Can maxillary sinusitis contribute to the development of obstructive sleep apnea (OSA)?

Maxillary Sinusitis and Obstructive Sleep Apnea: Pathophysiological Connection

Maxillary sinusitis can contribute to obstructive sleep apnea (OSA) through nasal obstruction mechanisms, inflammation, and altered breathing patterns. This relationship is supported by multiple lines of evidence in clinical guidelines.

Pathophysiological Mechanisms

1. Nasal Obstruction Pathway

• Nasal obstruction from maxillary sinusitis increases upper airway resistance, forcing mouth breathing 1
• Mouth breathing repositions the mandible inferiorly, reducing pharyngeal diameter and predisposing to airway collapse during sleep 2
• The nasal vestibule is a major site of resistance to airflow in healthy subjects, and increased resistance can worsen snoring and OSA 1

2. Inflammatory Mechanisms

• Inflammation from sinusitis can extend beyond the sinuses, affecting the entire upper airway
• Inflammatory mediators (histamine, leukotrienes, IL-1β, IL-4) found in high levels in rhinitis/sinusitis have been shown to worsen sleep quality in OSA 2
• Patients with NARES (Non-Allergic Rhinitis with Eosinophilia Syndrome) are specifically noted to be at increased risk for developing OSA 1

3. Sleep Disruption Effects

• Even without complete obstruction, sinusitis-related nasal congestion can cause:
  • Microarousals and sleep fragmentation
  • Reduced sleep quality
  • Subsequent daytime sleepiness and fatigue 3

Clinical Evidence and Guidelines

Established Connections

• The European Respiratory Journal guidelines recognize that nasal obstruction may predispose to sleep-disordered breathing 1
• Multiple studies demonstrate increased arousals, more frequent sleep stage changes, and increased obstructive apneas/hypopneas during sleep associated with nasal obstruction 1
• Clinical guidelines recommend formal evaluation for OSA in patients with chronic rhinitis and other risk factors for sleep-disordered breathing 1

Treatment Implications

• Intranasal corticosteroids can reduce nasal airway resistance and apnea-hypopnea frequency in patients with OSA and rhinitis 1
• Treatment of allergic rhinitis, particularly with intranasal steroids, has been shown to improve OSA 2
• Leukotriene receptor antagonists have shown positive results in adult OSA patients with concomitant allergic rhinitis 2

Special Considerations

Anatomical Factors

• Maxillary advancement surgery (used to treat OSA) can paradoxically lead to chronic rhinosinusitis in approximately 7.8% of patients due to altered sinus drainage patterns 4
• Nasal resistance was found to be an independent predictor of apnea-hypopnea index in non-obese OSA patients 3

Case Reports

• There are documented cases of sinus-related pathologies (such as antral choanal polyps) directly causing OSA, which resolved after treatment of the sinus condition 5

Clinical Approach

1. Consider OSA in patients with chronic maxillary sinusitis, especially with:

   • Daytime sleepiness
   • Snoring
   • Witnessed apneas
   • Morning headaches
   • Irritability or mood changes

2. Treat the underlying sinusitis to potentially improve OSA symptoms:

   • Intranasal corticosteroids (first-line therapy)
   • Appropriate antibiotics if bacterial infection is present
   • Leukotriene receptor antagonists when appropriate

3. Consider formal sleep evaluation in patients with persistent symptoms despite adequate treatment of sinusitis

While the relationship between maxillary sinusitis and OSA is complex and multifactorial, addressing nasal obstruction and inflammation can significantly improve sleep quality and potentially reduce OSA severity in affected patients.