Evaluation of the intranasal steroid treatment outcomes in adenoid tissue hypertrophy with or without allergic rhinitis.

PURPOSE: To compare the intranasal steroid (INS) treatment outcomes in patients with adenoid tissue hypertrophy (ATH) with or without allergic rhinitis (AR). MATERIALS AND METHODS: Medical records of 96 children diagnosed with ATH were retrospectively examined. The pediatric version of the Score for Allergic Rhinitis (SFAR) questionnaire was used to determine the AR status of the patients and classify them. The children were divided into two groups based on the questionnaire: Group 1, low probability of AR (SFAR<9); and Group 2, high probability of AR (SFAR≥9). Intranasal mometasone furoate (100 µg/mL) was used to treat ATH for at least 3 months. The severity of nasal obstruction and snoring was evaluated using the visual analog scale (VAS) score, the adenoid/choana (A/C) ratios before and after treatment were compared, and the rate of patient referral to surgery was recorded among groups. RESULTS: The change in the A/C ratio within the group between before and after treatment was significant (both P < 0.001). However, the reduction in the adenoid size was more significant in Group 1 than in Group 2 (P = 0.025). A significant improvement in the VAS scores was observed between before and after treatment in both groups (P < 0.001). Furthermore, the rate of surgical referral of Group 1 was significantly lower than that of Group 2 (P = 0.035). CONCLUSIONS: INS treatment was found more successful for reducing A/C ratio in ATH without AR. Related with this, when considering the INS treatment for ATH, AR status should be kept in mind for predicting the treatment success.

Effectiveness and safety of Chinese herbal medicine for pediatric adenoid hypertrophy: A meta-analysis.

OBJECTIVE: Chinese herbal medicine has been gradually used to treat pediatric adenoid hypertrophy. This meta-analysis were conducted to evaluate the clinical efficacy and safety of Chinese herbal medicine in the treatment of pediatric adenoid hypertrophy. METHODS: Randomized controlled trials involving Chinese herbal medicine in the treatment of pediatric adenoid hypertrophy were identified from Cochrane Central Register of Controlled Trials, PubMed, EMBASE, Chinese National Knowledge Infrastructure, Chinese Biomedical Database, Wanfang Database and VIP Information Database. The methodological quality of trials was evaluated with Cochrane Handbook criteria, and the Cochrane Collaboration's Review Manager 5.3 software was used for Meta-analysis. RESULTS: A total of 13 valid articles involving 1038 patients were included. The meta-analysis showed that: Compared with western medicine treatment, Chinese herbal medicine significantly improved clinical efficacy (RR = 1.33, 95% CI [1.24,1.43]), and significantly decreased A/N ratio (MD = -0.04,95%CI [-0.05,-0.03]). Chinese herbal medicine also prominently improved the quality of life (MD = -4.77,95%CI [-8.35,-1.20]). Meanwhile, it dramatically improved snoring (MD = -0.46,95%CI [-0.62,-0.30]); mouth breathing (MD = -0.52,95%CI [-0.66,-0.39]); nasal obstruction (MD = -0.56,95%CI [-0.68,-0.45]). CONCLUSION: Chinese herbal medicine has good clinical efficacy and safety on pediatric adenoid hypertrophy, which need to be confirmed by high quality, multiple-centre, large sample randomized controlled trials.

Traditional Chinese herbal formula relieves snoring by modulating activities of upper airway related nerves in aged rats.

AIM: The present study investigated whether intraperitoneal treatment with the herbal formula B210 ([B210]; a herbal composition of Gastrodia elata and Cinnamomum cassia) can reduce snoring in aged rats. Also, we studied possible neural mechanisms involved in B210 treatment and subsequent reduced snoring in rats. METHODS AND RESULT: We compared pressure and frequency of snoring, activities of phrenic nerve (PNA), activities of recurrent laryngeal nerve (RLNA) and activities of hypoglossal nerve (HNA), inspiratory time (TI) and expiratory time (TE) of PNA, and pre-inspiratory time (Pre-TI) of HNA in aged rats between sham and B210 treatment groups (30 mg/mL dissolved in DMSO). We found that aged rats that received B210 treatment had significantly reduced pressure and frequency of snoring than rats who received sham treatment. Also, we observed that aged rats that received B210 treatment had significantly increased PNA, RLNA, and HNA, extended TI and TE of PNA, and prolonged Pre-TI of HNA compared to rats that received sham treatment. In other words, B210 treatment may relieve snoring through modulating activities and breathing time of upper airway related nerves in aged rats. CONCLUSION: We suggested that the B210 might be a potential herbal formula for snoring remission.

Antioxidant Carbocysteine Treatment in Obstructive Sleep Apnea Syndrome: A Randomized Clinical Trial.

OBJECTIVE: This study aimed to examine the effects of carbocysteine in OSAS patients. METHODS: A total of 40 patients with moderate to severe obstructive sleep apnea syndrome (OSAS) were randomly divided into two groups. One group was treated with 1500 mg carbocysteine daily, and the other was treated with continuous positive airway pressure (CPAP) at night. Before treatment and after 6 weeks of treatment, all patients underwent polysomnography and completed questionnaires. Treatment compliance was compared between the two groups. Plasma was collected for various biochemical analyses. Endothelial function was assessed with ultrasound in the carbocysteine group. RESULTS: The proportion of patients who fulfilled the criteria for good compliance was higher in the carbocysteine group (n = 17) than in the CPAP group (n = 11; 100% vs. 64.7%). Compared with baseline values, the carbocysteine group showed significant improvement in their Epworth Sleepiness Scale score (10.18 ± 4.28 vs. 6.82 ± 3.66; P ≤ 0.01), apnea-hypopnea index (55.34 ± 25.03 vs. 47.56 ± 27.32; P ≤ 0.01), time and percentage of 90% oxygen desaturation (12.66 (2.81; 50.01) vs. 8.9 (1.41; 39.71); P ≤ 0.01), and lowest oxygen saturation level (65.88 ± 14.86 vs. 70.41 ± 14.34; P ≤ 0.01). Similar changes were also observed in the CPAP group. The CPAP group also showed a decreased oxygen desaturation index and a significant increase in the mean oxygen saturation after treatment, but these increases were not observed in the carbocysteine group. Snoring volume parameters, such as the power spectral density, were significantly reduced in both groups after the treatments. The plasma malondialdehyde level decreased and the superoxide dismutase and nitric oxide levels increased in both groups. The endothelin-1 level decreased in the CPAP group but did not significantly change in the carbocysteine group. Ultrasonography showed that the intima-media thickness decreased (0.71 ± 0.15 vs. 0.66 ± 0.15; P ≤ 0.05) but that flow-mediated dilation did not significantly change in the carbocysteine group. CONCLUSIONS: Oral carbocysteine slightly improves sleep disorders by attenuating oxidative stress in patients with moderate to severe OSAS. Carbocysteine may have a role in the treatment of OSAS patients with poor compliance with CPAP treatment. However, the efficiency and feasibility of carbocysteine treatment for OSAS needs further evaluation. TRIAL REGISTRATION: ClinicalTrials.gov NCT02015598.

Snoring in children.

Chronic snoring (≥4 nights per week) is not benign. Otherwise healthy children with chronic snoring and evidence of adenotonsillar hypertrophy can be referred directly for adenotonsillectomy. Snoring children <30 months or with significant medical comorbidities should be referred for specialist sleep evaluation. Older children with intermittent snoring or without significant medical comorbidities can be managed with a combination of medical and surgical interventions listed herein.

A systematic review of the pharmacological approaches against snoring: can we count on the chickens that have hatched?

BACKGROUND: Snoring is the sound produced by the vibration of the soft tissues caused by the air passing through a narrow upper airway during sleep. It is usually associated with the conditions that increase upper airway resistance, but can occur in their absence too (primary snoring). Considering its sheer prevalence, the associated comorbidities, like carotid atherosclerosis and the social disorder that it can represent, treatment for snoring must be considered even in the absence of any other medical condition. Treatment options include conservative approaches like weight reduction, smoking and alcohol cessation, sleep positioning, mechanical nasal dilators, and continuous positive airway pressure (CPAP) to more radical approaches like surgery. Till date, we have no drugs for treating the primary pathology of snoring. METHODS: A systematic literature search was carried out in PUBMED and EMBASE, and we found only nine randomized control trial's and one interventional study focusing on the pharmacotherapy of snoring per se, even as the literature is replete with studies evaluating drug therapy for obstructive sleep apnea. RESULT: Drugs evaluated include protriptyline, pseudoephedrine and domperidone, mometasone, nasal surfactant, Botulinum toxin type A, and some homeopathic and oil-based nasal sprays. The selected studies showed no strength in data and had a great methodological heterogeneity, so it is impossible to compare the analyzed studies. DISCUSSION: Even though there are no consistent data to support pharmacologic treatment for primary snoring, through the critical analysis of these studies, we have discussed about the future directions for clinical trials in this area to arrive at a clinically meaningful decision.

Nasal steroids in snorers can decrease snoring frequency: a randomized placebo-controlled crossover trial.

Although it is anecdotally known that nasal obstruction is associated with snoring, it remains unknown whether the application of nasal steroids could decrease oral/oro-nasal breathing and increase nasal breathing, and subsequently decrease snoring indices. This study evaluated the effect of nasal budesonide on breathing route pattern and snoring. Twenty-four snorers were enrolled in a randomized, double-blind, crossover trial of 1-week treatment with nasal budesonide compared with 1-week intervention with nasal placebo. At the start and end of each treatment period, patients underwent nasal resistance measurement and overnight polysomnography with concomitant measurement of breathing route pattern and snoring. Twelve patients were randomly assigned to a 1-week treatment with nasal budesonide, followed by 2-week washout period and a 1-week intervention with the nasal placebo; and 12 patients were randomly assigned to a 1-week intervention with nasal placebo, followed by 2-week washout period and a 1-week treatment with nasal budesonide. Nasal budesonide was associated with a decrease in oral/oro-nasal breathing epochs and concomitant increase in nasal breathing epochs, decrease of snoring frequency by [median (interquartile range)] 15.8% (11.2-18.8%), and an increase of rapid eye movement sleep; snoring intensity decreased only in patients with increased baseline nasal resistance by 10.6% (6.8-14.3%). The change in nasal breathing epochs was inversely related to the change in snoring frequency (Rs = 0.503; P < 0.001). Nasal budesonide in snorers can increase nasal breathing epochs, modestly decrease snoring frequency and increase rapid eye movement sleep.

Usefulness of snoreplasty in the treatment of simple snoring and mild obstructive sleep apnea/hypopnea syndrome - Preliminary report.

THE AIM OF THE STUDY: To assess the effectiveness of sodium tetradecyl sulfate injection in the region of the soft palate to treat primary snoring and mild obstructive sleep apnea/hypopnea syndrome. Sodium tetradecyl sulfate, a preparation belonging to detergents, widely applied in Poland to treat varices by the method of compressive sclerotherapy was used in the study. MATERIAL AND METHODS: The procedure of injected snoreplasty was performed in 21 patients, who were diagnosed with primary snoring or mild obstructive sleep apnea/hypopnea syndrome, based on subjective examination and polysomnography. Injected snoreplasty involves administration of sodium tetradecyl sulfate in the form of Fibrovein 1% or 3% preparation in the volume of 2ml, in the region of the soft palate. Injection of the preparation in the area of the soft palate induces the development of aseptic inflammation, which creates a scar which stiffens the soft palate and makes the tissues of this region less susceptible to vibrations. RESULTS: The patients after injected snoreplasty reported a significant decrease in the intensity of snoring. The markedly shortened total time of snoring was found in check-up polysomnography performed six months after the procedure. CONCLUSIONS: Injected snoreplasty is an effective procedure, especially, in patients manifesting persistent snoring. It is not indicated in the treatment of obstructive apneas during sleep. The advantages of this method are: minimal invasiveness, the low number of complications and slight pain.

The role of mometasone furoate nasal spray in the treatment of adenoidal hypertrophy in the adolescents: a prospective, randomized, cross-over study.

Aim of this work is to find out whether the symptoms attributable to adenoid hypertrophy in adolescents may be treated with intranasal mometasone furoate (MF) application. To learn if adenoid hypertrophy in adolescents may decrease in size with intranasal MF. A prospective, double blind, randomized, cross-over study was conducted in 28 subjects (12-18 years) with adenoidal hypertrophy. Subjects used intranasal MF or placebo for a duration of 6 weeks with a wash out period of 3 weeks. Subjective symptoms and adenoid size were evaluated. At the initiation of the study, there was no significant difference between the mean symptom scores for any of the sinonasal symptoms between the two treatment groups. There was significant improvement in total subjective symptoms (nasal blockage, rhinorrhea, cough, snoring and disruption of quality of life scores) with MF compared with placebo. Analysis of the symptoms separately showed a significant positive effect of MF on all symptoms except for rhinorrhea. Nasal endoscopic evaluation failed to demonstrate any difference in the reduction of the adenoid size between the two groups. MF has significant advantage over placebo for the symptoms attributable to adenoid hypertrophy in adolescents.

Clinical outcomes of traditional Chinese medicine compound formula in treating sleep-disordered breathing patients.

Sleep-disordered breathing (SDB) is a prevalent affliction, which can range from simple snoring to severely obstructive sleep apnea. Compared to current treatment options of SDB, traditional Chinese medicine (TCM) provides a noninvasive way to relieve SDB-related symptoms and deaths. The purpose of this retrospective study was to observe the progression of adult SDB patients who had taken compound formula SZ + NUH (concentrated herbal granules) for four weeks. Depending on subjects' individual needs, minor additions of formulas or single herbs were allowed. We found a significant amount of relief from snoring among the 118 enrolled subjects, according to before-after scores observed through the Snore Outcome Survey (SOS). Furthermore, as projected from the moderate linear correlation in before-after scores, we inferred that those cases with more severe snoring at baseline had greater improvement after treatment. Excessive daytime sleepiness was also significantly improved according to the results of the Epworth Sleepiness Scale (ESS). Assessment, using the SF-36 (Taiwanese version) revealed possible benefits of SZ + NUH in improving multiple facets of subjects' quality of life. During treatment, no significant side effects occurred. In conclusion, the TCM compound formula based on SZ + NUH could be a safe and effective option for SDB treatment.

Apnea-hypopnea indices and snoring in children diagnosed with ADHD: a matched case-control study.

OBJECTIVES: To measure apnea-hypopnea indices and snoring in children diagnosed with attention-deficit hyperactivity disorder (ADHD) in a case-control design. Additionally, the study design allowed us to investigate whether or not methylphenidate had any effect on breathing variables. METHODS: Twenty-eight children (22 boys) aged 6-12 years meeting diagnostic criteria for Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV ADHD were studied together with matched controls. Two nights of polysomnography (PSG) were conducted that included recordings of snoring waveforms. A randomly assigned 48-h on-off medication protocol was used for ADHD children. Control children's recordings were matched for PSG night, but medication was not used. A low apnea-hypopnea index (AHI) threshold of >1 event per hour was used to define sleep-disordered breathing (SDB) because of a clinical relevance in ADHD. RESULTS: Categorical analyses for paired binary data showed no significant differences between control and ADHD children for presence of an AHI >1 or snoring. Variables were extracted from a significantly shorter total sleep time (67 min) on the medication night in children with ADHD. Eight (28%) control and 11 (40%) ADHD children snored >60 dB some time during the night. Methylphenidate had no effect on central apneas, AHI, desaturation events, or any snoring data. CONCLUSIONS: Our PSG findings show no strong link between ADHD and SDB although our findings could be limited by a small sample size. Findings from PSG studies in the literature argue both for and against an association between ADHD and SDB. Our results suggest medication is not a factor in the debate.

To treat snoring with nasal steroids - effects on more than one level?

CONCLUSION: An inflammatory swelling in the uvula and nose due to vibration might be a contributing factor in snoring. The presence of corticosteroid receptors in the uvula indicates the possibility for treatment with local steroids. Use of mometasone furoate (MF) for 3 months reduced snoring and related symptoms in some patients. OBJECTIVE: To investigate the effect of a nasal steroid, MF, on snoring and related discomfort. SUBJECTS AND METHODS: In the first part of the study, uvular and nasal biopsies from six patients with social snoring were examined using immunohistochemistry to evaluate whether corticosteroid receptors were present. Then 100 snoring patients were invited to participate in the second part of the study. In all, 72 men and 22 women with a mean age of 47 years and BMI 27 answered a questionnaire about symptoms, had ENT status assessed and reported sleep and related variables for a 7 day period. After randomization to placebo or MF, they used a nasal spray for 3 months at a dosage of 200 microg. Thereafter the procedure was repeated. RESULTS: Corticosteroid receptors were present in the mucous membranes and around the blood vessels in all uvulas examined. A total of 84 patients were evaluated. No decrease in 'mean snoring score' was seen. Daytime sleepiness showed a slight improvement in the MF group and partners were less disturbed. Minor side effects were equal for both groups.

Bipolar radiofrequency uvulopalatoplasty combined with injection snoreplasty: a reasonable option for the problem of snoring.

OBJECTIVES: The aim of this study was to assess the effectiveness and morbidity of the combined use of bipolar radiofrequency uvulopalatoplasty and a sclerosing agent applied to the soft palate in patients with snoring and apnea during a 1-year follow-up period. METHODS: This was a prospective, nonrandomized study. Twenty-eight patients with primary snoring due to palatal flutter who fulfilled the inclusion criteria were enrolled. Under local anesthesia, a single procedure uvulopalatoplasty using bipolar radiofrequency applied with sterilized forceps was undertaken in combination with a sclerosing agent. RESULTS: Four patients required a repeat procedure 6 weeks after the initial operation. The postoperative Epworth Sleepiness Scale score improved significantly 360 days after surgery. Snoring, measured on the Visual Analogue Scale, decreased from 8.9 +/- 0.7 to 4.1 +/- 1.4 (p < 0.005). No complications were reported. The average reduction on the apnea-hypopnea index was from 24.2 +/- 7.1 to 12.8 +/- 4.4 (p < 0.005). CONCLUSION: Bipolar radiofrequency uvulopalatoplasty combined with injection snoreplasty is an ambulatory, cost-effective, simple, and safe method to reduce the occurrence and effects of snoring and apnea.

Treatment of habitual snoring with botulinum toxin: a pilot study.

The objective of this study was to investigate whether injections of botulinum toxin into the soft palate reduce snoring in a subgroup of patients that present an active process causing habitual snoring. The study was conducted in eight patients with habitual snoring but without evidence of obstructive sleep apnea. Polysomnography was performed for diagnostic purposes and to monitor sleep quality before and after treatment. The patients and their partners completed a questionnaire before and after treatment. Recordings of snoring noise before and after treatment were evaluated on a visual analog scale by a blinded assessor. Doses of 20 U of botulinum toxin type A (Dysport) were injected unilaterally into the muscles of the soft palate. Snoring was reduced in eight cases. The patients reported no major adverse effects. These results justify further studies of botulinum toxin therapy in patients with habitual snoring. The scheme presented for injections of botulinum toxin into the levator veli palatini muscle provides a rational basis for the design of such studies. Therapy with botulinum toxin for habitual snoring is safe, non-invasive, easy to perform, fully reversible, and thus warrants investigation under placebo-controlled, double-blind conditions. This treatment is appropriate for a disorder that is of paramount social importance but does not pose a medical threat to the individuals affected.

[Is pharmacologic treatment of sleep apnea efficient?].

High frequency of sleep disturbed breathing in adults is increasingly recognized. Obstructive sleep apnea, defined as the recurring obstruction of the upper airway is documented in 24% of adult males and 9% of females. The highest incidence is in the sixth decade. Snoring accompany 24% of middle aged man and 14% of females of the same age. Sleep apnea with the central origin, defined as the transient and recurrent cessation of breathing during sleep, is less frequent than obstructive sleep apnea. It can be identified in the wide spectrum of patients with medical, neurologic and neuromuscular diseases tightly connected with alveolar hypoventilation.

Treatment of severe snoring with a combination of pseudoephedrine sulfate and domperidone.

STUDY OBJECTIVES: Pharmacologic treatment of severe snoring has not been considered to be of great value. The objective of this study was to determine whether the combination of a nasal decongestant and a prokinetic drug would decrease or eliminate severe snoring. METHODS: Thirty healthy individuals whose sleeping partners reported that the patients had severe nightly snoring entered an open-label trial of 60 mg of pseudoephedrine and 10 mg of domperidone at bedtime for 30 days. Each night's snoring was scored on a diary by the sleeping partner. At the end of the open-label trial, a subset of subjects whose snoring had recurred were randomized to one or both placebo-controlled trials, either 60 mg of pseudoephedrine sulfate plus 10 mg of domperidone or to 30 mg of pseudoephedrine sulfate plus 10 mg of domperidone. In another placebo-controlled trial, the drug combination was compared with each component. RESULTS: In the open-label trial, 493 of 772 evaluable subject-nights were free of snoring; another 232 nights were scored as mild snoring. In the placebo-controlled trials, low-dose therapy caused a reduction in snoring, and high-dose therapy even a greater reduction in snoring. The drug combination was more effective than either agent alone. CONCLUSION: Treatment with a prokinetic agent plus a nasal decongestant reduced or eliminated severe snoring in the majority of subjects treated.

Resolution of nocturnal enuresis in snoring children after treatment with nasal budesonide.

Nocturnal enuresis has been associated with obstructive sleep apnea-hypopnea and may resolve after adenotonsillectomy. Nasal corticosteroids have improved symptoms and polysomnography findings in children with snoring. Two children with primary nocturnal enuresis, chronic nasal obstruction, and loud snoring underwent polysomnography. The apnea-hypopnea index was 4.9 and 7.3 episodes/hr, and the oxygen desaturation of hemoglobin index was 4.6 and 5.2 episodes/hr. After administration of budesonide, the frequency of snoring decreased, the polysomnography findings improved, and the enuresis resolved completely. Six months after treatment, both children were still dry at night. Administration of nasal corticosteroids is associated with resolution of enuresis in children with mild obstructive sleep-disordered breathing.

["Restricted ablation" of elongated uvula mucosa by the injection of the ethanol/steroid mixture: a new treatment for snoring and OSAS].

We developed a "Submucosal Ethanol/Steroid (E/S) Injection Method (SEIM)" using an injection prepared by dissolving steroid with powerful antiinflammatory effect, which has the excellent effect of contractile reduction in oral tissues. In this clinical trial, the ablation effect of SEIM on the abnormally elongated uvula and the soft palate was examined in each one clinical case of obstructive sleep apnea syndrome (OSAS) and simple snoring. In the OSAS, we found that the uvula was reduced from 15 to 10mm, the visual analog scale (VAS) of snoring was reduced from 10 to 4 points, and the respiration disturbance index of the apnea-hypopnea index (AHI) improved from 35.3 to 26.1 after treatment. In simple snoring, the uvula was reduced from 11 to 8.5mm and VAS was relieved from 7 to 2 points after treatment. Our approach will produce a great clinical significance for not only OSAS or simple snoring but also treatment of the allergic rhinitis, etc, because the contractile tissue reduction can be attained safely in these diseases without open surgical wounds and unnecessary deformation or destruction of the mucosal structure.

Study of lubricant-induced changes in chronic snorers (SLICCS).

OBJECTIVE: The efficacy of many of the noninvasive treatments for snoring has not been evaluated in controlled trials. This paper seeks to evaluate the efficacy of an oil-based spray in the treatment of snoring, in a double-blinded, placebo-controlled, crossover trial using objective acoustic analysis and subjective questionnaires. STUDY DESIGN AND SETTING: Participants were randomized to use both oil-based oral spray (treatment) and water-based oral spray (placebo) during a two-night in-home study period. Questionnaires were completed by participant and bed-partner in addition to audio-tape recordings which were analyzed for frequency, duration, and mean energy of snoring. RESULTS: Greatest snoring rate demonstrated 30% = benefit; 40% = no change; 30% = adverse effect (n = 20). Percent time snoring yielded: 30% benefit; 15% no change; 55% adverse effect (n = 20). Study data results for mean energy were (n = 12): benefit = 17%, no change = 33%, adverse effect = 50%. Bed-partner observations (n = 17) demonstrated 37% = benefit; 38% = no change; 25% = adverse effect. CONCLUSION/SIGNIFICANCE: Objective and subjective evaluation of the performance of the oil-based Snoreless spray in comparison to placebo demonstrated a lack of efficacy in snoring reduction.