseudo-steroid resistant asthma.

    BACKGROUND: Steroid resistant asthma (SRA) represents a small subgroup of those patients who have asthma and who are difficult to manage. Two patients with apparent SRA are described, and 12 additional cases who were admitted to the same hospital are reviewed. methods: The subjects were selected from a tertiary hospital setting by review of all asthma patients admitted over a two year period. Subjects were defined as those who failed to respond to high doses of bronchodilators and oral glucocorticosteroids, as judged by subjective assessment, audible wheeze on examination, and serial peak flow measurements. RESULTS: In 11 of the 14 patients identified there was little to substantiate the diagnosis of severe or steroid resistant asthma apart from symptoms and upper respiratory wheeze. Useful tests to differentiate this group of patients from those with severe asthma appear to be: the inability to perform reproducible forced expiratory manoeuvres, normal airway resistance, and a concentration of histamine causing a 20% fall in the forced expiratory volume (FEV1) being within the range for normal subjects (PC20). Of the 14 subjects, four were health care staff and two reported childhood sexual abuse. CONCLUSION: Such patients are important to identify as they require supportive treatment which should not consist of high doses of glucocorticosteroids and beta2 adrenergic agonists. Diagnoses other than asthma, such as gastro-oesophageal reflux, hyperventilation, vocal cord dysfunction and sleep apnoea, should be sought as these may be a cause of glucocorticosteroid treatment failure and pseudo-SRA, and may respond to alternative treatment.
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3/139. Resolution of obstructive sleep apnea syndrome after adenoidectomy in congenital central hypoventilation syndrome.

    We report on a 2 1/2-year-old boy who is currently ventilated at home by positive pressure ventilation through a nasal mask during the night because of congenital central hypoventilation syndrome (CCHS). Up to age 2 he had developed normally. A reevaluation was performed because of symptoms suggestive of obstructive sleep apnea syndrome (OSAS), including snoring, nocturnal sweating, frequent nighttime awakenings, speech impairment, daytime fatigue, and failure to thrive. A sleep study indicated obstructive apnea episodes lasting up to 40 s and arterial desaturations below 50% during spontaneous sleep. During mechanical ventilation snoring persisted, and capillary PCO2 rose to 60 mm Hg. Partial upper airway obstruction, leaking around the mask, and arousal movements developed on passive flexion of the neck to 20 degrees. After adenoidectomy, symptoms of OSAS resolved. There were no more obstructive apneas during spontaneous sleep, but obstructive apneas could be provoked by neck flexion to 20 degrees. During ventilation, neck flexion of 20 degrees was tolerated, but a 40 degrees flexion led to partial obstruction. In CCHS patients, the problem of upper airway obstruction is rarely noted because most patients are ventilated through a permanent tracheostomy. Today, noninvasive ventilation strategies are becoming more common. Reduced activity of upper airway muscles and impaired reflex mechanisms could lead to upper airway obstruction during face mask positive pressure ventilation in children with CCHS. Enlarged adenoids worsened this problem in our patient, leading to insufficient ventilation and OSAS. adenoidectomy resolved symptoms of OSAS and enabled successful nasal mask ventilation. Close follow-up of the patient avoided hypoxia and sequelae from OSAS such as pulmonary hypertension.
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4/139. Cosmetic enhancement associated with surgery for obstructive sleep apnea.

    OBJECTIVE: To document the capacity of surgery for obstructive sleep apnea (OSA) to incorporate techniques that incidentally improve the cosmetic features of the patients. STUDY DESIGN: Retrospective analysis of surgical outcomes at an academic practice. methods: Moderate to severe OSA usually requires multilevel pharyngeal surgery, including tongue base surgery. The surgical procedures, including hyoid myotomy and mandibular osteotomy with tongue advancement, afford the opportunity to address cosmetic deficits, such as microgenia and excessive submental skin and fat. Outcomes achieved using these procedures over a 4-year period were analyzed. RESULTS: Of 428 consecutive patients presenting for evaluation of sleep-related breathing disorders, 212 were deemed surgical candidates. Ninety-seven of these had office-based procedures for snoring, upper airway resistance syndrome, or mild OSA. The remaining 115 had formal surgical procedures done, and 68 of these had multilevel pharyngeal surgery. Of these, 12 had defined cosmetic deficiencies that were addressed at the time of the sleep apnea surgery. There were 7 men and 5 women, with a mean age of 48.2 years. The group was moderately obese (mean BMI = 31.8) and had moderate to severe OSA (mean RDI = 37.0, mean LSAT = 78%). Cosmetic deficits identified included turkey gobbler deformity (n = 8), microgenia (n = 6), excessive submental fat (n = 2), and nasal deformity (n = 1); several patients had more than one addressable problem. All patients achieved an improved postoperative appearance. Representative photographs are presented. CONCLUSIONS: A surgical approach to the management of sleep apnea affords an opportunity to also address cosmetic deficiencies, including excessive submental skin and fat, microgenia, and nasal deformities.
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5/139. Evaluation of sleep apnea syndrome with low-field magnetic resonance fluoroscopy.

    The aim of this study was to assess the upper airway status of sleep apnea syndrome (SAS) patients with low-field MR fluoroscopy. Twenty patients with clinically diagnosed SAS underwent upper airway monitoring using MR fluoroscopy for 5 min while awake and for 30 min while asleep. A 0.064-T permanent-magnet MR imaging system was used for the study. No patients required any sedative drugs because of the very small gradient noise, except in one case. No occlusion was observed while patients were awake. Nine patients showed repeated occlusion at retropalatal (Rp) pharynx, whereas 11 demonstrated both simple Rp occlusion and combined retropalato-retroglossal (Rp Rg) occlusions (complex occlusion). The mean frequency of occlusion in complex cases was significantly higher than that in simple Rp cases (p < 0.05). Low-field MR fluoroscopy was useful in determining the occlusion level while asleep in patients with SAS because of its quiet gantry and long-term monitoring capability. The MR fluoroscopy technique should prove to be a valuable clinical tool for the diagnosis and for determining the appropriate therapy in patients with SAS.
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6/139. Screening for hypothyroidism in sleep apnea.

    Primary sleep apnea-hypopnea syndrome (obstructive sleep apnea [OSA]) and hypothyroidism have many signs and symptoms in common. The overlap in clinical presentation, and the sleep-disordered breathing that can accompany hypothyroidism, create a significant risk of misdiagnosis of sleep apnea among patients referred to sleep clinic who have undiagnosed hypothyroidism. We determined the point prevalence of hypothyroidism in our sleep clinic patients with newly diagnosed sleep-disordered breathing. Of 290 sequential patients referred to sleep clinic, 200 (69%) patients judged at high risk for OSA underwent polysomnography (PSG) and biochemical screening for hypothyroidism. Of these, 124 (62%) were judged to have sleep apnea. This included three patients (1.5% of patients undergoing PSG or 2. 4% of those judged to have OSA) who were also discovered to have previously undiagnosed hypothyroidism. These three patients with "secondary" sleep apnea were treated with thyroxine therapy alone, and followed with sequential sleep studies and serum thyroid hormone assays; symptoms, sleep-disordered breathing, nocturnal hypoxia, and thyroid deficiency resolved simultaneously. We conclude that biochemical screening for hypothyroidism is required to prevent inadvertent misdiagnosis of hypothyroid sleep-disordered breathing as primary sleep apnea, and that it is a cost-effective component of the investigation of sleep apnea.
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7/139. Obstructive sleep apnoea in a puerperal patient with Hallermann-Streiff syndrome.

    A 26 yr old puerperal female with Hallermann-Streiff syndrome developed serious obstructive sleep apnoea syndrome during pregnancy. She underwent an elective Caesarean section delivery, but ending the pregnancy did not improve her clinical symptoms. By treating her with nasal continuous positive airway pressure, a worsening of her headaches and glaucoma was prevented. The administration of acetazolamide controlled all of her symptoms. Treatment with nasal ventilation is the best initial approach. It is also important to assure normal oxygenation before pregnancy since the foetus may suffer from the severe deprivation that may occur in these patients.
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8/139. Age-related changes in the epiglottis causing failure of nasal continuous positive airway pressure therapy.

    At 65 years of age, a former coal miner, now 72-years-old, developed a progressive loss of concentration with daytime sleepiness and sleep disturbances. work-up in pneumological and medical sleep centres resulted in diagnosis of chronic obstructive pulmonary disease (COPD), borderline obstructive sleep apnoea syndrome and, later, upper airway resistance syndrome. In addition, there was evidence of reduced efficiency of sleep. Neither the initial administration of theophylline nor the later use at night of hyperbaric respiration led to improvement in the patient's symptoms. Instead, the patient developed loud snoring, as well as the inability to sleep while in a lying position. At age 71 years, otorhinolaryngological examination resulted in findings of age-related changes in the epiglottis, that completely blocked the hypopharynx upon inspiration. polysomnography, which was possible only in a half-seated position, revealed reduction in deep sleep, with a maximum oxygen saturation of 77 per cent at an apnoea-hypopnoea index (AHI) of 4.8. Partial resection of the epiglottis with laser surgery resulted in complete improvement of diurnal drowsiness and reduced stamina. Sleeping in a supine position again became possible. polysomnography revealed normalization of sleep architecture, but unchanged, low efficiency of sleep. This case underscores the importance of an interdisciplinary approach to the treatment of sleep-related breathing disorders.
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9/139. Unexpectedly severe sleep and respiratory pathology in patients with amyotrophic lateral sclerosis.

    Daytime fatigue and sleep disturbance are frequent complaints in patients with amyotrophic lateral sclerosis (ALS). However, polysomnographic data are sparse. Nocturnal respiratory insufficiency may occur despite nearly normal daytime pulmonary function. We describe the clinical presentation and polysomnographic findings in two patients with clinically and electrophysiologically confirmed ALS with minimal weakness but excessive daytime sleepiness. polysomnography in the first patient showed a respiratory disturbance index of 43.5, and profound oxygen desaturations to 62%. The second patient had prolonged periods of hypoventilation, with oxygen saturations oscillating between 86 and 83%. Both patients showed severe sleep maintenance insomnia with a sleep efficiency < 40% and frequent arousals while asleep. Application of continuous positive airway pressure (CPAP) restored normal nocturnal ventilation, blood oxygenation and sleep parameters in the first patient; compliance, however, was poor. The second patient was unable to tolerate CPAP. We conclude that ALS patients with excessive daytime sleepiness or insomnia should undergo polysomnography to adequately diagnose nocturnal respiratory insufficiency and sleep disturbance. compliance with treatment, however, may be poor.
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10/139. Chiari malformation and sleep-disordered breathing: a review of diagnostic and management issues.

    Chiari Malformation (CM) encompasses several patterns of congenital or acquired cerebellar herniation through the foramen magnum. This may result in brain-stem compression that impacts control of breathing and is associated with obstructive and central apneas. A high clinical suspicion for sleep-disordered breathing is needed in the care of such patients after as well as before corrective surgery. To introduce a review of CM with a focus on the relevance to sleep medicine, we present a case of a 13-year-old female who was diagnosed with CM Type 1 in the course of an evaluation of symptomatic central sleep apnea. After initial improvement following surgery there was recurrence of brain-stem compression. The only clinical expression of which was polysomnographically evident recurrence of sleep apnea.
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