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resolutions of N-acetyl aspartate (NAA), choline (Cho), creatine (Cre), and myoinositol (mI) metabolites have been examined.
NAA, an amino-acid derivative, is primarily located in neurons and is thought to
be a marker of neuronal viability. Reductions of NAA may reect neurodegeneration [46, 47]. Abnormal levels of Cho suggest inammation, cellularity, and membrane degradation associated with demyelination [48]. A decrease in the ratio of
NAA to Cho has been utilized as an indicator of cerebral metabolic injury, such as
gliosis and impairment of neuronal and axonal function [49–51].
MRS is a useful neuroimaging tool for OSA study, because it provides a measure
of cerebral metabolic change that may reect pathologic insults to brain integrity.
V. K. Paramasivan et al.
21.6.23 Functional Neuroimaging
Functional neuroimaging helps to examine cerebral activation in response to an
external probe. fMRI images are generally acquired using the blood-oxygen-leveldependent (BOLD) technique. This noninvasive, high spatial and temporal resolution technique enables the acquisition of images dependent on the MR signal’s
sensitivity to excesses of cerebral blood ow associated with an increase of synaptic
activity in the brain.
Functional neuroimaging techniques are ideal for investigating acute changes in
the brain associated with the performance of various challenges like respiratory and
cognitive. These neuroimaging ndings support the presence of OSA-associated
neurofunctional and white-matter impairments, particularly in the frontal lobes and
hippocampus. Such impairment is consistent with proposed models of the central
nervous system and cognitive dysfunction in OSA implicating small vessel disease
[52] and the prefrontal cortex [53].
21.7 Role ofUltrasound inIdentifying
theAirway Obstruction
Ultrasonography (USG) is increasingly being explored as a tool for evaluating
upper airway anatomy and pathologic characteristics, with clinical use developing
in areas as broad as the diagnosis of laryngeal and swallowing abnormalities, guidance for percutaneous tracheostomy and cricothyrotomy, and also in sleep apnea.
The use of conventional ultrasound systems to image the upper airway has been
limited because the air column attenuates ultrasound energy. A computer-controlled
bidirectional ultrasound system combines two conventional ultrasound devices with
computer image processing to yield images of upper airway structures.
Submental ultrasonography of neck can be used to assess tongue base thickness,
subcutaneous fat thickness, palatal thickness, retropalatal diameter, retroglossal
diameter and upper airway length during normal tidal expiration, forced inspiration,
and Muller’s maneuver (Fig.21.17).
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389
Fig. 21.17 Submental USG image of upper airway in various position
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V. K. Paramasivan et al.
Due to the convenience, inexpensiveness, no irradiation, and ofce-based procedure, it can be commonly used to examine the neck in OSAS patients. USG has
been used for sleep disorder patients, to evaluate the carotid intima-media thickness
and level of obstruction in recent years [54–56]. Lahav etal. [57] rst used a tongue
base USG to measure the width of the tongue base and demonstrated the possible
role of USG in diagnosing OSAS.Shu etal. [55] used the retropharyngeal diameter
to determine the severity of OSA and proposed a prediction model. Chen etal. [56]
veried the tongue base thickness, providing a quantitative assessment of the retroglossal airway. These reports show a promising role for USG in diagnosing OSAS.
Take-Home Message
• Imaging the upper airway is essential for the diagnosis and treatment planning of
OSA patients because it can detect the level, degree, and causes of the upper
airway obstruction. In addition, it has a denite role in predicting treatment
response and monitoring of patients with OSAS after therapy.
• X-ray nasopharynx will help us measure the size of adenoidal hypertrophy and
document the difference after treatment. Lateral cephalometry and 3D recon-
structed imaging of facial bone are important imaging modalities when planning
for any skeletal framework surgery. Both CT and MRI can provide an excellent
evaluation of the various anatomical planes of the site of obstruction, which
enables better clinical assessment as well as better planning for a possible surgi-
cal approach. With dynamic MRI, we perform a volumetric analysis of the air-
way and the surrounding structure. Functional MRI is mainly used to analyze
cognitive function to assess the severity of OSAS and its effect on the brain. In
addition, submental USG are still in research phase where it needs further devel-
opment for routine practice.
• There are various radiological modalities of investigation available for the upper
airway assessment. We need to choose the right examination for our patient.
Sometimes, more than one investigation may be needed, and they may be com-
plimentary to each other.
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Allergic Rhinitis andOSA
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22
AlvaroCarvallo andGabrielGastaminza
22.1 Allergic Rhinitis
Allergic rhinitis (AR) is the most prevalent allergic disease. It affects a signicant
portion of the population, with a prevalence of conrmed AR of up to 28% among
European adults, a number that seems to be increasing worldwide [1]. In Spain, it is
also the most frequent reason for consultation in allergy departments in both adult
(62%) and pediatric (54%) populations [2, 3]. Its prevalence increases during the
rst years of life. Nasal symptoms are persistent (almost 30%) during the third
decade of life and lower above 60years [4]. The symptoms that most frequently
establish a diagnosis of rhinitis are nasal congestion, anterior and posterior rhinorrhea, sneezing, and nose itching. AR is frequently and characteristically accompanied by ocular symptoms (conjunctival erythema, epiphora or pruritus) and bronchial
symptoms (cough, wheezing, and dyspnea). Other allergic diseases, such as atopic
dermatitis and food allergy, are also more frequent among AR patients.
In AR, the symptoms are elicited by exposition to an allergen. For this reason,
during a study of a patient with rhinitis, it is essential to carry out a complete clinical
history on the temporality of the symptoms, their geographical or seasonal variation, and their relationship with specic exposures. It is essential to ask about the
characteristics of the home environment, the products to which the patient is exposed
at work, the hobbies they may practice, or any pets they might own.
A. Carvallo (*) · G. Gastaminza
Department of Allergy and Clinical Immunology, Clínica Universidad de Navarra,
Pamplona, Spain
e-mail: acarvallo@unav.es
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
P. M. Baptista et al. (eds.), Obstructive Sleep Apnea,
https://doi.org/10.1007/978-3-031-35225-6_22
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A. Carvallo and G. Gastaminza
22.1.1 Mechanisms ofAllergic Rhinitis
Allergen exposure causes inammation of the mucosa that is part of type 2 inammation, which is also involved in chronic rhinosinusitis with nasal polyps
(CRSwNP). This inammation is driven by Th2 lymphocytes or group 2 innate
lymphoid cells (ILC2) and induced by local dendritic cells. Typical cytokines
involved are IL-4, IL-5 and IL-13. IL-4 induces the production of local immunoglobulin E (IgE) antibodies (specic to the allergen in AR or polyclonal in the case
of CRSwNP) [5, 6]. IL-5 is a potent stimulator of the recruitment and survival of
eosinophils [7]. IL-13 is a signicant contributor to the development of a late nasal
response and can be responsible for the persistent nasal blockage in AR [8]. A representation of this allergenic response, including type 2 inammation, can be seen
in Fig.22.1.
Specic IgE to a perennial or seasonal allergen can be locally produced in the
nasal mucosa, without being present in serum. In patients suffering a local AR
(LAR), skin prick testing (SPT) with aeroallergens and specic IgE determination
in serum yield negative results. LAR diagnosis can only be conrmed with a nasal
challenge test. Most of these patients are monosensitized to a single allergen, but
almost 40% of them are polysensitized [9]. In addition, some patients suffering
symptoms of perennial rhinitis have positive SPT to seasonal allergens only. These
patients can be labeled as mixed rhinitis (coexistence of AR and NAR) or dual AR
(coexistence of AR and LAR). In these patients, with discordance between clinical
history and SPT results, accurate diagnosis can only be established with a nasal
Fig. 22.1 Mechanisms of type 2 inammation in the upper airway epithelium
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challenge test or by performing an invitro challenge test with the patient’s basophils, the Basophil Activation Test (BAT) [10].
22.1.2 Clinical Relevance inAllergy Diagnosis
Sensitization to an allergen is not equal to allergy. Clinical relevance is required to label
a patient as allergic, which means there must be congruence between clinical history
and the results obtained by allergy tests. Not every sensitization found on allergy tests
elicits symptoms and thus does not always equal allergy. Therefore, careful interpretation of allergy tests, positive or negative, is required to perform an accurate diagnosis.
When no clinically relevant allergens are identied, a diagnosis of non-allergic rhinitis
(NAR) can be established. When exposition to the allergen is continuous, as is the case
with house dust mites and pets, the relationship between symptom onset and contact
with the allergen can be lost. For this reason, some patients are sensitized to dust mites
or other non-seasonal allergens that do not have the suspicion that their symptoms
might be allergy related. In these cases, the main symptom is usually nasal congestion.
Table22.1 shows the main allergens that commonly cause respiratory allergies.
Table 22.1 Main allergens
causing respiratory allergy
House dust and
storage mites
Pets Cat
Grass pollen Lolium perenne
Tree pollen Cupressus arizonica
Weed pollen Parietaria judaica
Molds Alternaria alternata
Other allergens Natural rubber latex
Dermatophagoides pteronyssinus
Dermatophagoides pharinae
Lepidogliphus destructor
Blomia tropicalis
Tyrophagus putrescentiae
Acarus siro
Dog
Rodent
Phleum pratense
Olea europaea
Platanus acerifolia
Betula verrucosa
Plantago lanceolata
Ambrosia elatior
Chenopodium album
Salsola kali
Artemisia vulgaris
Cladosporium herbarum
Aspergillus fumigatus
Penicillium notatum
Ispaghula
Horse
Cockroach
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A problem that allergy specialists must deal with frequently is a low degree sensitization to a perennial allergen, usually to house dust mites. In these cases, doubts
arise about the clinical relevance of this sensitization. The rst option to elucidate
this problem would be to conduct a nasal provocation test with a mite extract.
However, this test needs to be standardized, is time-consuming, and may sometimes
be unavailable. Another possibility, as mentioned above, is to perform a BAT.In this
test, basophils are isolated from the patient’s blood and incubated invitro with the
mite extract; subsequently, the percentage of basophils that have been activated
(dened as expressing protein CD63in their membrane) with different concentrations of the extract is measured, obtaining a dose/response curve [10]. Another helpful method would be the determination of specic IgE to recombinant allergens.
Finally, the presence of sensitization to certain mite allergens (Der p7 and Der p23)
has been more frequently associated with the presence of allergic symptoms after
exposure to mites [11].
Clinical Relevance
A allergy diagnosis requires three elements: a symptom suggestive of allergy,
a proven sensitization to an allergen, and clinical relevance between the rst
two elements. Careful interpretation of allergy test results is paramount to
performing an accurate diagnosis.
A. Carvallo and G. Gastaminza
22.2 Rhinitis andOSA
22.2.1 General Findings
The relationship between rhinitis and OSA has been a topic of study due to their
shared involvement of the upper airways. Nasal obstruction during the day, which
AR patients commonly experienced by, has been identied as an independent risk
factor for OSA [12]. Rhinitis symptoms are common among OSA patients, with a
prevalence of 56% in this population [13]. Rhinitis not only coexists with OSA in a
signicant proportion of patients but is also linked with several sleep parameters
and OSA outcomes. In addition, the severity of rhinitis symptoms positively correlates with increased daytime sleepiness and negatively correlates with continuous
positive airway pressure (CPAP) compliance [14].
22.2.2 Rhinitis andCPAP Use
The impact of rhinitis on CPAP tolerance and compliance is a matter of interest.
Continuous CPAP use causes an early inammatory response of the nasal mucosa
[15], which explains why rhinorrhea, nasal congestion, and sneezing are reported as
side effects of CPAP [16, 17]. Neutrophils in the nasal mucosa experience a
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