Adaptation to Hypoxia in Sleep Apnea Patients: Multifaceted Mechanisms.

Obstructive sleep apnea syndrome (OSA) is a form of sleep disordered breathing. The key phenomena are multiple repetitive pauses or restriction of airflow in the airway, defined as apnea and hypopnea. This study was based on a retrospective analysis of the results of polysomnographic (PSG) recordings of 230 adult patients (62 women and 168 men), being evaluated for OSA. The mean age, body mass index (BMI), apnea-hypopnea index (AHI), and pulse oximetry (SO2 nadir) of all patients were 50.4 ± 12.7 years, 30.4 ± 5.4 kg/m2, 33.6 ± 26.6 1/h, and 80.7 ± 12.1%, respectively. Statistical analysis was performed taking into account the moment of obstructive apnea occurrence and duration, sleep stage, and the SaO2 nadir associated with these events. We found a lengthening of apneic episodes with progressing of sleep-time, which depended on the sleep-time. There was rather a fast increase in apnea duration in the first quartile of sleep-time. In the later sleep phases, the dynamics of the increase were four-fold weaker. The lengthening of apnea duration was dependent on the severity of AHI, but was hardly related to the sleep stage or arterial desaturation. In conclusion, the results revealed two time scales of a lengthening of apneic episodes as a function of sleep-time in OSA patients. Sympathetic activation and spleen reflex may be involved in the observed phenomenon. Although the exact mechanisms of increasing duration of apneic episodes with the passage of sleep remain elusive, we believe these mechanisms are liable to be multifaceted.

The correlation of the results of the survey SNOT-20 of objective studies of nasal obstruction and the geometry of the nasal cavities.

INTRODUCTION: In this paper were verified the correlation between the results of the survey SNOT-20 and the results of the objective tests of nasal obstruction which are rhinomanometry and acoustic rhinometry before and after surgical treatment, such as septoplasty, septoconchoplasty, ethmoidectomy and septoethmoidectomy. MATERIAL AND METHODS: The material used in this study was 233 patients diagnosed routinely in the Rhinomanometry Laboratory of the Department of Otolaryngology at the Medical University of Warsaw, reporting rhinological problems. Data were obtained from 70 women (31,4%) ranging in ages from 18 to 81 years of age and 153 men (68,6%) ranging in ages from 16 to 81 years of age. The researches presented in the study were made using the device RhinoMetrics SRE 2100 which combines the Rhinomanometer (RhinoStream) and Acoustic Rhinometer (RhinoScan) Interacoustics AS (Denmark). Survey SNOT-20 (Sino-Nasal Outcome Test-20) in Polish was completed by patients before surgery and during the postoperative control visits. RESULTS: The calculated correlations between the objective parameter, which was the resistance to the flow of air through the nasal cavity , and the subjective feelings of respondents expressed in the survey SNOT-20 were generally weak, and statistical significance was achieved with respect to the first question survey (the severity of the nose obstruction) for all components of resistance flow. DISCUSSION: The feeling of nasal obstruction is the most reproducible and reliable complaint reported by the patient with rhinological problems.

[Comparative analysis of the treatment results of the nasal obstruction using septoplasty and septokonchoplasty]. / Analiza porównawcza wyników leczenia zaburzen droznosci nosa z zastosowaniem septoplastyki i septokonchoplastyki.

The nasal septal deviation coexistent with turbinate hypertrophy is considered one of the most common causes of nasal patency disorders. There is no doubt that septoplasty in most such cases is a proper treatment method. It is more difficult to clearly identify indications and predict the consequences of septoconchoplasty. The main aim of this study is to compare the impact of each of these procedures on subjective and objective measures of nasal patency. The authors retrospectively reviewed 132 medical records of patients treated in the Department of Otolaryngology, Medical University of Warsaw in the period from March 2012 to January 2013 due to nasal obstruction. Each patient had septoplasty or septoconchoplasty performed. Before treatment, each patient responded to questions in a standardized questionnaire SNOT 20. In addition, each patient was performed upon for anterior rhinomanometry before and after shrinking the nasal mucosa. Finally, the study involved a group of 30 people - 15 after septoplasty (group A) and the same number after septoconchoplasty (group B), who attended control examination carried out by the same scheme 6 weeks and 6 months after surgery. SNOT 20 poll was repeated 6 months after surgery. Analysis of the rhinomanometry results showed no statistically significant differences between the two treatment groups. Average values of the nasal resistance after surgery as compared to their baseline values in all measurements were smaller in each of the groups but the differences were also not statistically significant. However, comparing the results of the subjective assessment of nasal patency and associated signs and symptoms showed statistically significant differences between pre and postoperative results in both groups and the patients of group B felt more improvement than patients in group A. The study authorizes the conclusion that in justified cases septoconchoplasty gives better results than septoplasty.

[Angifibroma juvenile--evolution of surgical management]. / Ewolucja chirurgicznych metod leczenia wlókniaka mlodzienczego.

INTRODUCTION: Juvenile Angiofibroma has been challenged generations of surgeons. The problem is, not only in specific clinical features of the tumour, but also in difficult surgical approach to anatomical area in which it is located. THE AIM OF THE STUDY: was to analyze development of surgical techniques in treatment of juvenile angiofibroma and potential conditions which influence on therapy results. MATERIAL AND METHOD: The retrospective study that analyzes 47 juvenile angiofibroma cases, which were treated in the Otorhinolaryngology Department of Warsaw Medical University in years 1980­2010. RESULTS: The five surgical approaches were used in the group of patients, filled in this study. The use of midfacial degloving has become increasingly popular, replacing lateral rhinotomy and transpalatal approach, which were commonly used in early nineties of the last century. The infratemporal approach was used in one case of disease with parapharyngeal and infratemporal extension. One of the recent patients was treated, first time in history of the Department, using endoscopic approach. The routine protocol of treatment includes preoperative CT and MRI and angiography with embolization of the main tumour vessels. The gradual, but consequent improvement in therapy results is revealed as reduction of recurrence from 35% to 20%. CONCLUSIONS: In therapy of juvenile angiofibroma become popular surgical techniques, which are not connected with visible scars and which reduce tissue trauma in operated area. Besides mastering surgical skills, the independent condition, which improves therapy results, is using modern diagnostic and therapeutic procedures. They contribute to better assessment of tumour location and extension, and reduction of intraoperative blood loss.

[Draf III procedures: the ENT Department, Medical University of Warsaw experience]. / Operacje z dostepu Draf III w materiale Kliniki Otolaryngologii WUM.

UNLABELLED: During last decades Draf III procedure gained popularity in treatment of different pathologies of the frontal sinus such as chronic sinusitis or benign tumors. We present a series of 10 patients treated with this procedure from a 2-year-period. Indications included: chronic rhinosinusitis--four patients, frontal sinus mucocele--four patients (one with destruction of the posterior table), osteoma--one patient (stage 3 according to Kennedy's grading system), and inverted papilloma--one patient (Krouse T3 lesion). Observation period ranged from 4 months to 2 years. RESULTS: There were no early complications. Gradual narrowing of the created ostium was observed in all of the patients. This led to total obstruction in two, and stenosis (not allowing for passing with 4 mm endoscope) in another two patients. The patient after inverted papilloma removal showed no recurrence in 11 months follow-up. CONCLUSION: Draf III procedure is alternative for external approach that can be used for treatment of chronic rhinosinusitis and benign frontal sinus tumors of different size.

[Iatrogenic CSF leak as a complication of osteoplastic flap surgery of the frontal sinus]. / Jatrogenne plynotoki w przebiegu operacji osteoplastycznych zatoki czolowej.

THE AIM OF THE STUDY: to evaluate CSF leak as a complication of osteoplastic flap surgery of the frontal sinus. MATERIAL AND METHODS: Medical recordings of the patients that underwent osteoplastic flap surgery of the frontal sinus were analyzed. RESULTS: among 62 patients operated between 2000 and 2007 there were 4 cases of intraoperative CSF leak (6.5% of cases). In all complicated cases indication for surgery was benign large tumor of the frontal sinus, among them there were two cases of osteoma, one cholesterol granuloma and ossifying fibroma. All CSF leaks were successfully closed with multilayer underlay or overlay graft. The technical aspects of the osteoplastic flap surgery of the frontal sinus are discussed.

[The analysis of the admissions to the laryngological emergency service in Otolaryngology Department of Warsaw Medical University]. / Analiza przypadków zglaszanych na ostry dyzur laryngologiczny w Klinice Otolaryngologii Akademii Medycznej w Warszawie.

OBJECTIVE: The aim of our work was to carry out an qualitative analysis of the all cases delt with in otorhinolaryngological emergency unit throughout one year. The information gathered and observations made can result in the valid grounds for streamlining of otorhinolaryngological emergency services in the future. RESEARCH DESIGN AND METHODS: We examined the medical documentation of 7930 subjects (3.972 females and 3.958 males, of the average age 42 years), who appeared in the otorhinolaryngological emergency unit of SP CSK AM in Warsaw from the 1th of January to the 31th of December 2006. RESULTS: The actual emergency cases accounted for 40% of all cases. The most common were: injuries (12.80%), epistaxises (13.11%), foreign bodies (5.11%). The rest of the cases did not need the summary intervention on emergency admission. These were mostly: ear inflamations (21.32%), upper respiratory tract infecions (10.77%), cerumen in the external ear (8.98%). In 2006, 5,51% of all cases were admitted to the otorhinolaryngological ward and up to 5.22% sent to other specialists. CONCLUSIONS: The majority of the cases delt with in the otorhinolaryngological emergency unit did not need the immediate intervention. A part of these was not within the competence of the otorhinolaryngologist. The high proportion of such patients can prolong the time of anticipation for highly specialised aid in the states of real threat to human's life and health and cause other damages that can be harmful to the pacient himself.

Dynamics of early phase congestion after nasal allergen provocation.

BACKGROUND: It is generally accepted that congestion during the nasal provocation is most pronounced at about 15 minutes after allergen application. However, it may reach its peak at a different time. This can cause inaccurate assessment of the nasal challenge. The aim of this study was to evaluate the dynamics of early phase congestion during nasal allergen provocation (NPT) and its reproducibility. METHODS: Two nasal allergen challenges were performed in 26 allergic rhinitis volunteers. Acoustic Rhinometry measurements were recorded beJbre, and then every 5 minutes/for 30 minutes after the allergen application. The sum of cross-sectional areas at the level of the head of inferior nasal turbinate (CSA-2) of both nasal passages was analyzed. RESULTS: The mean time to the occurrence of maximum congestion was 20 minutes. The maximum congestion differed significantly from that recorded at 10, 15 and 20 minutes. The observed patterns of congestive response were not consistent, with inter- and intra-individual differences regarding the time to maximum congestion. Percentage change in airway dimension recorded at the maximum congestion was found the least variable. CONCLUSIONS: Evaluation of the maximum congestion pattern during the NPT gives more accurate data compared to a single measurement of nasal patency.

[The role of functional nasal surgery in the treatment of obstructive sleep apnea syndrome]. / Znaczenie czynnosciowej chirurgii nosa w leczeniu obturacyjnego bezdechu podczas snu (OBPS).

INTRODUCTION: Nasal obstruction is widely mentioned among the factors influencing pathophysiology of obstructed breathing disorders during sleep. However numerous observations confirms such relation, influence of nasal surgery on frequency and intensity of obstructive episodes during sleep remains modest and unpredictable in vast majority of cases. The aim of this study was to evaluate the role of functional nasal surgery in the treatment of Obstructive Sleep Apnea Syndrome (OSAS). MATERIAL AND METHODS: The study included 83 subjects with OSAS diagnosed by polysomnography and elevated nasal resistance due to different deformities of nasal skeleton. All patients underwent appropriate surgical treatment. Evaluation of day somnolence using Epworth Scale and subjective analysis of snoring and other sleep disturbances using linear scale was carried before and after surgery. Objective results of treatment were assessed by polysomnograpy performed 3 to 4 months after operation. RESULTS: The results obtained in our group of patients showed a large discrepancy between the subjective estimation of the treatment indicated by the patients and the objective determinations of the polysomnographic test. The average day somnolence intensity was decreased approximately 2 times and 72 (86%) patients stated that snoring intensity as well as other night time symptoms of sleep apnea greatly diminished. Furthermore in the group of 19 patients who continued nCPAP therapy after surgery the side effects of this treatment diminished and lower therapeutic pressure could be provided. CONCLUSIONS: Correction of nasal obstruction have to be considered in all patients with OSAS because it may help relieve airway obstruction during sleep and improve the general quality of live at least in patients self estimation. Furthermore, an improvement of nasal patency diminishes the side effects of nCPAP therapy and provides lower therapeutic pressure.

[What should we know about uvula doing uvulopalatoplasty]. / Co powinnismy wiedziec na temat jezyczka wykonujac uwulopalatoplastyke.

INTRODUCTION: Investigators have been interested in the structure and function of the uvula for centuries. Some of them emphasized its influence on the tone of voice, others its immunological role. Since the times of Hippocrates, people have been afraid of the uvula oedema, as it could lead to apnea and death. It was also suspected that upper airway diseases originated from the uvula. That's why excision of the uvula has been a common practice in folk medicine carried out as a ritual act in the North Africa and Middle East for many centuries up to now. Nowadays Evidence Based Medicine recommends uvulectomy as a part of surgical treatement in any form of sleep related obstructive breathing disorders. The aim of this study was to present the specific function of the uvula and draw the practical conclusions concerning uvulopalatopharyngoplasty. MATERIAL AND METHODS: Histological analysis of the uvula and soft palate samples obtained by UPPP from 37 adults suffering from moderate OSAS was performed. RESULTS: This investigation revealed that the uvula contained significantly more salivary glands with predominant serous type in comparison with the palatine arches tissue. Glandular follicles were composed of the pyramid-shaped epithelial cells lying on the basement membrane. Between these there were myoepithelial cells which pushed serous secretion to the excretory ducts. CONCLUSIONS: Histologically unique structure of the uvula, when compared with other parts of the soft palate, suggests that the uvula plays a very important role in moistening the oropharyngeal mucosa. Since the feeling of dryness in the throat is one of the most frequent complaints after UPPP, the modification of the standard operative technique in order to preserve the uvula, should be considered.

[Nasal polyps is not a homogenous pathology]. / Polipy nosa--niejednorodna patologia.

UNLABELLED: Nasal polyposis is still a disease of unknown etiology. Looking at its clinical course it seems to be not homogenous pathology. Inflammation of the mucosa, mainly eosinophilic is probably the most important factor, which leads to the development of nasal polyps. THE AIM OF STUDY: To analyze and compare the history data and eosinophilic inflammation parameters in patients with nasal polyps. MATERIAL AND METHODS: 67 patients with nasal polyposis were included into the study. They were divided into three groups: PP-primary nasal polyps (n = 33-49.2%); A-polyps and bronchial asthma without aspirin intolerance (n = 19-28.4%); ASA-polyps and aspirin-induced asthma (n = 15-22.4%). The history data were taken using patient's questionnaire. To assess the eosinophilic inflammation intensity the blood and nasal eosinophilia and serum eosinophilic cationic protein (ECP) concentration were measured. RESULTS: The average age of all patients was 55 +/- 1.5 (range 32-76), the age distribution was comparable in all groups. The ratio males:females--1.5:1 (PP--2.7:1; A--1.1:1; ASA--0.7:1. The females with nasal polyps much more often suffer from asthma than males (p = 0.036). The age when polyps were first seen was 45.1. The duration of nasal polyps was 10 +/- 10 years (range 0.5-30 years): PP-- 10 +/- 9; A-- 14 +/- 11; ASA-- 7 +/- 7 (A/ASA-- p = 0.045). Period of 6.6 years of rhinitis had preceded the diagnosis of nasal polyposis (PP--7.3; A--7.1; ASA--4.5). Age when asthma was developed (A+ASA groups)--45.5; the duration of asthma was 11 +/- 9 years. 58% of patients had polypectomy/ethmoidectomy (PP--45%; A--60%; ASA--80%). The number of operations per one patient: 1.3 (PP--1.0; A--1.2; ASA--2.0), the most often performed in ASA group (PP/ASA-- p = 0.01 and A/ASA-- p =0.045). The mean interval between polypectomies in all patients--9.1 years (PP--10; A--12, ASA--3.5). Blood eosinophilia: 5.6 +/- 0.4% (PP-- 4.6 +/- 0.5; A-- 6.2 +/- 0.9; ASA-- 7.2 +/- 0.9% and PP/ASA-- p = 0.019; PP/A+ASA-- p = 0.03). Nasal eosinophilia: 18.5 +/- 3% (PP-- 15.0 +/- 4; A-- 15.5 +/- 6; ASA-- 30.0 +/- 8% and PP/ASA-- p = 0.01; A/ASA-- p = 0.02). Serum ECP concentration: 24 +/- 2 microg/l. CONCLUSIONS: The patient's history and the intensity of eosinophilic inflammation are not similar in all nasal polyposis patients, that support the classification into PP, A and ASA groups. The most severe clinical picture and the highest values of eosinophilic parameters are observed in ASA group. Aspirin intolerance seems to be unfavourable prognostic factor in nasal polyposis.

[Effect of nasal obstruction on subjective assessment of sleep quality by the patients with obstructive sleep apnea]. / Wplyw zaburzen droinosci nosa na subiektywna ocene jakosci snu u pacjentów z obturacyjnym bezdechem podczas snu.

In 52 patients with Obstructive Sleep Apnea Syndrome (OSAS) and nasal obstruction due to nasal septum deformation, hypertrophy of inferior nasal concha or posttraumatic external nose deformity the evaluation of the day somnolence using the Epworth Scale was carried out. The patients were randomly divided in to two groups. The first group consisted of 40 patients who were subjected to appropriate corrective surgery of the nasal obstruction. The remaining 12 patients constituted the control group. After 3 month each of the patients was asked to fill in the same questionnaire. Among the patients who underwent the surgical procedure day somnolence intensity was decreased approximately 2 times whereas in the control group no significant changes were observed. Results of this study could be crucial for the discussion concerning the complex influence of the nasal obstruction on the pathomechanism and symptomatology of obstructive breathing disorders during sleep.

[Frontal sinus mucocele]. / Sluzowiak zatok czolowych w materiale Kliniki Otolaryngologii AM w Warszawie.

Between 1995 and 2000 twenty-two patients were treated for frontal sinus mucocele in the Department of Otorhinolaryngology of Medical University of Warsaw. History and physical examination revealed several-year-old chronic rhinosinusitis (CRS) in all but one cases. Thirteen patients had been previously operated on for this reason at least once. Conservative management, mainly in periods of symptom deterioration, was applied in other patients. The only patient with negative history of CRS had undergone in the past head injury with fracture and dislocation of the anterior wall of the frontal sinus, in the past. All patients were treated surgically with use of the intranasal endoscopic approach in 15 cases, osteoplastic surgery of the frontal sinus in 5 cases and combination of both in 2 cases. Diagnostic and management protocol is discussed and compared with data presented in the literature.

[Functional nasal surgery in the treatment of obstructive sleep apnea]. / Czynnosciowa chirurgia nosa w leczeniu obturacyjnego bezdechu podczas snu.

UNLABELLED: The study included 22 males with significant decrease in nasal patency, at age of 44+/-7 yrs with body mass index 28.9+/-3.8 kg/m2, diagnosed with obstructive sleep apnea syndrome (OSAS) by polysomnography. All patients underwent functional, corrective nasal surgery. In one patient an infection in the wound occurred. Postoperatively 19 (86%) patients reported significant subjective improvement. With regard to polysomnography, one patient was cured and in another one a decrease of AHI to more than 50% of baseline was found. In 6 (27.3%) patients AHI rose from 33.2+/-13 to 53.6+/-21.2. CONCLUSION: Nasal surgery in OSAS shows limited effectiveness. Because of multilevel decrease in airway patency, some of the patients may need a step-wise approach to surgical treatment.

[Labyrinthine fistulas: surgical management]. / Przetoki perylimfatyczne--postepowanie chirurgiczne.

The authors presented management rules and the results of surgical treatment in perilymphatic fistulas. Materials comprise 7 cases of cholesteatoma and 6 cases after previously performed so called conservative modified operation of the ear. In 3 cases cholesteatomas were destroying the membranous structures or were being adherent to them. In these cases labyrinthectomy was performed with partial conservation of hearing in one patient. In the remained 10 cases the fistulas were cleaned and sealed with 3 layers of tissues--fascia, cartilage and fascia. After the ossicular chain was reconstructed in one stage. Discharge, and vertigo were stabilised in all cases. It was stated that cleaning of the labyrinthine fistula during cholesteatoma removal does not influence on bone conduction thresholds.

[Uvulopalatopharyngoplasty and laser assisted uvulopalatoplasty in treatment of patients with sleep related breathing disorders]. / Zastosowanie uwulopalatofaryngoplastyki oraz uwulopalatoplastyki laserowej w leczeniu chorych z zaburzeniami czynnosci oddechowej podczas snu.

In the years 1996-1999 in the Department of Otolaryngology of Medical Academy in Warsaw 58 patients with respiratory disorders during sleep were treated using uvulopalatoplasty in 35 cases and laser uvulopalatoplasty in 23 cases. The authors describes operation technique, qualification criteria and results assessed on the basis of basic values of polysomnographic study as well as subjective feelings of patients.

[Midfacial degloving approach in the surgical treatment of angiofibroma juvenile]. / Zastosowanie dostepu poprzez wynicowanie powlok twarzy (midfacial degloving approach) w chirurgii wlókniaka mlodzienczego.

From 1996 through 2001 8 male with a diagnosis of juvenile angiofibroma were managed at the ENT Department of Medical University in Warsaw using midfacial degloving approach. Surgical technique as well as pre- and postoperative management of these patients were described. According to authors' experience midfacial degloving approach enables the broad exposition of the operating field.

[Clinical effects of surgical treatment of obstructive sleep apnea syndrome]. / Efekty kliniczne chirurgicznego leczenia obturacyjnego bezdechu podczas snu.

Aim of this study was to estimate the efficiency of surgical interventions in the treatment of obstructive sleep apnea (OSAS). Inclusion criteria for treatment were: presence of anatomical abnormalities within upper airways, a will to undergo surgical procedure and no medical contraindication for this treatment. Study group consisted of 43 men at age 42.8 +/- 6.8 year with mean pretreatment value of AHI: 49.5 +/- 21.5. Nasal surgery was performed in 26 cases interventions improving patency of nose were performed, uvulopalatopharyngoplasty in 17 and in two the tonsillectomy. Diagnosis of OSAS was made on the basis of typical complains and symptoms and results of nocturnal polysomnography. During follow-up, subjective improvement was reported by 35 (81%) of patients. Polysomnography revealed a significant decrease of AHI to below 15 in 10 (23%) cases; a lowering over 50% of AHI was obtained in 6 (14%) cases: in another 7 (16%) an increase in post-surgery AHI value was noticed. Efficiency of each intervention is presented as follows: tonsillectomy: 100%, uvulopalatopharyngoplasty: 41% and nasal surgery: 4.2%. Deterioration of OSAS in 7 cases was most probably due to more sleep on back during the follow-up.

[Tracheobronchopathia osteochondroplastica]. / Tracheobronchopatia osteochondroplastyczna.

Tracheobronchopathia osteochondroplastica (TO) is a rare disease of unknown etiology affecting mainly the trachea and large bronchi. It is characterized by the presence of multiple submucosal osseus and/or cartilaginous nodules. The authors report a case of 74-year-old woman in whom fiberoptic bronchoscopy, performed because of hemoptysis, revealed typical feature of TO. Besides the typical nodules protruding into the lumen of trachea and main bronchi, a small soft nodule in the larynx was found. On histological examination it was showed to be polyp with regions of inflammation and necrosis. The direct relation between such a laryngeal polyp and TO seems to be very unlikely.