Plonjon Guatrlı Hastada Obstrüktif Uyku Apnesi: Vaka Sunumu

Birçok predispozan faktörün (obezite, nazal obstruksiyon, adenoid hipertrofisi, makroglossi vb.) obstrüktif uyku apne sendromu (OUAS) ile ilişkili olduğu bildirilmektedir. Bu faktörlere ilave olarak hipotiroidizm ve büyük guatrın da OUAS ile ilişkili olduğu bildirilmiştir. Bununla birlikte bu ilişki tam olarak gösterilememiştir. Plonjon guatrlı vakamızda tiroidektominin OUAS’a varsa etkisini ve bası ile OUAS arasındaki ilişkiyi göstermek istedik. Yetmiş iki yaşında, vücut kitle indeksi 26,8 kg/m2 olan kadın hasta iki yıl önce uykuda solunum durması, horlama, sabahları olan baş ağrısı, gündüzleri uykuya meyil şikâyetleri ile başvurdu. Hastaya yapılan tetkiklerinde, ötiroid plonjon guatra bağlı trakeanın sola deviye olduğu saptandıktan sonra polisomnografisi (PSG) ile ağır OUAS tanısı konuldu. Hastanın apne-hipopne indeksi (AHİ) 63,1/h ölçüldü. Hastaya tedavi amacıyla nazal 7cm H2O ile devamlı pozitif havayolu basıncı (CPAP) uygulandıktan sonra AHİ 11,4/h’e geriledi. Hastaya tanı konulduktan bir ay sonra tiroidektomi operasyonu uygulandı. Ameliyat sonrası 8. haftada kontrol amacıyla yapılan PSGde; AHİ 34,8/h bulundu. Tiroidektomi sonrası tiroidektomi öncesine göre total uyku zamanında %16; AHİ’de %44,8; obstruktif apne indeksinde %84,7; hipopne indeksinde %19; ortalama desatürasyon indeksinde %38,3; evre 3’te %52,4; REM’de %28,6 düzeylerinde bir iyileşme saptanmıştır. Tiroidektomi sonrası OUAS’ın ağırlığının değişmediği ancak kısmi bir düzelme sağlandığı görüldü. Tiroidektomi sonrası CPAP basınçlarda bir iyileşme olabileceği ancak CPAP tedavisinin kesilemeyeceği kanaatine varılmıştır. Ayrıca birinci basamak muayene merkezlerine uykuya meyil, halsizlik ve horlama şikâyetleri ile başvuran hastalarda OUAS olabileceği unutulmamalıdır.

[Obstructive Sleep Syndrom in Patient with Plonjon Guatr: Case Report]

A large number of predisposing factors (obesity, nasal obstruction, adenoid hypertrophy, macroglossia, etc.) are reported to be associated with obstructive sleep apnea syndrome (OUAS). In addition to these factors, the large goiter and hypothyroidism were reported to be associated with OSAS as well. However, this relationship could not yet be fully demonstrated. In our case related to plonjon goiter, we wanted to show the effect of hyroidectomy to OSAS –if there is- and the relationship between pressure and OSAS. Two years ago, a 72-year-old female with BMI: 26.8 kg/m2 patient was admitted to our clinic with complaints of respiratory standstill during sleep, snoring, morning headaches and drowsiness during daylight. In the chest X-ray, chest computed tomography and ultrasonography applied to the patient, it was detected that the trachea was deviated to the left due to euthyroid plonjon goiter and severe OSAS and polisomnografisi (PSG) was diagnosed for the patient. The patient's apnea-hypopnea index (AHI) was measured 63.1/h. With the aim of treatment, in 7cm H2O pressure, nasal continuous positive airway pressure (nCPAP) was applied to the patient and AHI decreased to the level of 11.4/h. Thyroidectomy was performed one month after the diagnosis. AHI was found 34.8 /h on the PSG applied for the purpose of 8 week-postoperative control. There were recovery on the levels of total sleep time, AHI, obstructive apnea index, hypopnea index, average desaturation index, stage 3 and REM as 16%, 44.8%, 84.7%, 19%, 38.3%, 52.4% and 28% respectively when compared the preoperative term with and postoperative term. It was demonstrated that there was no change of the in the degree of OSAS after thyroidectomy but only some partial improvement in the OSAS. The conclusion that there may be some improvements in nCPAP pressures after thyroidectomy and nCPAP treatment should not be stopped was reached. Also, it should be kept in mind that patients who apply to the primary care centers with the complaints of drowsiness, snorring and fatigue may be diagnosed as OSAS.

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  • 1. Young T, Peppard PE, Gottlieb DJ. Epidemiology of obstructive sleep apnea: A population health perspective. Am J Respir Crit Care Med 2002; 165 (9):1217-3.
  • 2. Grunstein RR, Sullivan CE. Sleep apnea and hypothyroidism: mechanisms and management. Am J Med 1988; 85(6): 775–779.
  • 3. Lin C-C, Tsan K-W, Chen P-J. The relationship between sleep apnea syndrome and hypothyroidism. Chest 1992; 102(6): 1663–1667.
  • 4. Netterville JL, Coleman SC, Smith JC, et al. Management of substernal goiter. Laryngoscope 1998; 108 (11 Pt 1):1611-17.
  • 5. Stafford N, Youngs R, Waldron J, Baer S, Randall C. Obstructive sleep apnoea in association with retrosternal goitre and acromegaly. J Laryngol Otol 1986; 100 (7):861–863.
  • 6. Schwab RJ, Goldberg AN. Upper airway assessment: Radiographic and other imaging techniques. Otolaryngol Clin North Am 1998; 31(6):931-68.
  • 7. Grunstein RR. Sleep-related breathing disorders. Nasal continuous positive airway pressure treatment for obstructive sleep apnoea. 1995; 50 (10):1106-13.
  • 8. Kribbs NB, Pack AI, Kline LR, et al. Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea. Am Rev Respir Dis 1993; 147(4):887-95.
  • 9. Guilleminault C, Simmons FB, Motta J, et al. Obstructive sleep apnea syndrome and tracheostomy. Long-term follow-up experience. Arch Intern Med 1981; 141 (8):985-8.
  • 10. Wittels EH, Thompson S. Obstructive sleep apnea and obesity. Otolaryngol Clin North Am 1990; 23(4):751-60.
  • 11. Staff ord N, Youngs R, Waldron J, et al. Obstructive sleep apnoea in association with retrosternal goitre and acromegaly. J Laryngol Otol 1986; 100 (7):861-3.
  • 12. Deegan PC, McNamara VM, Morgan WE. Goitre: A cause of obstructive sleep apnoea in euthyroid patients. Eur Respir J 1997; 10(2):500-2.
  • 13. Eloy JA, Omerhodzic S, Som PM, Genden EM. Goitrous Hashimoto’s thyroiditis presenting as obstructive sleep apnea. Th yroid 2007; 17(7):691- 2.
  • 14. De Felice A, Fuschillo S, Martucci M, et al. Euthyroid goitre and sleep apnea. Monaldi Arch Chest Dis 2006; 65(1):52-5.