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The impact of pharyngeal fat tissue on the pathogenesis of obstructive sleep apnea

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Abstract

Purpose

Obesity is the most important risk factor for obstructive sleep apnea (OSA); however, the exact underlying mechanisms are still not fully understood. The aim of this study was to examine the morphology of upper airways in overweight habitual snorers and in mild OSA patients. Furthermore, the associations between weight loss, parapharyngeal fat pad area and OSA were assessed in a 1-year randomised, controlled follow-up study originally conducted to determine the effects of lifestyle changes with weight reduction as a treatment of OSA.

Methods

Thirty-six overweight adult patients with mild OSA [apnea–hypopnea index (AHI) 5–15 events/h] and 24 weight-matched habitual snorers (AHI < 5 events/h) were included in the study. All patients underwent nocturnal cardiorespiratory recordings and multislice computed tomography (CT) of parapharyngeal fat pad area, the smallest diameter and area in naso-, oro- and hypopharynx, the smallest diameter and area of the whole pharyngeal airway, the distance from the hyoid bone to the mandibular plane and to cervical tangent as well as the distance between mandibular symphysis and cervical spine. In addition, OSA patients were further randomised to receive either an active 1-year lifestyle intervention with an early weight loss programme or routine lifestyle counselling. After 1 year, the cardiorespiratory recordings and CT scans were repeated.

Results

The pharyngeal fat pad area was significantly larger, and the distance from the hyoid bone to cervical spine was longer in patients with OSA than in habitual snorers (p = 0.002 and p = 0.018, respectively). The multiple regression analysis showed that besides a large pharyngeal fat pad area and a long distance from the cervical spine to hyoid bone, also a short distance from the mandibular symphysis to cervical tangent increased a risk to OSA. During the 1-year follow-up in OSA patients, the pharyngeal fat pad area and AHI decreased significantly in the intervention group (p = 0.003 and p < 0.001, respectively).

Conclusions

In the early stages of OSA, the pharyngeal fat pad seems to play an important role in the development of disease in overweight patients. Furthermore, weight reduction by lifestyle intervention-based programme reduces both central obesity and pharyngeal fat pads, resulting in an improvement of OSA.

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References

  1. Young T, Peppard PE, Gottlieb DJ (2002) Epidemiology of obstructive sleep apnoea. A population health perspective. Am J Respir Crit Care Med 165:1217–1239

    Article  PubMed  Google Scholar 

  2. Young T, Skatrud J, Peppard PE (2004) Risk factors for obstructive sleep apnoea in adults. JAMA 291:2013–2016

    Article  CAS  PubMed  Google Scholar 

  3. Fisher D, Pillar G, Malhotra A, Peled N, Lavie P (2002) Long-term follow-up of untreated patients with sleep apnoea syndrome. Respir Med 96:337–343

    Article  CAS  PubMed  Google Scholar 

  4. Dávila-Cervantes A, Dominiguez-Cherit G, Borounda D, Gamino R, Vargas-Vorackova F, Gonzáles-Barranco J, Herrera MF (2004) Impact of surgically-induced weight loss on respiratory function: a prospective analysis. Obes Surg 14:1389–1392

    Article  PubMed  Google Scholar 

  5. Kajaste S, Brander PE, Telakivi T, Partinen M, Mustajoki P (2004) A cognitive-behavioral weight reduction program in the treatment of obstructive sleep apnea syndrome with or without initial nasal CPAP: a randomized study. Sleep Med 5:125–231

    Article  PubMed  Google Scholar 

  6. Tuomilehto HP, Seppä JM, Partinen MM, Peltonen M, Gylling H, Tuomilehto JO, Vanninen EJ, Kokkarinen J, Sahlman JK, Martikainen T, Soini EJ, Randell J, Tukiainen H, Uusitupa M; Kuopio Sleep Apnea Group (2009) Lifestyle intervention with weight reduction. First-line treatment in mild obstructive sleep apnea. Am J Respir Crit Care Med 179:320–327

    Article  Google Scholar 

  7. Oliven A, Kaufman E, Kaynan R, Oliven R, Steinfeld U, Tov N, Odeh M, Gaitini L, Schwarz AR, Kimmel E (2010) Mechanical parameters determining pharyngeal collapsibility in patients with sleep apnea. J Appl Physiol 109:1037–1044

    Article  PubMed  Google Scholar 

  8. Schwartz AR, Patil SP, Squier S, Schneider H, Kirkness JP, Smith PL (2010) Obesity and upper airway control during sleep. J Appl Physiol 108:430–435

    Article  PubMed Central  PubMed  Google Scholar 

  9. Sutherland K, Lee RWW, Philips CL, Dungan G, Yee BJ, Magnussen JS, Grunstein RR, Cistulli PA (2011) Effect of weight loss on upper airway size and facial fat in men with obstructive sleep apnea. Thorax 66:797–803

    Article  PubMed  Google Scholar 

  10. Vgontzas AN (2008) Does obesity play a major role in the pathogenesis of sleep apnoea and its associated manifestations via inflammation, visceral adiposity, and insulin resistance? Arch Physiol Biochem 114:211–223

    Article  CAS  PubMed  Google Scholar 

  11. Bonsignore MR, McNicholas WT, Montserrat JM, Eckel J (2012) Adipose tissue in obesity and obstructive sleep apnoea. Eur Respir J 39:746–767

    Article  CAS  PubMed  Google Scholar 

  12. Berger G, Berger R, Oksenberg A (2009) Progression of snoring and obstructive sleep apnoea: the role of increasing weight and time. Eur Respir J 33:338–345

    Article  CAS  PubMed  Google Scholar 

  13. American Academy of Sleep Medicine Task Force (1999) Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. The report of an American Academy of Sleep Medicine Task Force. Sleep 22:667–689

    Google Scholar 

  14. Horner RL, Shea A, Mclvor J, Guz A (1989) Pharyngeal size and shape during wakefulness and sleep in patients with obstructive sleep apnoea. Q J Med S 72:719–735

    CAS  Google Scholar 

  15. Schwab RJ, Gupta KB, Gefler WB, Metzger LJ, Hoffman EA, Pack AI (1995) Upper airway and soft tissue anatomy in normal subjects and patients with sleep-disordered breathing. Significance of the lateral pharyngeal walls. Am J Respir Crit Care Med 152:1673–1689

    Article  CAS  PubMed  Google Scholar 

  16. Segal Y, Malhotra A, Pillar G (2008) Upper airway length may be associated with severity of obstructive sleep apnea syndrome. Sleep Breath 12:311–316

    Article  PubMed  Google Scholar 

  17. Yucel A, Unlu M, Haktanir A, Acar M, Fidan F (2005) Evaluation of the upper airway cross-sectional area changes in different degrees of severity of obstructive sleep apnea syndrome: cephalometric and dynamic CT study. Am J Neuroradiol 26:2624–2629

    PubMed  Google Scholar 

  18. Barkdull GC, Kohl CA, Patel M, Davidson TM (2008) Computed tomography imaging of patients with obstructive sleep apnea. Laryngoscope 118:1486–1492

    Article  PubMed  Google Scholar 

  19. Schwab RJ, Gefter WB, Hoffman EA, Gupta KB, Pack AI (1993) Dynamic upper airway imaging during awake respiration in normal subjects and patients with sleep disordered breathing. Am Rev Respir Dis 148:1385–1400

    Article  CAS  PubMed  Google Scholar 

  20. Morrell MJ, Arabi Y, Zahn B, Badr S (1998) Progressive retropalatal narrowing preceding obstructive apnea. Am J Respir Crit Care Med 158:1974–1981

    Article  CAS  PubMed  Google Scholar 

  21. Bhattacharyya N, Blake SP, Fried MP (2000) Assessment of the airway in obstructive sleep apnea syndrome with 3-dimensional airway computed tomography. Otolaryngol Hear Neck Surg 123:444–449

    Article  CAS  Google Scholar 

  22. Polo OJ, Tafti M, Fraga J, Porkka KVK, Dejean Y, Billiard M (1991) Why don't all heavy snorers have obstructive sleep apnea? Am Rev Respir Dis 143:1288–1293

    Article  CAS  PubMed  Google Scholar 

  23. Caballero P, Alvarez-Sala R, Garcia-Rio F, Prados C, Hernan MA, Villamor J, Alvarez-Sala JL (1998) CT in the evaluation of the upper airway in healthy subjects and in patients with obstructive sleep apnea syndrome. Chest 113:111–116

    Article  CAS  PubMed  Google Scholar 

  24. Shigeta Y, Ogawa T, Tomoko I, Clark GT, Enciso R (2010) Soft palate length and upper airway relationship in OSA and non-OSA subjects. Sleep Breath 14:353–358

    Article  PubMed Central  PubMed  Google Scholar 

  25. Ferguson KA, Ono T, Lowe AA, Ryan CF, Fleetham JA (1995) The relationship between obesity and craniofacial structure in obstructive sleep apnea. Chest 108:375–381

    Article  CAS  PubMed  Google Scholar 

  26. Hou HM, Hägg U, Sam K, Rabie ABM, Wong RWK, Lam B, Ip MS (2006) Dentofacial characteristics of Chinese obstructive sleep apnea patients in relation to obesity and severity. Angle Orthod 76:962–969

    Article  PubMed  Google Scholar 

  27. Tangugsorn V, Krogstad O, Espeland L, Lyberg T (2000) Obstructive sleep apnoea: multiple comparisons of cephalometric variables of obese and non-obese patients. J Craniomaxillofac Surg 28:204–212

    Article  CAS  PubMed  Google Scholar 

  28. Mayer P, Pepin JL, Veale D, Ferretti G, Daschaux C, Levy P (1996) Relationship between body mass index, age and upper airway measurements in snorers and sleep apnoea patients. Eur Respir J 9:1801–1809

    Article  CAS  PubMed  Google Scholar 

  29. Pahkala R, Puustinen R, Tuomilehto H, Ahlberg J, Seppä J (2011) Risk factors for sleep-disordered breathing: the role of craniofacial structure. Acta Odontol Scand 69:137–143

    Article  PubMed  Google Scholar 

  30. Chi L, Comyn FL, Mitra N, Reilly MP, Wan F, Maislin G, Chmiewski L, Thorne-FitzGerald MD, Victor UN, Pack AI, Schwab RJ (2011) Identification of craniofacial risk factors for obstructive sleep apnoea using three-dimensional MRI. Eur Respir J 38:348–358

    Article  CAS  PubMed  Google Scholar 

  31. Pillar G, Shehadeh N (2008) Abdominal fat and sleep apnea: the chicken or the egg? Diabetes Care 31:303–309

    Article  Google Scholar 

  32. Schwarz AR, Gold AR, Schubert N, Stryzak A, Wise RA, Permutt S, Smith PL (1991) Effects of weight loss on upper airway collapsibility in obstructive sleep apnea. Am Rev Respir Dis 144:494–498

    Article  Google Scholar 

  33. Peppard PE, Young T, Palta M, Skatrud J (2000) Prospective study on the association between sleep-disordered breathing and hypertension. N Engl J Med 342:1378–1384

    Article  CAS  PubMed  Google Scholar 

  34. Hlavac MC, Catcheside PG, McDonald R, Eckert DJ, Windler S, McEvoy RD (2006) Hypoxia impairs the arousal response to external resistive loading and airway occlusion during sleep. Sleep 29:624–631

    PubMed  Google Scholar 

  35. Tsai HH, Ho CY, Lee PL, Tan CT (2009) Sex differences in anthropometric and cephalometric characteristics in severity of obstructive sleep apnea syndrome. Am J Orthod Dentofacial Orthop 135:155–164

    Article  PubMed  Google Scholar 

  36. Sahlman J, Seppä J, Herder C, Peltonen M, Peuhkurinen K, Gylling H, Vanninen E, Tukiainen H, Punnonen K, Partinen M, Uusitupa M, Tuomilehto H (2012) Effect of weight loss on inflammation in patients with mild obstructive sleep apnea. Nutr Metab Cardiovasc Dis 22:583–590

    Article  CAS  PubMed  Google Scholar 

  37. Tuomilehto H, Gylling H, Peltonen M, Martikainen T, Sahlman J, Kokkarinen J, Randel J, Tukiainen H, Vanninen E, Partinen M, Tuomilehto H, Uusitupa M, Seppä J; Kuopio Sleep Apnea Group (2010) Sustained improvement in mild obstructive sleep apnea by diet- and physical activity-based lifestyle intervention: postinterventional follow-up. Am J Clin Nutr 92:688–696

    Article  Google Scholar 

  38. Lindberg E, Taube A, Janson C, Gislason T, Svärdsudd K, Boman G (1998) 10-year follow-up of snoring in men. Chest 144:1048–1055

    Article  Google Scholar 

  39. Collop NA, Anderson WM, Boehlecke B, Claman D, Goldberg R, Gottlieb DJ, Hudgel D, Sateia M, Schwab R (2007) Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. The diagnosis of obstructive sleep apnea in adult patients. Portable monitoring task force of the American Academy of Sleep Medicine. J Clin Sleep Med 3:737–747

    PubMed  Google Scholar 

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Acknowledgments

We express our special thanks to Taina Poutiainen, a specially trained nurse, and Riitta Myllykangas, a dental hygienist, for their contributions to this study. In addition, warm thanks go to Veli-Matti Vartiainen, oral radiologist, and Anna Sutela, neuroradiologist, of the Department of Clinical Radiology, Kuopio University Hospital and University of Eastern Finland, for the demonstrative MRI figure. The members of Kuopio Sleep Apnea Group Matti Pukkila, Tatu Kemppainen, Tomi Laitinen, Tiina Lyyra-Laitinen, Ritva Vanninen, Heimo Viinamäki, Keijo Peuhkurinen, Kari Punnonen, Kati Venäläinen, Erkki Soini and Janne Martikainen are also cordially acknowledged. This study was supported by grants from the Hospital District of Northern Savo, Kuopio University Hospital, the Finnish Cultural Foundation and the Pulmonary Association Heli.

Conflict of interest

We declare that we have no conflicts of interest.

Role of funding sources

The funding sources had no role in the study design or in the collection, analysis or interpretation of the data.

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Correspondence to R. Pahkala.

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Pahkala, R., Seppä, J., Ikonen, A. et al. The impact of pharyngeal fat tissue on the pathogenesis of obstructive sleep apnea. Sleep Breath 18, 275–282 (2014). https://doi.org/10.1007/s11325-013-0878-4

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  • DOI: https://doi.org/10.1007/s11325-013-0878-4

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