We studied two populations of patients who snored and had frequent nocturnal asthma attacks: ten overweight men presenting with typical obstructive sleep apnoea syndrome, and a group of five adolescents with regular snoring and an increase in negative inspiratory oesophageal pressure during stage II non-rapid eye movement (NREM) and rapid eye movement (REM) sleep. All subjects presented cranio-mandibular abnormalities at cephalometric evaluation, with a narrow space behind the base of the tongue. Both populations were treated with nasal continuous positive airway pressure (CPAP) during sleep. Snoring and partial or complete airway obstruction were eliminated, as were the nocturnal asthma attacks. Two adolescents treated with upper airway surgery after nasal CPAP showed no nocturnal asthma at short-term follow-up. Nasal CPAP had no effect on daytime asthma. One hypothesis is that a subgroup of asthmatic patients with small pharynxes may have enhanced vagal stimulation during sleep compared with other asthmatic patients. This enhancement would be related to the repetitive Muller manoeuvres noted with airway obstruction during sleep. Combined with the local effects of snoring, this extra vagal stimulation would be a precipitating factor in nocturnal asthma attacks.
Many therapeutic approaches, including mandibular surgery, have been proposed for the treatment of obstructive sleep apnoea syndrome. In the largest study of its type yet reported, 54 patients (population A) underwent mandibular surgery: 36 had palato-pharyngoplasty and inferior sagittal osteotomy of the mandible with hyoid myotomy and resuspension, and 18 (population B) had maxillo-mandibular hyoid advancement, a procedure consisting of palato-pharyngoplasty, inferior sagittal osteotomy of the mandible with hyoid myotomy and, several months later, a maxillo-mandibular osteotomy. Criteria for procedure selection and for evaluation of results were pre-set, and clinical and polygraphic follow-up occurred 6-8 months after final surgery. In population A, 32 of the 36 patients had improved; but only 20 were evaluated as "satisfactory". In contrast, all of the population B patients were judged satisfactory. Four of the population B patients received nasal continuous positive airway pressure (CPAP) before any surgery, and both approaches gave similar good polygraphic results. The degree of skeletal cranio-facial deficiencies, particularly retrognathia, is crucial for procedure selection. We describe potential procedural risks and problems.
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