Letter to the Editor

NASAL DILATOR FOR MANAGEMENT OF SLEEPAPNEA To the Editor: Sleep disorders are commonly caused by nasal obstruction. Fatigue, when present in those with nasal problems and otherwise unexplained, is often considered secondary to poor or inadequate sleep.‘,’ Nasal obstruction itself is associated with many systemic reflexes, including changes in intrathoracic pressure, pulse, and blood pressure.3 Reports during the 19th century proposed a nasal reflex rather than sleep disturbance as the origin of fatigue in many patients with nasal obstruction. The following case describes fatigue associated with nasal obstruction promptly relieved by a nasal dilator and therefore unrelated to sleep abnormalities. The patient was a 4%year-old man with a lo-year history of unexplained persistent fatigue unrelieved by rest. The fatigue was especially pronounced on awakening but continued throughout the day. It was not associated with pharyngitis, lymphadenopathy, myalgias, headache, or known sleep disturbance. Aside from fatigue, symptoms were limited to nasal congestion especially on the left side and a “heavy-headedness” sensation in the head. Four comprehensive examinations over the 10 symptomatic years were without relevant findings. Symptoms of nasal congestion and a cyst in the left maxillary sinus noted on a sinus roentgenogram prompted the following procedures: creation of antral windows, removal of the maxillary cyst, nasal septum reconstruction, and partial resection of the inferior turbinates; all with no effect on the fatigue. Approximately 8 years after the onset of fatigue, the patient noted that relief could be obtained by pressing up the left external nares. This observation suggested dysfunction of the nasal valve and prompted reconstruction using cartilage grafts, a procedure that was unsuccessful in relieving his inadequate air flow or his fatigue. At the suggestion of a consultant he purchased a nasal dilator for the left anterior nares and obtained almost immediate relief of the fatigue. Fatigue consistently returned within 15 minutes if the dilator was removed and promptly resolved when reinserted, indicating the lack of any association with sleep.

250

American

Journal

of Otolaryngology,

Systemic reactions to nasal disease are well documented in the medical literature but fatigue, when associated with nasal obstruction, is generally considered secondary to sleep abnormalities. Before the clear association of nasal obstruction and sleep abnormalities was known, reports in the older literature postulated a “nasal reflex” to explain the resolution of fatigue and a number of other significant complaints after nasal surgery or cauterization. In 1898, Wells reported cases of neurological and mental manifestations of nasal disease associated with extraordinary fatigue.* At the time of the linkage of nasal symptoms with fatigue and inability to concentrate was well accepted enough to generate the term “aprosexia nasalis.” More recent research documents profound changes in blood pressure, pulse, and respiration with nasal obstruction. Furthermore, nasal stimulation is associated with vasoconstruction, laryngeal construction, and bronchoconstriction. Cottle maintained that air currents stimulating the nasal mucosa effect remote organs by nerve pathways and may be responsible for a state of ill health. Nasal valve movements, he also noted, were largely responsible for the “rest” obtained by the body during sleeps5 This case report suggests that unilateral nasal obstruction may be responsible for fatigue independent of any effect it might have on sleep. ALEXANDER C. CHESTER, MD

Georgetown University Medical Center Washington,

DC

REFERENCES 1. Zwillich CW, Pick&t C, Hanson FN, et al: Disturbed sleep and prolonged apnea during nasal obstruction in normal men. Am Rev Respir Dis 124:158-160, 1981 2. Olsen DK, Kern EB, Westbrook PR: Sleep and breathing disturbance secondary to nasal obstruction. Otolaryngo1 Head Neck Surg 89:804-810, 1981 3. Barelli PA, Loch WE, Kern EB, et al (eds): Rhinology: The Collected Writings of Maurice H. Cottle, M.D. Rochester, MN American Rhinologic Society, 1987, pp 191192 4. Wells WA: Some nervous and mental manifestations occurring in connection with nasal disease. Am J Med Sci 116:677-692, 1898 5. Barelli PA, Loch WE, Kern EB, et al (eds): Rhinology: The Collected Writings of Maurice H. Cottle, M.D. American Rhinologic Society, 1987, pp 102-105

Vol 13, No 4 (July-August),

1992: p 250

Nasal dilator for management of sleep apnea.

Letter to the Editor NASAL DILATOR FOR MANAGEMENT OF SLEEPAPNEA To the Editor: Sleep disorders are commonly caused by nasal obstruction. Fatigue, whe...
115KB Sizes 0 Downloads 0 Views