Original ArticleChoking during sleep: can it be expression of arousal disorder?

- Choking during sleep may be caused by cardio-respiratory and non-respiratory disorders.
- 11 patients awoke with the feeling of swallowing a fictive object stuck in their throat, and choking.
- These non-stereotypic events occurred exclusively upon arousals from N3, without any apnea/hypopnea or epileptic activity.
- All patients had former or current concomitant sleepwalking/sleep terror.
- Swallowing and choking during sleep can be a specialized form of arousal disorders.

BackgroundChoking during sleep may be caused by various respiratory and non-respiratory problems.ObjectiveWe aimed at documenting a new, rare cause of hallucinatory choking.MethodsWe documented the clinical and video-polysomnographic features of 11 adult patients referred for swallowing and choking during sleep. We conducted a systematic search for similar sensations in 68 consecutive adult patients with sleepwalking/sleep terrors and in 37 patients with obstructive sleep apnea.ResultsThe 11 patients with sleep-related swallowing and choking were all current or former sleepwalkers. The symptoms occurred during the first third of the night. The patients consistently reported a frequent hallucinatory feeling of swallowing an unusual object (ring, nails, pebble, chewing gum, spoon, fork, electrical cables, lizard tail, needles, brush, computer, or gas container) that blocked the upper airways during sleep, followed by attempts to unblock them by spitting or swallowing water. When monitored, the choking sensations were not stereotypic, and occurred exclusively during arousals from N3 sleep, despite normal airway patency and absence of epileptic activity. The patients demonstrated simultaneous intense adrenergic stimulation and emotional distress. Of the 68 sleepwalkers, 13% had occasional choking sensations and 4% once inhaled a fictitious object. In the sleep apnea group, choking was never the motive of referral, but 38% of patients had occasional choking sensations, and 5% once inhaled something fictitious.ConclusionAlthough insular seizure could also be discussed, these results suggest that sleep-related swallowing and choking syndrome may be a rare, specialized variant of the arousal disorders in some cases.