10.14639/0392-100X-N1578
Objective. The aim of our study was to investigate the presence of dysphagia in patients with Obstructive Sleep Apnoea (OSA) and to correlate swallowing impairment with hypnologic and anatomic parameters. Methods. The study population includes 36 patients suffering from OSA. Patients were divided into two groups using the presence of dysphagia as a distinctive parameter. Group 1 included 27 OSA patients without signs of dysphagia and Group 2 included 9 OSA patients with signs of dysphagia. Results. The age of patients in Group 2 was higher compared with the age of patients in Group 1. Analysis of Continuous Positive Airway Pressure (CPAP), obtained in the titration phase, showed that OSA patients with signs of dysphagia required a higher level of CPAP pressure than those who were not affected by swallowing abnormalities (12.6 ± 1 vs 10.5 ± 1.9 p = 0.003). No other differences in anthropometric, hypnologic, or arterial blood gas values were found between the two groups. Conclusions. In clinical practice, all OSA patients should undergo a complete ENT exam, including assessment of swallowing, before CPAP therapy is started. This may predict the need for higher CPAP pressure settings to resolve apnoea episodes in the presence of dysphagia as well as guide the choice of CPAP interfaces (orofacial vs. nasal) in these patients.
text/xml
1827-675X
1578
en
Maria Luisa Fiorella
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
CPAP
The association between dysphagia and OSA
Text.Serial.Journal
https://www.actaitalica.it/
42
OSAHS
2022-02-07
2021-03-22
2022-03-07
2022-03-07
82-88
1
Maria Luisa Fiorella
2022/02/07
10.14639/0392-100X-N1578
82
Otolaryngology Unit, Department of Biomedical Sciences, Neuroscience and Sensory Organs, University of Bari “Aldo Moro”, Italy
1827-675X
CPAP
88
The association between dysphagia and OSA
https://www.actaitalica.it/article/download/1578/732
42
ACTA OTORHINOLARYNGOLOGICA ITALICA 2022;42:82-88; doi: 10.14639/0392-100X-N1578




OSAHS


The association between dysphagia and OSA
Disfagia e OSA
Lorenzo Marra1, Giada Cavallaro2, Valentina Di Lecce3, Giorgio Castellana4, Carla Santomasi3, Vincenzo Di Nicola2,
Nicola Antonio Adolfo Quaranta2, Giovanna Elisiana Carpagnano3, Onofrio Resta3, Maria Luisa Fiorella2
1
  Respiratory Disease Unit, “San Giuseppe Moscati” Hospital, Taranto, Italy; 2 Otolaryngology Unit, Department of Biomedical
Sciences, Neuroscience and Sensory Organs, University of Bari “Aldo Moro”, Italy; 3 Institute of Respiratory Disease, Department of
Basic Medical Science, Neuroscience and Sensory Organs, University of Bari “Aldo Moro”, Italy; 4 Respiratory Rehabilitation of the
Institute of Bari, Istituti Clinici Scientifici Maugeri IRCCS, Bari, Italy


SUMMARY
Objective. The aim of our study was to investigate the presence of dysphagia in patients
with Obstructive Sleep Apnoea (OSA) and to correlate swallowing impairment with hypno-
logic and anatomic parameters.
Methods. The study population includes 36 patients suffering from OSA. Patients were
divided into two groups using the presence of dysphagia as a distinctive parameter. Group 1
included 27 OSA patients without signs of dysphagia and Group 2 included 9 OSA patients
with signs of dysphagia.
Results. The age of patients in Group 2 was higher compared with the age of patients in
Group 1. Analysis of Continuous Positive Airway Pressure (CPAP), obtained in the titra-
tion phase, showed that OSA patients with signs of dysphagia required a higher level of
CPAP pressure than those who were not affected by swallowing abnormalities (12.6 ± 1 vs
10.5 ± 1.9 p = 0.003). No other differences in anthropometric, hypnologic, or arterial blood
gas values were found between the two groups.
Conclusions. In clinical practice, all OSA patients should undergo a complete ENT exam,
including assessment of swallowing, before CPAP therapy is started. This may predict the
need for higher CPAP pressure settings to resolve apnoea episodes in the presence of dys-
phagia as well as guide the choice of CPAP interfaces (orofacial vs. nasal) in these patients.
                                                                                                     Received: March 22, 2021
KEY WORDS: obstructive sleep apnoea syndrome, dysphagia, swallowing impairment,                      Accepted: September 29, 2021
CPAP                                                                                                 Published online: February 7, 2022

                                                                                                     Correspondence
RIASSUNTO                                                                                            Giada Cavallaro
Obiettivo. Il nostro studio ha avuto come obiettivo la ricerca nei pazienti OSA di evidenze          Otolaryngology Unit, Department of Biomedical
di disfagia e l’associazione della presenza di disfagia alla anatomia delle prime vie aero-          Sciences, Neuroscience and Sensory Organs, Uni-
digestive e ai parametri ipnologici ed emogasanalitici di questi pazienti.                           versity of Bari “Aldo Moro”,
Metodi. Tutti i pazienti sono stati sottoposti a emogasanalisi, spirometria, rinomanometria,         p.zza G. Cesare, 70120 Bari, Italy
videofibrorinolaringoscopia, valutazione fibroendoscopica della deglutizione (FEES), poli-           E-mail: giadacavallaro@live.it
sonnografia notturna, studio di titolazione della pressione di lavoro di CPAP, somministra-
zione del questionario “SWAL-QOL”.                                                                     How to cite this article: Marra L, Caval-
Risultati. Il 25% della popolazione studiata ha presentato segni subclinici di disfagia. Il            laro G, Di Lecce V, et al. The association
gruppo dei pazienti non disfagici era formato da soggetti più giovani rispetto al gruppo               between dysphagia and OSA. Acta Otorhi-
dei pazienti disfagici. Il distretto orofaringeo è risultato essere il sito di ostruzione più fre-     nolaryngol Ital 2022;42:82-88. https://doi.
quente per entrambi i gruppi. Nello studio di titolazione della pressione di lavoro di CPAP,           org/10.14639/0392-100X-N1578
i pazienti disfagici necessitano di valori di pressione più alti.
Conclusioni. Un paziente OSA su 4 ha presentato segni di disfagia. La disfagia è associata           © Società Italiana di Otorinolaringoiatria
a valori più elevati di pressione allo studio di titolazione della CPAP. I pazienti OSA hanno        e Chirurgia Cervico-Facciale
un rischio più elevato di presentare disturbi di deglutizione con l’avanzare dell’età rispetto
alla popolazione generale.                                                                                          OPEN ACCESS

PAROLE CHIAVE: sindrome delle apnee ostruttive nel sonno, disfagia, disturbi di                      This is an open access article distributed in accordance with
                                                                                                     the CC-BY-NC-ND (Creative Commons Attribution-Non-
deglutizione, CPAP                                                                                   Commercial-NoDerivatives 4.0 International) license. The
                                                                                                     article can be used by giving appropriate credit and mentio-
                                                                                                     ning the license, but only for non-commercial purposes and
                                                                                                     only in the original version. For further information: https://
                                                                                                     creativecommons.org/licenses/by-nc-nd/4.0/deed.en




82
                                                                                  A multidisciplinary approach to obstructive sleep apnoea




Introduction                                                      nasal septum deviation, choanal atresia, macroglossia, hy-
                                                                  pertrophy of the soft palate, uvula, lingual tonsil and turbi-
Obstructive Sleep Apnoea (OSA) is characterised by re-            nates, malformations of epiglottis, fat deposits around the
peated episodes of upper airway occlusion, associated with        pharynx) 9.
oxyhaemoglobin desaturations and brief awakenings from            The complications of OSA may include cognitive impair-
sleep (arousals) 1. Due to sleep fragmentation, signs and         ment, depression, nocturnal oesophageal reflux and noc-
symptoms of OSA include snoring, abrupt awakenings ac-            turia 10.
companied by gasping or choking and excessive daytime             Some studies have shown that patients with OSA may be af-
sleepiness. This latter condition inevitably leads to an in-      fected by swallowing dysfunctions, which reflects the abnor-
crease in cardiovascular risk (risk of arterial hypertension,     mal function of nerves and muscles in the suprapharynx 11.
myocardial infarction and cerebral ischaemia) 2 and worsen-       The aim of the present study was to investigate the pres-
ing of the subject’s quality of life, as well as an obvious in-   ence of oropharyngeal dysphagia in patients with OSA and
crease in the frequency of road or occupational accidents 3.      to correlate swallowing impairment with hypnologic, ana-
The disruption of the oro-nasal airflow lasts, by definition,     tomic and arterial blood gas values.
for at least 10 seconds and can be complete (apnoea) or
partial (hypopnoea) 4.
The severity of OSA is scored according to the number of          Materials and methods
apnoeas or hypopnoeas, recorded during the study, per hour        Thirty-six OSA patients from the Sleep Disorder Centre of
of sleep (apnoea/hypopnoea index - AHI). OSA is therefore         “Department of Respiratory Disease” were recruited and
classified as mild (AHI > 5, but < 15 per hour), moderate         assessed at “ENT Clinic”, University of Bari. Of the 36 pa-
(AHI > 15, but < 30 per hour) and severe (AHI > 30 per hour) 5.   tients enrolled, 26 were males and 10 females (respectively,
During nocturnal respiratory events, the size of the upper        72.2% and 27.8%).
airway depends on the balance between forces that would           The exclusion criteria included age > 75 years and < 45
collapse the airway (such as negative intraluminal pressure       years, daytime respiratory failure, Overlap Syndrome
and increased tissue-extraluminal pressure) and those that        (Chronic Obstructive Pulmonary Disease and OSA), obe-
maintain airway (contraction of pharyngeal dilator muscles).      sity hypoventilation syndrome (OHS), neuromuscular dis-
The most frequent sites of pharyngeal collapse are the soft       orders, neurological diseases, gastroenterological diseases,
palate, lateral pharyngeal walls, palatine tonsils and base       craniofacial malformations, decompensated clinical and
of the tongue. The larynx can also be involved as a site of       psychiatric illnesses and patients who had used CPAP ther-
obstruction.                                                      apy in the preceding three months.
During sleep, the compensatory tonic input to the motor           Participants were approached and informed about the study
neurons of the pharyngeal dilator muscle is lost, causing         objectives and significance, before confirming their avail-
collapse of the pharyngeal airway until chemoreceptor             ability to take part in the present research.
stimuli activate the neuromuscular compensatory functions         All patients underwent the following tests:
that maintain airway patency. The use of CPAP or surgi-           • recent and remote pathological anamnesis, family his-
cal treatments of OSA reduce collapse in the upper airway            tory and pharmacological anamnesis. Patients were also
tract between the supraglottic region of the larynx and hy-          interrogated about dietary and other habits, comorbidi-
popharynx, which results in improved oxyhaemoglobin                  ties and general symptoms of sleep disorders.
saturation and reduced hypercapnia 6.                             • Body Mass Index (BMI);
The risk factors for OSA include anatomic-functional ab-          • Epworth Sleepiness Scale (ESS);
normalities in the nasal and nasopharyngeal area (“naso-          • arterial blood gas analysis;
pharyngeal level”), in the back palatal area and at the Isth-     • spirometry;
mus of fauces (“oropharyngeal level”) and in the region           • full-night cardiorespiratory polygraphy recording (Nox-
that includes the hyoglossus-mandibular complex and the              T3, Nox Medical Inc. Reykjavik, Iceland). The follow-
rear lingual space (“hypopharyngeal level”) 7.                       ing data were collected: snoring sound, body position,
Specifically, Waldeyer ring hypertrophy is widespread in             activity, heart rate, nasal pressure, oxyhaemoglobin
the OSA paediatric population8, while in adulthood, both             saturation, and thoracic and abdominal movements. The
the alterations of the splanchnocranial skeletal morpho-             hypnological parameters obtained were evaluated by a
type and the anatomical pathologies and dysmorphisms of              physician experienced in sleep breathing disorders;
the upper aero-digestive tract have been reported to play a       • clinical examination to assess the anatomical charac-
decisive role in the pathogenesis of OSA (nasal growths,             teristics of the upper airways [Friedman tongue posi-



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L. Marra et al.




   tion staging system (FTP), tonsil hypertrophy grading         Table I. Demographic and clinical characteristics of the cohort.
   scale] 12;                                                     Patients (n)                                                        36
• rhinomanometry;                                                 Age (years, Mean ± SD)                                         60.7 ± 11.1
• fiber optic nasopharyngolaryngoscopy of the upper air-          Male gender n (%)                                              26 (72.2%)
   ways, during which a modified Muller maneuver at oro-          BMI (Mean ± SD)                                                33.6 ± 6.9
   pharyngeal and hypopharyngeal levels was carried out           ESS (Mean ± SD)                                                   7±5
   according to the nose oropharynx hypopharynx and lar-          OSA severity n (%)
   ynx (NOHL) classification 13;                                     Mild                                                          3 (8%)
• fibre optic endoscopic evaluation of swallowing (FEES)             Moderate                                                      6 (17%)
   using boluses of different texture: liquid, semisolid and
                                                                     Severe                                                       27 (75%)
   solid bolus. We analysed the anatomical structures and
                                                                  CPAP Pressure (Mean ± SD)                                      11.1 ± 1.9
   the functional aspects of the swallowing events, accord-
                                                                  Tonsil volume n (%)
   ing to the following criteria : (a) premature oral leakage,
                                                                     Grade 1                                                      19 (53%)
   if the bolus entered the pharynx without eliciting the
                                                                     Grade 2                                                      11 (31%)
   swallowing reflex; (b) laryngeal penetration if the bo-
   lus penetrated the laryngeal vestibule but not below the          Grade 3                                                       6 (16%)
   vocal cords; (c) tracheal aspiration if the bolus passed       Friedman tongue position staging system n (%)
   below the vocal cords; lastly, (d) pharyngeal stasis if the       Grade 1                                                       4 (11%)
   bolus remained in the valleculae and/or pyriform sinuses          Grade 2                                                       6 (17%)
   after the swallowing sequence, using the Yale Pharyn-             Grade 3                                                      14 (39%)
   geal Residue Severity Rating Scale 14. The Yale Phar-             Grade 4                                                      12 (33%)
   yngeal Residue Severity Rating Scale is a standardised,        Post-swallowing stasis at FEES n (%)                             9 (25%)
   anatomically defined, image-based assessment of post-         SD: standard deviation; BMI: Body Mass Index; ESS: Epworth Sleepiness Scale; OSA:
                                                                 Obstructive Sleep Apnoea Syndrome; CPAP: continuous positive airway pressure; FEES:
   swallow pharyngeal residue, based on a 5-grade rating         Fibre-optic endoscopic evaluation of swallowing.
   of the amount of residue in two locations, the vallecula
   and the pyriform sinus as observed during fiberoptic en-
   doscopic evaluation of swallowing;                            ity Rating Scale, none/trace grade of severity of vallecular
• the Italian version of SWAL-QOL questionnaire on               residue was observed in 2 subjects (22.2%) mild grade of
   quality of life in dysphagia 15;                              severity of vallecular residue was observed in 3 (33.3%)
• CPAP titration study.                                          and moderate grade of severity in 4 (44.4%) subjects, but
The results are presented as percentages for categorical         no participant showed severe vallecular residue.
variables and as mean ± standard deviation (SD) for con-         As for the pyriform sinus location, 3 (33.3%) respondents
tinuous variables. The proportions were compared using           showed none/trace, and 4 patients (44.4%) had mild sever-
the Pearson χ2 test. The means were compared using the           ity of residue. While the remaining 2 (22.2%) subjects had
two-tailed Student’s t-test. A p value < 0.05 was considered     moderate severity of residue, no individuals with severe
as significant.                                                  residue in the pyriform sinuses were observed.
                                                                 In the group of patients who presented bolus residue after
                                                                 swallowing, 8 patients had severe OSA (88.9%) and 1 pa-
Results                                                          tient had moderate OSA (11.1%).
The clinical and demographic characteristics of the 36 pa-       No cases of laryngeal penetration or tracheal aspiration
tients in this study are presented in Table I.                   were observed. We used the NOHL classification system
Oropharyngeal examination revealed that 53% of subjects          and found that the oropharyngeal level was the most fre-
(n = 19) had grade 1, 31% had grade II (n = 11) and 16           quent obstruction site (average value 2.5 ± 1.13) followed
(n = 6) had grade III tonsil size.                               by the hypopharynx level (average value = 1.62 ± 1.04), the
According to the Friedman tongue position staging system,        larynx (average value 0.26 ± 0.57) and nasal level (average
11% of the cases (n = 4) were classified as FTP stage 1,         value 0.18 ± 0.39) (Fig. 1).
17% (n = 6) as stage 2, 39% (n = 14) as stage 3 and 33%          Using the presence of dysphagia as a distinctive parameter,
(n = 12) as stage 4.                                             the cohort of patients was divided into two groups. Group 1
The results of FEES demonstrated that a post-swallow resi-       included 27 patients with OSA without signs of dysphagia
due with solid bolus texture was present in 25% of patients      and Group 2 included 9 patients with diagnosis of OSA and
(n = 9). According to the Yale Pharyngeal Residue Sever-         signs of dysphagia.



84
                                                                                               A multidisciplinary approach to obstructive sleep apnoea




                                                                         Table II. Anthropometric, hypnologic and arterial blood gas values.
                                                                                                        Group 1            Group 2           p
                                                                                                         (n. 27)             (n. 9)
                                                                          Age (years)                      58.3 ± 10.5         67.9 ± 10            0.02
                                                                          BMI                               33.6 ± 7.4          33.7 ± 5             Ns
                                                                          Gender (M) n(%)                  18.0 (66.6)        8.0 (88.8%)            Ns
                                                                          AHI                              38.1 ± 22.6         44.8 ± 17             Ns
                                                                          ODI                              35.6 ± 23.1        42.5 ± 19.5            Ns
                                                                          TST90                            26.9 ± 26.7        30.6 ± 17.6            Ns
                                                                          Mean nocturnal SO2                92.0 ± 2.3         91.3 ± 1.8            Ns
                                                                          pO2                              83.4 ±15.2         77.4 ± 11.1            Ns
                                                                          pCO2                              40.6 ± 3.9         40.1 ± 3.5            Ns
Figure 1. NOHL classification. N: Nose; O: oropharynx; H: hypopharynx;
L: larynx; percentage of patients and grade of obstruction.               HCO3-                             27.3 ± 3.2         26.9 ± 2.8            Ns
                                                                          Diurnal SO2                       96.1 ± 1.9         95.3 ± 1.8            Ns
                                                                         BMI: Body Mass Index; AHI: Apnoea Hypopnoea Index; ODI: Oxygen Desaturation Index;
                                                                         TST90: Total Sleep Time with oxyhaemoglobin saturation below 90%; SO2: oxyhaemo-
Anthropometric, hypnologic and arterial blood gas values                 globin saturation. Ns: Not statistically significant.
were compared between the two groups: Patients in Group
2 (dysphagia) were older than patients in Group 1 (no dys-
phagia). Statistically significant differences were not de-              Table III. Tonsillar size, Friedman tongue position staging system, upper air-
tected in other items (Tab. II).                                         way collapsibility and nasal resistances.
No significant differences were found between the two                                                           Group 1          Group 2         p
groups with respect to the grading of tonsil size, Friedman               Tonsil size
tongue position staging system, sites of upper airway col-                   Grade 3-4                                3                  2             Ns
lapse, or nasal resistances (Tab. III).                                      Grade 1-2                               24                  7             Ns
There was also no significant difference between the SW-                  Friedman tongue position
AL-QOL scores of patients with and without signs of dys-                  staging system
phagia (Tab. IV).                                                            Grade 3-4                               17                  8             Ns
Finally, we analysed the CPAP pressures obtained in the                      Grade 1-2                               10                  1             Ns
titration phase in the 2 groups: OSA patients with signs                  Upper airway collapsibility
of dysphagia required higher level of CPAP pressure than                     Oropharynx                              18                  6             Ns
OSA patients not affected by swallowing abnormalities                        Other district                          9                   3             Ns
(p = 0.003) (Tab. V).                                                     Nasal resistances
                                                                             Yes                                      9                  4             Ns
Discussion                                                                   No                                      18                  5             Ns
Although our sample size is not large, the OSA patients                  Group 1: patients with OSA without dysphagia. Group 2: patients with OSA and signs of
                                                                         dysphagia. Ns: Not statistically significant.
enrolled (average age 60.7 years) showed a prevalence
of dysphagia of 25%. The recent literature 16 has already
highlighted a prevalence of swallowing disorders between                 enrolled 72 patients (54 men and 18 women); all patients
16% and 78% in the population affected by OSA under the                  underwent fibre optic evaluation of swallowing using bo-
age of 75 years, which is consistent with our result. Fur-               luses of different textures and each patient also completed
thermore, our data show that the perception of swallowing
                                                                         the SWAL-QOL questionnaire: 64 patients (89%) present-
abnormalities among the same type of patients appears to
                                                                         ed spillage, 20 (28%) presented piecemeal deglutition, 26
have little-to-no significance.
Our patients completed autonomously the Italian version                  patients (36%) presented penetration and 30% presented
of the SWAL-QOL test before FEES examination: the                        retention. Comparing the SWAL-QOL scales in OSA pa-
SWAL-QOL scores of patients with and without signs of                    tients with and without signs of dysphagia, they found a
dysphagia (Group 1 and Group 2, respectively) showed no                  small difference in only two spheres (general burden and
significant difference between the two groups, suggesting                symptoms) of the SWAL-QOL questionnaire. These stud-
that patients who suffer from OSA may present subclini-                  ies show that the evaluation of dysphagia cannot be per-
cal manifestations of abnormal swallowing. Schindler et al.              formed exclusively using self-assessment questionnaires, but



                                                                                                                                                           85
L. Marra et al.




Table IV. The SWAL-QOL scores.                                                             for the study of dysphagia and revealed no significant dif-
                                          Group 1             Group 2             p        ference between patients with and without dysphagia in
 Burden                                    9 ± 1.6            8.7 ± 2.3          Ns        the site of obstruction during Muller maneuver. Addition-
 Eating desire                           14.7 ± 3.8          13.4 ± 2.2          Ns        ally, no anatomical differences were noted between the
 Eating duration                          9.3 ± 1.3           8.7 ± 2.1          Ns        two groups in terms of Friedman tongue position staging
 Symptoms                                 61 ± 6.9            59 ± 8.5           Ns        system, grading of tonsil size and nasal resistances. CPAP
 Food Selection                           8.4 ± 2.4           8.3 ± 2.3          Ns        titration showed that OSA patients with dysphagia required
 Communication                             8.9 ± 2            9.3 ± 1.1          Ns        higher levels of pressure compared to patients without
 Fear                                    17.7 ± 3.3          17.6 ± 3.5          Ns        swallowing disorders. This finding could be dependent on
 Mental health                           22.6 ± 4.5          22.8 ± 3.4          Ns        the lower genioglossus muscle responsiveness during sleep
 Social functioning                       22.8 ± 4           22.9 ± 2.4          Ns        that can be observed in some OSA patients, according to a
 Fatigue                                 10.4 ± 3.3          8.4 ± 4.4           Ns        study by Eckert et al., where the author analysed the patho-
 Sleep                                   7.3 ± 2.4           6.8 ± 2.7           Ns        physiologic causes of OSA and proposed a phenotypical
SWAL-QOL questionnaire dysphagia-related quality of life concepts (food selection, bur-    definition of disease. Eckert’s study shows that more than
den, mental health, social functioning, fear, eating duration, eating desire, communica-   30% of OSA patients seem to have a poor muscle respon-
tion) and SWAL-QOL general quality of life concepts (sleep and fatigue). Group 1: pa-
tients with OSA without dysphagia. Group 2: patients with OSA and signs of dysphagia.
                                                                                           siveness, as measured by genioglossus electromyogra-
Ns: Not statistically significant.                                                         phy 21. The success of therapy in this type of OSA patients
                                                                                           with dysphagia should include careful follow-up to ensure
                                                                                           a good compliance of the patient, despite the high CPAP
Table V. CPAP titration.                                                                   pressure setting. This may also help improve the patient
                                          Group 1             Group 2             p        acceptance of CPAP therapy.
 CPAP titratiomn (cmH2O)                 10.5 ± 1.9           12.6 ± 1         0.003       Moreover, the treatment of OSA with CPAP seems to be
CPAP: continuous positive airway pressure. Group 1: patients with OSA without dyspha-      able to reverse the endoscopic findings of swallowing dys-
gia. Group 2: patients with OSA and signs of dysphagia.
                                                                                           function and to improve the quality of life, according to the
                                                                                           criteria measured by the SWAL-QOL questionnaire, as dem-
that performing instrumental investigations is crucial 17. In                              onstrated in the study by Caparroz et al. on 70 adult patients
particular, 41 heavy snorers and 15 non-snoring volunteers                                 with moderate or severe OSA. The study analysed the signs
were video-radiographically examined by Jaghagen et al.                                    and symptoms of oropharyngeal dysphagia using FEES
with regards to the oral and oropharyngeal phases of swal-                                 and SWAL-QOL in 18 patients with signs of dysphagia, of
lowing. The most common finding of abnormal pharyngeal                                     whom 12 were treated with CPAP for 3 months. The results
swallowing function in snorers was repeated premature bo-                                  revealed that the treatment of OSA with CPAP was able to
lus leakage down to different levels of the pharynx before                                 reverse the endoscopic findings of dysphagia and improve
the swallowing reflex was elicited (51%), followed by pre-                                 quality of life, as measured by the SWAL-QOL test 22.
mature bolus leakage that intermittently continued down to                                 Moreover, assessing the presence of dysphagia in OSA pa-
the piriform sinus (12%) and the presence of bolus residual                                tients plays a fundamental role in prevention of one of the
in pharynx (10%) 18. Valbuza et al. studied 11 patients with                               most frequent complications in swallowing deficiency: in-
OSA ad 14 non-snoring volunteers who were evaluated us-                                    halation pneumonia. The incidence of inhalation pneumo-
ing FEES: 64% of OSA patients presented premature oral                                     nia in the elderly rises with increasing age and Cabre et al.
leakage, 55% presented pharyngeal stasis of the bolus after                                showed that, in a population of 134 patients, aged over 75
swallowing and no cases of laryngeal penetration or tracheal                               years, hospitalised for pneumonia, 55.2% presented signs
aspiration were observed, which explains why patients with                                 of oropharyngeal aspiration. Dysphagia can therefore be
swallowing dysfunction remained asymptomatic 19. Recent-                                   considered a poor prognostic factor in terms of mortality 23
ly, 60 patients with OSA were subjected to cephalometric                                   but OSA alone, per se, seems to carry a greater risk of de-
evaluation, orofacial myofunctional evaluation with score                                  veloping pneumonia 24. Chiner et al. demonstrated that the
(OMES-E) and swallow video fluoroscopy exam by Val-                                        presence of OSA is associated with a greater risk of devel-
arelli et al. The OSA patients showed substantial orofacial                                oping community acquired pneumonia, and AHI correlates
and pharyngeal muscular impairment, swallowing disorders,                                  with the severity of infection 25. This connection between
narrower pharynx and lower hyoid position compared to a                                    OSA and the pulmonary infections provide strong evidence
control group 20.                                                                          of the need to follow OSA patients with dysphagia, for
Our study demonstrated that FEES is particularly reliable                                  which the infective risk is certainly greater.



86
                                                                                       A multidisciplinary approach to obstructive sleep apnoea




Conclusions                                                        References
Our data demonstrate that all OSA patients should undergo
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the presence of dysphagia with the aim of obtaining satisfac-           2001;164:2031-2035. https://doi.org/10.1164/ajrccm.164.11.2102028
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acknowledged that pressures that are too high are associated            Sleep Medicine. Rules for scoring respiratory events in sleep: up-
with compliance issues in long-term CPAP therapy. Howev-                date of the 2007 AASM Manual for the Scoring of Sleep and As-
                                                                        sociated Events. Deliberations of the Sleep Apnea Definitions Task
er, the age of patients belonging to the dysphagic group was            Force of the American Academy of Sleep Medicine. J Clin Sleep Med
higher compared with the non-dysphagic group, and there-                2012;8:597-619. https://doi.org/10.5664/jcsm.2172
fore age acts as a confounding factor in predicting the use of     5
                                                                        Ruehland WR, Rochford PD, O’Donoghue FJ, et al. The new AASM
higher CPAP titration pressures. Our data also highlight that           criteria for scoring hypopneas: impact on the apnea hypopnea index.
                                                                        Sleep 2009;32:150-157. https://doi.org/10.1093/sleep/32.2.15
it is possible to identify a “new category” of OSA patients,       6
                                                                        Weaver TE, Maislin G, Dinges DF, et al. Relationship between
“dysphagic OSA”, who need strict follow-up considering                  hours of CPAP use and achieving normal levels of sleepiness and
that they need higher levels of positive airway pressure in             daily functioning. Sleep 2007;30:711-719. https://doi.org/10.1093/
PAP therapy and they might present a higher risk of develop-            sleep/30.6.711
ing pneumonia compared with non-dysphagic OSA patients.            7
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                                                                        nants of sleep-disordered breathing across the spectrum of clinical
Finally, our study is in line with the recent literature in oto-        and nonclinical male subjects. Chest 2002;122:840-851. https://doi.
laryngology in confirming the opportunity to consider OSA               org/10.1378/chest.122.3.840
as a complex pathology that requires a multidisciplinary ap-       8
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proach for diagnosis and follow-up, in order to provide per-            and obstructive sleep apnea: is there any meaningful correlation?
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sonalised and effective long-term treatment.                            s1807-59322011000800007
                                                                   9
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Conflict of interest statement                                          atic head and neck physical examination with severity of obstructive
The authors declare no conflict of interest.                            sleep apnea-hypopnea syndrome. Laryngoscope 2003;113:973-980.
                                                                        https://doi.org/10.1097/00005537-200306000-00011
                                                                   10
                                                                        Ayas NT, Drager LF, Morrell MJ, et al. Update in sleep-disordered
Funding                                                                 breathing 2016. Am J Respir Crit Care Med 2017;195:1561-1566.
The authors received the “Research Projects of National                 https://doi.org/10.1164/rccm.201701-0048UP
Relevance 2017 n. 2017JNKCYZ” funding for this work.               11
                                                                        Teramoto S, Ishii T, Matsuse T. Relationship between swallowing
                                                                        function and gas exchange during day and night in patients with ob-
Authors’ contributions                                                  structive sleep apnea syndrome. Dysphagia 2001;16:249-253. https://
                                                                        doi.org/10.1007/s00455-001-0083-7
Conceptualization: LM, GC, GC, MLF, OR; Data curation:             12
                                                                        Friedman M, Salapatas AM, Bonzelaar LB. Updated Friedman
LM, GC, VDL, GC, MLF; Formal analysis: LM, GC, VDL;                     staging system for obstructive sleep apnea. Adv Otorhinolaryngol
Writing – original draft: LM, GC, VDL, MLF; Writing –                   2017;80:41-48. https://doi.org/10.1159/000470859
review and editing: LM, GC, VDL, GC, CS, VDN, NAAQ,                13
                                                                        Vicini C, De Vito A, Benazzo M, et al. The nose oropharynx hy-
GEC, OR, MLF.                                                           popharynx and larynx (NOHL) classification: a new system of di-
                                                                        agnostic standardized examination for OSAHS patients. Eur Arch
                                                                        Otorhinolaryngol      2012;269:1297-300.       https://doi.org/10.1007/
Ethical consideration                                                   s00405-012-1965-z
The study was approved by the Institutional Review Board           14
                                                                        Neubauer PD, Rademaker AW, Leder SB. The Yale Pharyngeal
of teaching hospital Policlinico of Bari (protocol number               Residue Severity Rating Scale: an anatomically defined and image-
                                                                        based tool. dysphagia. 2015;30:521-528. https://doi.org/10.1007/
6750).                                                                  s00455-015-9631-4
The research was conducted ethically, with all study pro-          15
                                                                        Ginocchio D, Alfonsi E, Mozzanica F, et al. Cross-cultural adapta-
cedures being performed in accordance with the require-                 tion and validation of the italian version of SWAL-QOL. Dysphagia
ments of the World Medical Association’s Declaration of                 2016;31:626-634. https://doi.org/10.1007/s00455-016-9720-z
Helsinki.
                                                                   16
                                                                        Bhutada AM, Broughton WA, Focht Garand KL. Obstructive sleep
                                                                        apnea syndrome (OSAS) and swallowing function - a systematic
Written informed consent was obtained from each patient                 review. Sleep Breath 2020;24:791-799. https://doi.org/10.1007/
for study participation and data publication.                           s11325-020-02037-w




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