Choking during sleep: can it be expression of arousal disorder?

Background Choking during sleep may be caused by various respiratory and non-respiratory problems. Objective We aimed at documenting a new, rare cause of hallucinatory choking. Methods We 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. Results. The 11 patients with sleep-related swallowing and choking were all current or former sleepwalkers. The symptoms occurred during the first third of the night. Patients consistently reported the frequent hallucinatory feeling of swallowing an unusual object (ring, nails, pebble, chewing gum, spoon, fork, electrical cables, lizard tail, needles, brush, computer, 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. Conclusion While insular seizure could also be discussed, these results suggest that sleep-related swallowing and choking syndrome may be in some cases a rare, specialized variant of the arousal disorders.