Editorial
Positional nasal congestion. Sleep apnea’s forgotten cousin
La congestión nasal posicional. El hermano olvidado de la apnea del sueño
Christian Calvo-Henríqueza,b,
, Romina Abelleirac, Francisco J. González-Barcalac
Corresponding author
a Rhinology Study Group of the Young-Otolaryngologists of the International Federations of Oto-rhino-laryngological Societies (YO-IFOS), París, France
b Service of Otolaryngology, Hospital Complex of Santiago de Compostela, Santiago de Compostela, La Coruña, Spain
c Service of Pneumology, Hospital Complex of Santiago de Compostela, Santiago de Compostela, La Coruña, Spain
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Sleep apnea’s forgotten cousin" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "453" "paginaFinal" => "454" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Christian Calvo-Henríquez, Romina Abelleira, Francisco J. González-Barcala" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Christian" "apellidos" => "Calvo-Henríquez" "email" => array:1 [ 0 => "Christian.Ezequiel.Calvo.Henriquez@sergas.es" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Romina" "apellidos" => "Abelleira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "Francisco J." "apellidos" => "González-Barcala" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Rhinology Study Group of the Young-Otolaryngologists of the International Federations of Oto-rhino-laryngological Societies (YO-IFOS), París, France" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Service of Otolaryngology, Hospital Complex of Santiago de Compostela, Santiago de Compostela, La Coruña, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Service of Pneumology, Hospital Complex of Santiago de Compostela, Santiago de Compostela, La Coruña, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La congestión nasal posicional. El hermano olvidado de la apnea del sueño" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Nasal obstruction as an independent cause of sleep apnea is a controversial topic<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>. However, there is no doubt about its role in the subjective quality of sleep or in the tolerance and acceptance of CPAP<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> or mandibular advancement devices<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The sensation of nasal obstruction after going to bed is a common complaint among patients attending otolaryngology and pulmonology consultations, especially among patients with sleep disorders<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>. This phenomenon is known as a postural effect and is explained by inferior turbinate hypertrophy in the supine position.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The pathophysiology behind this phenomenon is still unclear. Three main hypotheses have been proposed. The first suggests that nasal venous stasis occurs in a supine position. This hypothesis is supported by the fact that nasal resistance has been shown to increase when the internal jugular vein is compressed<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>. The second hypothesis suggests a reflex phenomenon mediated by deep baroreceptors, since nasal resistance increases when the axillary artery or the sides of the body are compressed, without needing to be a supine position<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a>. The third hypothesis, based mainly on animal studies, suggests that parasympathetic tone increases in the supine position<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7–9</span></a>.</p><p id="par0020" class="elsevierStylePara elsevierViewall">There are several validated methods for measuring nasal ventilatory function, the gold standard being active anterior rhinomanometry<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>. Rhinomanometry calculates nasal resistance, i.e., the effort the subject has to make to breathe through the nose, from nasal airflow and the difference in pressure between the two nostrils. In the study of positional nasal congestion, De Vito et al. recommend performing both seated and supine rhinomanometry in a procedure they called positional rhinomanometry<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>.</p><p id="par0025" class="elsevierStylePara elsevierViewall">So far, 12 authors have explored changes in nasal resistance in a supine position using positional rhinomanometry, all of whom reported an increase in nasal resistance when patients lie down. Five groups included a total of 266 patients with snoring or sleep apnea<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,11–14</span></a>. The 4 studies that were suitable for pooling in a meta-analysis showed a combined effect of worsening nasal resistance of 0.20<span class="elsevierStyleHsp" style=""></span>Pa<span class="elsevierStyleHsp" style=""></span>s/cm<span class="elsevierStyleSup">3</span>. Another 5 authors who studied healthy volunteers found a worsening of 0.10<span class="elsevierStyleHsp" style=""></span>Pa<span class="elsevierStyleHsp" style=""></span>s/cm<span class="elsevierStyleSup">3</span> in this subgroup. To date, only 2 controlled studies have been conducted. One compared healthy controls with patients with sleep apnea<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>, while the other compared snorers with non-snorers<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>. In the first, Virkkula et al. found no statistically significant differences in increased nasal resistance between the two groups<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>. In contrast, Desfonds et al. did not perform this comparison, but they did provide data from which it could be calculated, revealing statistically significant differences, with a greater increase in nasal resistance being observed in patients who snore<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The reader unfamiliar with rhinomanometry might wonder if this effect is clinically relevant. Normal nasal resistance varies between 0.3–0.5<span class="elsevierStyleHsp" style=""></span>Pa<span class="elsevierStyleHsp" style=""></span>s/cm<span class="elsevierStyleSup">3</span>. A level of resistance higher than 0.80<span class="elsevierStyleHsp" style=""></span>Pa s/cm<span class="elsevierStyleSup">3</span> is considered severe nasal obstruction. Thus, it is understood that a worsening of 0.20<span class="elsevierStyleHsp" style=""></span>Pa<span class="elsevierStyleHsp" style=""></span>s/cm<span class="elsevierStyleSup">3</span> on the scale presented is clinically relevant. However, it is interesting to note that the relationship between nasal resistance and nasal airflow is exponential. In patients with borderline nasal resistance (0.3–0.5), small variations in nasal resistance can cause large variations in airflow. This may cause the patient to switch from nasal breathing to mouth breathing. Few authors have explored this variable. In their series, De Vito et al. found that 31% of patients with apnea, with normal baseline nasal resistance, developed pathological resistance in a supine position<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>. In this study, the authors set 0.5<span class="elsevierStyleHsp" style=""></span>Pa<span class="elsevierStyleHsp" style=""></span>s/cm<span class="elsevierStyleSup">3</span> as the limit, so this percentage may have been higher if a stricter standard, such as 0.3<span class="elsevierStyleHsp" style=""></span>Pa<span class="elsevierStyleHsp" style=""></span>s/cm<span class="elsevierStyleSup">3</span>, had been used.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Little information is available on the treatment of this phenomenon. Topical nasal corticosteroids have been shown to normalize positional nasal congestion after 2 weeks in patients with allergic rhinitis<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>. A study in patients following radiofrequency turbinate reduction was performed in which positional nasal congestion was followed up in patients with vasomotor rhinitis<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>. However, no information is currently available on treatment in patients with sleep-disordered breathing.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In our opinion, the available evidence is insufficient to make clear recommendations. However, there is a clear imbalance between risk and benefit. First of all, we should ask our patients if nasal obstruction occurs when they go to bed, as we might be surprised by how common this complaint is. This possibility should even be explored in patients who are unaware of the problem, but who report that during the day they breathe through their nose, but at night they sleep with their mouth open. This effect can be confirmed by a risk-free examination that is available in many specialized centers. We therefore believe that, with the current evidence, we have an obligation to explore this possibility in our patients. The treatment of this condition may be more controversial. There is little doubt surrounding the use of topical nasal corticosteroids, which have a high safety profile, and radiofrequency turbinate reduction, a minimally invasive though more controversial surgical technique, may be worth exploring.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-10-26" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Calvo-Henríquez C, Abelleira R, González-Barcala FJ. La congestión nasal posicional. El hermano olvidado de la apnea del sueño. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 66 | 10 | 76 |
| 2024 October | 630 | 67 | 697 |
| 2024 September | 762 | 54 | 816 |
| 2024 August | 712 | 75 | 787 |
| 2024 July | 545 | 48 | 593 |
| 2024 June | 418 | 42 | 460 |
| 2024 May | 299 | 35 | 334 |
| 2024 April | 268 | 21 | 289 |
| 2024 March | 297 | 22 | 319 |
| 2024 February | 335 | 37 | 372 |
| 2024 January | 318 | 28 | 346 |
| 2023 December | 259 | 23 | 282 |
| 2023 November | 257 | 28 | 285 |
| 2023 October | 298 | 44 | 342 |
| 2023 September | 209 | 34 | 243 |
| 2023 August | 284 | 33 | 317 |
| 2023 July | 264 | 24 | 288 |
| 2023 June | 244 | 17 | 261 |
| 2023 May | 302 | 20 | 322 |
| 2023 April | 278 | 33 | 311 |
| 2023 March | 286 | 40 | 326 |
| 2023 February | 233 | 21 | 254 |
| 2023 January | 201 | 31 | 232 |
| 2022 December | 216 | 25 | 241 |
| 2022 November | 200 | 39 | 239 |
| 2022 October | 193 | 44 | 237 |
| 2022 September | 146 | 26 | 172 |
| 2022 August | 162 | 39 | 201 |
| 2022 July | 165 | 52 | 217 |
| 2022 June | 83 | 51 | 134 |
| 2022 May | 98 | 29 | 127 |
| 2022 April | 53 | 25 | 78 |
| 2022 March | 50 | 42 | 92 |
| 2022 February | 25 | 27 | 52 |
| 2021 July | 2 | 0 | 2 |
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