Proothi Michael, Grazina Victor J R, Gold Avram R
Stony Brook University Sleep Disorders Center, Renaissance School of Medicine at Stony Brook University, 240 Middle Country Road, Smithtown, NY, 11787, USA.
Department of Oral and Maxillofacial Surgery, Stony Brook University School of Dental Medicine, Stony Brook, NY, 11794-8705, USA.
J Med Case Rep. 2019 Aug 14;13(1):252. doi: 10.1186/s13256-019-2182-9.
Chronic insomnia and obstructive sleep apnea are both common sleep disorders. Chronic insomnia is thought to result from stress-related physiologic hyperarousal (somatic arousal) that makes it difficult for an individual to fall or stay asleep. Obstructive sleep apnea is thought to result from obstructive respiratory events causing arousals, sleep fragmentation, and recurrent oxygen desaturation. Although the two disorders seem different, they predispose to the same long-term, stress-related illnesses, and when they occur in the same individual, each affects the other's response to treatment; they interact. This report of three cases describes patients with both chronic insomnia and obstructive sleep apnea in whom the chronic insomnia remitted with no specific treatment following treatment of obstructive sleep apnea with maxillomandibular advancement.
Our three Caucasians patients each presented with severe, chronic insomnia associated with somatic arousal and fatigue occurring either alone, in association with bipolar disorder, or with temporomandibular joint syndrome. Polysomnography revealed that each patient also had mild obstructive sleep apnea, despite only one snoring audibly. One patient experienced a modest improvement in her somatic arousal, insomnia severity, and fatigue with autotitrating nasal continuous positive airway pressure, but the other two did not tolerate nasal continuous positive airway pressure. None of the patients received treatment for insomnia. All three patients subsequently underwent maxillomandibular advancement to treat mild obstructive sleep apnea and experienced prolonged, complete resolution of somatic arousal, chronic insomnia, and fatigue. The patient with bipolar disorder also experienced complete remission of his symptoms of depression during the 1 year he was followed postoperatively.
These three cases lend support to the hypothesis that chronic insomnia and obstructive sleep apnea share a pathophysiology of chronic stress. Among patients with obstructive sleep apnea, the stress response is directed at inspiratory airflow limitation during sleep (hypopnea, snoring, and inaudible fluttering of the throat). Therefore, when chronic insomnia and obstructive sleep apnea occur in one individual, aggressive treatment of obstructive sleep apnea may lead to a reduction in chronic stress that causes the patient's chronic insomnia to remit.
慢性失眠和阻塞性睡眠呼吸暂停都是常见的睡眠障碍。慢性失眠被认为是由与压力相关的生理过度觉醒（躯体觉醒）导致的，这使得个体难以入睡或保持睡眠状态。阻塞性睡眠呼吸暂停被认为是由阻塞性呼吸事件引起觉醒、睡眠片段化和反复的氧饱和度下降所致。尽管这两种疾病似乎不同，但它们易引发相同的长期、与压力相关的疾病，并且当它们在同一个体中出现时，每种疾病都会影响对方对治疗的反应；它们相互作用。本报告的三例病例描述了患有慢性失眠和阻塞性睡眠呼吸暂停的患者，在通过上颌下颌前移治疗阻塞性睡眠呼吸暂停后，慢性失眠在未进行特定治疗的情况下得到缓解。
我们的三名白种人患者均表现为严重的慢性失眠，伴有躯体觉醒和疲劳，这些症状单独出现、与双相情感障碍相关或与颞下颌关节综合征相关。多导睡眠图显示，尽管只有一名患者有明显的打鼾声，但每名患者还患有轻度阻塞性睡眠呼吸暂停。一名患者使用自动调压鼻持续气道正压通气后，其躯体觉醒、失眠严重程度和疲劳有适度改善，但另外两名患者不耐受鼻持续气道正压通气。所有患者均未接受失眠治疗。随后，所有三名患者均接受上颌下颌前移以治疗轻度阻塞性睡眠呼吸暂停，并经历了躯体觉醒、慢性失眠和疲劳的长期、完全缓解。患有双相情感障碍的患者在术后随访的1年中，其抑郁症状也完全缓解。
这三例病例支持了慢性失眠和阻塞性睡眠呼吸暂停具有慢性应激病理生理学的假说。在阻塞性睡眠呼吸暂停患者中，应激反应针对睡眠期间的吸气气流受限（呼吸浅促、打鼾和喉咙无声颤动）。因此，当慢性失眠和阻塞性睡眠呼吸暂停在一个个体中同时出现时，积极治疗阻塞性睡眠呼吸暂停可能会减轻导致患者慢性失眠的慢性应激，从而使慢性失眠得到缓解。
