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Sharipov Sanjar Salomovich, Tashkent State Dental Institute Khasanov Ulugbek Saidakramovich, Tashkent Medical Academy Vokhidov Ulugbek Nuridinovich, Tashkent State Dental Institute Department of Otorhinolaringology E-mail: dr_ulugbek@list.ru
MODERN ASPECTS OF TREATMENT OF RHONCHOPATHY
Abstract: Snoring is very common in the general population with around 35-45% ofmen and 15-28% ofwomen reporting habitual snoring. We studied 25 full text publications from base of PubMed from 2015 to 2017 on the topic "rhonchopathy". The study showed that the diagnose and treatment of rhonchopathy requires a careful approach, which further improves the effectiveness of treatment and improving the quality of life of patients. Keywords: rhonchopathy, diseases of ENT-organs, diagnose, treatment.
Snoring is the hallmark symptom of a spectrum of sleep- majority of individuals who snore do not suffer from OSAS related breathing disorders collectively termed sleep-dis- with EDS and would be classified as non-apneic or simple
snorers. Obviously, however, a large proportion of this population would not be sufficiently disturbed by snoring to seek medical advice and, indeed, it is not clear from the current research what proportion of people would seek treatments if these were both successful and easily available.
Of relevance to the treatment of non-apneic snoring within a UK context, two RCTs [2] were identified that had been conducted within the UK. Both of the trials were excluded from the review as neither, in line with current UK practice, had undertaken PSG or oximetry at baseline if patients presented with an ESS score of less than 10. Obstructive sleep apnea had been ruled out in patients in both studies on the basis of the ESS score and clinical examination. The first of these trials, conducted by some authors [3], assessed differences in postoperative pain with LAUP compared with coblation uvulopalatoplasty in conjunction with tonsillectomy (CP). The impact of surgical technique in the reduction of subjectively assessed snoring loudness was also assessed at 1 year in the 30 patients completing treatment. Results indicated that there was a significant reduction in snoring loudness in both groups but no between-group differences were observed. However, significant reductions in postoperative pain were observed in the CP group after day 8 and were maintained until after day 15.
The second trial another authors [4] compared LAUP with punctate palatal diathermy in 83 patients. At a mean follow-up time of greater than 18 months there were no statistically significant differences between the treatment groups in measures of patient perception of benefit from surgery or subjective evaluations of snoring improvement. In the postoperative period, however, there were significant differences
ordered breathing (SDB) [2]. Snoring is not a symptom of either sleep-related hypoventilation, as occurs in neuromus-cular diseases or obesity, or the breathing patterns in Cheyne-Stokes respiration [2]. The pathophysiological cause of SDB is sleep-induced intermittent airway obstruction. At one end of the spectrum is nonapneic or primary snoring without arousals, oxygen desaturations or significant changes in intrathoracic pressure. At the other end of the spectrum is severe obstructive sleep apnea syndrome (OSAS) characterized by frequent apnea/hypopnea events, abnormally negative intra-thoracic pressures, frequent arousals and disrupted sleep architecture, leading to excessive daytime sleepiness (EDS) [4]. Milder forms of OSAS and upper airway resistance syndrome (UARS) also form part of the spectrum. Patients with UARS have arousals during sleep related to abnormally increased work of breathing and increased upper airway resistance, but the respiratory disturbance index (RDI) may remain normal. These arousals commonly result in symptoms of EDS [5].
The aim of the review was to study the views on modern methods of diagnosing and treating rhonchopathy.
Materials of research was 25 full text publications from base ofPubMed from 2015 to 2017 on the topic "rhonchopathy".
Results of research. Snoring is very common in the general population with around 35-45% of men and 15-28% of women reporting habitual snoring [1]. Risk factors for the development and worsening of snoring include increasing age, male gender, obesity (in part used as a proxy marker for neck circumference), alcohol ingestion, smoking, sedative use and nasal obstruction. Snoring is also more common in respiratory conditions such as asthma and chronic obstructive pulmonary disease (COPD) [1]. Clearly, therefore, the
Section 11. Medicine
in the degree of pain in favour of treatment with punctuate palatal diathermy (mean difference = 22.14; 95% CI 7.9836.31). The relative risk observed for treatment complications for LAUP relative to punctuate palatal diathermy was 1.42 (95% CI 0.93-2.17).
The study of foreign scientists [6] was a RCT. Participants were studied at both shortterm and long-term follow-up times with results from the two time points reported separately in two papers published.
The other study [5] was a non-randomized CCT. Across the two studies there were a total of107 non-apnea snoring patients, of whom 45 underwent UP3 and 62 underwent LAUP. The baseline test to rule out OSAS [5] was an overnight sleep study using a DENSA Compact Sleep Apnea Screening System; in some study [8] it appeared to be oximetry. Participant baseline demographics in both of the studies were not reported separately for the UP3 and LAUP groups except for age in the another study. The mean age of the participants ranged from 49.40 to 51.96 years. The proportion of men was 87% and 76% in the two studies respectively.
Evidence on the clinical effects of UP3 versus LAUP was limited. The two identified studies [2,7] were of poor quality and few between-group comparisons were made. Heterogeneity between the two studies precluded pooling of the evidence. One RCT [6] assessing the SI found that it was significantly reduced in both the UP3 and the LAUP groups (n = 18 and n = 29 respectively) at short-term follow-up after surgery (mean 3.4 months, range 2-11 months) but there was no significant difference between the two groups in the number of patients who had either a lower SI or a higher SI after the surgery. The UP3 (n = 11) and LAUP (n = 12) SI of 23 patients pooled from the two groups dropped from 135.6 snores/hour at baseline to 38.2 snores/hour at short-term follow-up and 21.7 snores/hour at long-term follow-up (median 45 months, range 29-56 months). The reduction from baseline to long-term follow-up was statistically significant. SI decreased from baseline to long-term follow-up in both the UP3 and LAUP groups; however, the reduction was not significantly different between the two groups.
Based on very limited evidence from two small poor-quality studies UP3 appears to be more efficacious than LAUP in improving some subjectively measured snoring outcomes and snoring-related problems. However, this effect was not consistently observed across all subjective outcome measures. Both UP3 and LAUP seemed to reduce the SI and snoring loudness; however, the effects did not differ between the two operations.
A total of seven studies assessed the effects of RFA techniques [2]. In six of the studies surgery was to the soft palate [3] and in the remaining study it was to the tongue base [4]. The available evidence consisted of one RCT [6], which
compared soft palate RFA with placebo; one CCT conducted [5], in which soft palate RFA was compared with the short-term use of a MAS; and five pre-post studies, four of which assessed RFA to the soft palate [8] and one that evaluated bipolar RFA of the tongue base [7].
Study sample sizes were small ranging from 9 to 45 participants, with a median of 20. Overall there was a total of151 participants across the studies. Duration of follow-up ranged from 10 weeks to 1 year.
In six of the studies patients had undergone a PSG at baseline to rule out O SAS [1] and in the remaining study patients had undergone a sleep study (type unspecified) [1]. Investigations at baseline to assess the site of airway narrowing included clinical examination alone [4]; clinical examination in conjunction with endoscopy plus or minus cephalometric radiography [3]; lateral cephalometry alone [4]; and endoscopy alone [6]. In one study baseline tests were not reported [8]. The age range of participants included in the studies was from 26 to 67 years. Some authors [7] assessed bed partner-rated snoring levels, ESS and postoperative adverse events in 23 patients (12 in the RFA group and 11 in the placebo group).
From the small number of studies available the evidence suggests that at 1 year of follow-up after RFA of the soft palate there is a significant decrease in partner-reported levels of snoring severity. However, any treatment benefit with RFA may only be moderate as an unweighted mean decrease of only 3.24 points was observed for partner-reported snoring levels. Additionally, relapse rates may be quite high at longer follow-up times. There is no strong evidence to suggest that subjectively assessed partner-reported snoring levels are correlated with objective measures of snoring sound intensity. In all studies treatment with RFA had a positive effect on levels of ESS but in only two studies did these reach statistical significance. However, this is likely to be a reflection of the fact that patients' baseline levels of ESS were within the range considered normal, and therefore a floor effect would be in operation. The majority of the available evidence suggests that RFA has no detrimental or positive effects upon any PSG parameters, such as AHI or sleep oxygen saturation levels. Additionally, there was no evidence either from cephalometric or from MRI-assessed measurements of the palate that RFA has any overall significant effect on palatal width or length. No serious adverse events were reported and overall complication rates across the studies were low.
Five studies reported in six publications assessed the effects of palatal stiffening techniques for palatal flutter snoring [2]. Four studies assessed palatal implants and one assessed injection snoreplasty. The available evidence base consisted of one small RCT that evaluated the effects of increased rigidity in palatal implants [3] and four pre-post studies, three
of which assessed palatal implants [7] and one that assessed injection snoreplasty [4]. Overall across the studies a total of 134 participants were included. Study sample size was small ranging from 12 to 40 with a median of 27. In the four studies that assessed palatal stiffening techniques [1] the duration of follow-up ranged from 3 to 12 months.
From the limited evidence available it appears that, in the year after treatment with Pillar implants, there is a significant decrease in partner and patient-reported levels of snoring severity. However, this treatment benefit appears to be relatively modest, with an unweighted mean decrease of 2.68 points on a 10-point VAS scale.
None of the studies attained a mean post-treatment score of less than 4 and, in the two studies in which it was reported, only 23.5% and 22% of patients achieved a VAS score of < 3. There is no evidence to suggest that partner-reported levels of snoring severity are corroborated by objective measures of snoring sound intensity, as no significant differences in any measure of objective snoring sound intensity were reported. In all studies Pillar implants had a significant positive benefit on ESS scores, but these were within the range considered normal at baseline. The limited available evidence also suggests that the use of Pillar implants does not have any significant positive or negative effects on any PSG-measured indices and, where any changes were reported, these may well be related to the 'noise' associated with the measurement of these
parameters. Postoperative pain and swallowing and speech difficulties were all rated as mild or mild to moderate, and the use of the technology does not appear to be associated with any moderate or serious adverse events.
Given the limited very poor-quality evidence available on the effects of injection snoreplasty it is not possible to draw any conclusions regarding the safety and efficacy of this treatment without consideration of substantive further evidence on the use of this technology.
The study, conducted by many authors [3, 7, 8], assessed the effects of Continuous positive airway pressure (CPAP) in the treatment of non-apnea snoring. The aim of the study was to evaluate the effect of discontinuing nasal continuous positive airway pressure (NCPAP) treatment on the snoring characteristics of patients. The study included 18 non-apnea snorers who were allocated to either NCPAP or a no-treatment control group. The control group were studied twice, at baseline and at 30 days' follow-up.
There is very little evidence available on the effects of CPAP for the management of non-apnea snoring. What evidence is available suggests that the use of CPAP may be effective in reducing levels of snoring, without having any adverse effects on PSG-measured parameters. However, given the poor-quality evidence available it is not possible to draw any definitive conclusions regarding the efficacy and safety of the use of CPAP for the management of non-apneic snoring.
References:
1. Camacho M., Certal V., Abdullatif J. et al., "Myofunctional therapy to treat obstructive sleep apnea: a systematic review and meta-analysis," Sleep,- Vol. 38.- No. 5.- 2015. - P. 669-675.
2. Camacho M., Certal V., Capasso R. "Comprehensive review of surgeries for obstructive sleep apnea syndrome". Brazilian Journal of Otorhinolaryngology,- Vol. 79.- 2013. - No. 6.- P. 780-788.
3. Camacho M., Dunn B., Torre C. et al. "Supraglottoplasty for laryngomalacia with obstructive sleep apnea: a systematic review and meta-analysis," The Laryngoscope,- 2015.
4. Certal V., Nishino N., Camacho M., Capasso R. "Reviewing the systematic reviews in OSA surgery," Otolaryngology - Head and Neck Surgery,- Vol. 149.- No. 6.- 2013.- P. 817-829.
5. Chouard C. H. Did Napoleon suffer from chronic rhonchopathy? Acta Otolaryngol.- 2017.- Apr; 137 (4): 361-364.
6. Elizarova L. N., Grinchuk V. I. General oxygen supply in males with rhonchopathy. Vestn Otorinolaringol.- 2007; (6): 43-7.
7. Esenbaeva A. K. Clinical features, diagnostics, and treatment of rhonchopathy. Vestn Otorinolaringol.- 2011;(5): 88-91.
8. Turovsky A. B., Tardy M. V., Kondrashin V. The effectiveness of surgical repair of nasal breathing with snoring and obstructive sleep apnea syndrome. Russian Rhinology,- 2015.- No. 4.- P. 8-12.
