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SLEEP APNEA AND SNORING

Snoring is typically described as the annoying sounds generated by the loose redundant soft tissue of the airway in the sleeping individual (1)

Contrary to the older opinion, recent studies of snoring sounds indicate that snoring occurs during inspiration and expiration, rather than only during inspiration as was thought previously. Furthermore, snoring can be heard during exclusively nasal breathing, exclusively oral breathing, and during combined oronasal breathing.

Risk factors

Cigarette smoking, male gender, age greater than 40 years, obesity, respiratory symptoms (cough or sputum production and wheeze) and the use of alcohol or medications as aids to sleep are associated with increased prevalence of snoring (2)

Sleep apnea syndrome

Definition

It is the cessation of airflow from the mouth and nose during sleeping period for more than 10 seconds for more than 5 times per hour (3)

Types of SAS

Three types of apnea can be observed during sleep.

1-Central apnea: occurs when both airflow and respiratory efforts are absent, it is a relatively rare disorder caused by a neurological defect in the control of respiration, such as degenerative neurological disease, intracranial neoplasm, narcotic or sedative overdose (5)

2-Obstructive apnea: occurs when respiratory efforts persist, although airflow is absent at the nose and mouth.

It is characterized by repetitive episodes of upper airway obstruction that occur during sleep.

3-Mixed apnea: many patients exhibit apneas in which both central and obstructive pattern occur.

In mixed apneas there is a period of absent airflow in which no efforts occur followed by the appearance of respiratory efforts, also without airflow (4)

 

Pathophysiology of snoring and obstructive sleep apnea

Pathophysiology of snoring

Snoring is one sign of number of different disorders. The sounds of snoring originate in the collapsible part of the airway where there is no rigid support, that is from the epiglottis to the choanae.It involves the soft palate, uvula, tonsils, tonsillar pillars, base of tongue, and pharyngeal muscles and mucosa(5)

 Factors contribute snoring

1-Incomplete tone of palatal, lingual and pharyngeal muscles is the most adult onset snoring

2-Space-occupying masses impinging on the airway can contribute to snoring, as enlarged tonsils and adenoid, enlarged base of the tongue.

3-Excessive length of the soft palate and uvula narrows the nasopharyngeal aperture

4-Restriction to airflow in the nose creates increased negative pressure during inspiration, which draws together the flaccid tissue in the collapsible part of the airway, where they vibrate and cause snoring (5)

 Pathophysiology of obstructive sleep apnea

It is well recognized that airflow obstruction in obstructive

sleep

apnea is caused by collapse of the pharynx, although the precise anatomic and structural factors leading to pharyngeal collapse are not known, it is generally appreciated that collapse is caused by a complex interaction of structural and neuromuscular factors(6)

 Complications of snoring and obstructive sleep apnea

1- Autonomic nervous system changes

The neural function that are responsible for taking the body from wakefulness to sleep and sleep to wakefulness as well as transitions from one sleep stage to another(7)

 2-Cardio-vasculare system changes

Increased negative intrathoracic pressure raises left ventricular transmural pressure, which is a major factor in left ventricular after-load. This will result in decreased stroke volume and cardiac output, and decrease in the left ventricular preload also can increase the reduced stroke volume. Hypoxemia also will impair myocardial contractility and activity sympathetic nervous activity (8)

*Ischemic heart disease can also be seen in individuals with preexisting coronary artery disease can have aggravation of their symptoms during apneic events (9)

*Cardiac arrthymias of varying types are quite common in apneic patients (10)

*Hypertension can be seen in approximately 50%of patients with obstructive sleep apnea (11)

3--Cerebrovascular system changes, the body response to these changes in PO2 could be seen as an attempt to give much needed blood flow to the cerebral and coronary vascular system, however cerebral blood flow during sleep is actually decreased in the apneic patients (12)

 4_Renal system changes, an increased level of arterial natriuretic peptide showed increased during sleep in patients with sleep apnea (9)

5-Excessive daytime sleepiness

6-Psychological changes patients are quite irritable and can exhibit rapid mood changes, in males may be sexual dysfunction

 DIAGNOSIS OF SAS

1- History

A- History of snoring and SAS must be taken from bed partners and others listeners about the degree of snoring, attacks of apnea

B- History should involve inquiry about risk factors for snoring and obstructive sleep apnea e.g. alcohol, sedatives, tranquilizers, and testosterone.

C- History of prior oropharyngeal surgery (13)

  2-Examination

1- General   *obesity                    *maxillary hypoplasia

                   *macroglossia   *micrognathia

                   *acromegaly      *Down, s synd.

 2- Blood pressure

Multiple studies have linked systemic hypertension to OSA.

Reversal of the apnea reduces the catecholamine level and results in a reduction of blood pressure

 3- Body mass index and collar size

Routine evaluation of height, weight, and collar size, many studies had demonstrated that obesity and collar size correlate with the presence of apnea

 The body mass index calculated

BMI= weight /height

 4 – Nasal examination

a- External examination

*Deviation or deformity of the bony pyramid or dorsum

*previous trauma

*narrowness of the external nose –tip

b- Internal examination

* septal deviation

* turbent hypertrophy

* nasal polyp

* nasal mass

 c- Endoscopic fibrotic nasopharyngoscopy

 5 – Craniofacial skeleton

For relative position of the mandible and maxilla, and dental occlusion 
6- Oral cavity and oropharynex

Careful examination of oral cavity and oropharynex is of principal importance in patients with OSA because many of the surgical procedures performed to improve OSA are performed on this area,

 7- Neck

Examination of the neck begins with measurement of the circumference of the neck at the cricothyroid membrane.

The neck can be described as * short * thick Examination *thyroid pathology *other pathology:  *position of hyoid bone, thyroid cartilage relative to the mandible can be measured.

3-Investigations  

The reasons for investigations in a case of snoring with or without OSA are:

1-To assess the patient's general condition

2-To differentiate between simple snoring and OSA

3- To assess the site of obstruction

 1- Investigation to assess the patient's general condition

A- Vital signs   (hypertension, arrhythmia)

B- CBC    (anemia, polycythemia)

C- Thyroid function test (hypothyroidism)

D- Chest X –ray (cardiomegaly, pulmonary disorders

E- ECG (routine)

F- Blood gases (hypoventilation and or hypoxemia

G- Lung function tests (if there is suspicion of pulmonary disorder

 2- Investigations to differentiate between simple snoring and OSA

A-Polysonography

It is a standards investigation in the diagnosis of OSA and others forms of sleep related disorders, it measure the following parameters

 1-Electroencephalogram (allows the division of non REM sleep)

2-Submental electromyogram (allows the differentiation between REM sleep and arousal)

3-Elecrto oculogram (detects REM sleep stage)

These three measurements are needed for sleep staging and allow differentiation between sleep and wakefulness

4-Oxygen saturation

5-Electrocardiogram

6-Nasal and oral airflow can detected simply its presence or absence

7-Chest and abdominal movements (movment allows the differentiation between central and OSA)

8-Tracheal microphones

9-Esophageal balloon manometer (measurements of respiratory efforts)

10-Sleeping position detector

 On the basis of Polysonography the apnea will be classified as

OSA characterized by absence of airflow at the nose and mouth despite the presence of respiratory effort

Central sleep apnea the patient's airway is normal, but airflow is abscent, abscent respiratory effort (14)

 B-Over night esophageal pressure monitoring

Intra thoracic pressure monitoring has aided in the diagnosis of upper airway resistance syndrome

An obstructive event apnea or hypopnea is easily recognized with increasingly negative inspiratory pressure with falling oxygen saturation, and suddenly renormalized of the pressure with rise in oxygen sat.

Central apnea recognized by absence of pressure fluctuations.                                         

3- Investigations to assess the site of obstruction

A- Sleep nasoendoscopy

1- Simple palatal snoring: the noise comes from the vibration of the soft palate and vibration of the walls of the velopharyngeal sphincter and upper oropharynex

2- Single level palatal obstruction: the obstruction is occurring at the velopharyngeal level only

3-Intermittent multi segmental collapse :as in 2 and the oropharyngeal area but between the inspiratory efforts the area returns to its open

4-Sustained multi segmental collapse; like 3 but without open in the collapsed area

4- Tongue base level obstruction: the velopharyngeal sphincter remains patent but the obstruction at the level of the tongue (15)

B- Flexible nasopharyngoscopy

C- Continuous pharyngo esophageal pressure monitoring

D-Radiological

1-Lateral head and neck x ray

2-CT scanning for the pharynx

3-MRI for upper airway and soft tissue resolution

E- Acoustic reflection techniques

This is a non invasive technique based on analysis of sound wave reflected from the respiratory system

F-Snoring sound analysis

Treatment of snoring and obstructed sleep apnea

Non surgical treatment                  * Surgical treatment   

Non surgical treatment

1-Elimination of the risk factors

A-Weight control

B-Avoidance of alcohol and sedatives

2-Mechanical devices

A-Sleeping position devices

B-Oral devices

C-Nasal dilators

D-Continuous positive airway pressure

Surgical treatment

1- Nasal and nasopharyngeal surgery

The aim of the nasal surgery is to improve nasal patency and to minimize oral breathing during sleep

*septoplasty   *turbenectomy  *polypectomy *adenoidectomy.

2-Oropharyngeal

§  uvulopalatopharyngoplasty

§  laser assisted uvulopalatoplasty

§  electrocautary assisted uvulopalatoplasty

§  radio frequency assisted uvulopalatoplasty

 Uvulopalatopharyngoplasty                                                                                      

It is operation for relieve oropharyngeal obstruction by excision of excessive soft tissue that involves the free margin of the soft palate, uvula, tonsils, and posterior lateral pharyngeal wall.

 Complications

1- Bleeding 2-6%

2- Breathing difficulties it is regarded as an emergency and need immediate management endotracheal intubation or tracheostomy

3- Pain and dysphagea it usually lasts for 4-6 days

4- Hyper nasal speech massy last 7-14 days

5- Eustachian tube dysfunction

6- Nasopharyngeal palatal stenosis (16)

 Laser assisted uvulopalatoplasty

The CO2 laser has many advantages over the scalpel, it reduce the post operative edema and pain and allows for faster and better healing (17)

 Disadvantages and complications

1 post operative pain may still for 5-10 days and may need narcotics must be prescribed for 1 week

2-the cost of the equipment is expensive

 Electrocautary assisted uvulopalatoplasty

 Electrocautary was used for uvulopalatoplasty long before the laser, but it has some disadvantages comparing to the laser, the needle may mask the vision, it is much more painful (17)

 Radio frequency assisted uvulopalatoplasty

Radio frequency is a form from of electrosurgery, but the pain is much less in this procedure in comparison to the laser assisted procedure or cauyary, complications are minimal.

Bleeding and local infection are rarely, the success rate of this procedure is within the same range as that of using laser.(18)

REFERENCES

1-Fairbanks DN.Snoring:Surgical vs non-surgical management.Laryngoscope 1984;94:1188-1192.

2-Bloom JW, Kaltenborn WT, and Quan SF.Risk factors in a general population for snoring:Importance of cigarette smoking and obesity .chest 1998;93(4):678-693.

3-Croft CB and Pringle MB. Snoring and obstructive sleep apnea.In: Scott Browns OtolaRYNGOLOGY.Kerr AG, Oxford Londone1997;4 (18):1-19.

4-Guilleminault C,T ilikan A. The sleep apnea syndrome.Ann.Rev.Med.1976; 27:465-484.

5-Fairbanks DN.Snoring:An overview with historical prospectives.In:Snoring and obstructive sleep apnea.Raven Press,New York 1987:1-13.

6-Schwartz AR.Pharyngeal airway obstruction in obstructive sleep apnea and clinical implication.Otolaryngologic clinics of North America 1993; 31(6):911-918

7-Surrat PM.Flouroscopic and computer tomographic features of the pharyngeal airway in obstructive sleep apnea.AM Rev.Respir Dis 1983; 127:487-492.

8-Ringler J.Hypoxemia alone doesnot explain blood pressure elevation after obstructive apneas.J Appl Physiol 1990; 69:2143-2148

9-Coleman J. Complications of snoring, upper airway resistance syndrome, and obstructive sleep apnea syndrome in adults.Otolaryngologic Clinics of North America 1999; 32(2):223-234

10-Tilkian A, Motta J. Cardiac arrhythmias in sleep apnea.In:Sleep apnea syndrome.New Yourk1978:197-210

11-Hla KM, Young TB.Sleep apnea and hypertention:Ann Int Med 1994;120:382-388.

12-Rice D.Snoring .Otolaryngologic clinics of North America 1986; 16:211-218.

13-Douglas NJ,Thomas S,and Jan MA.Clinical value of polysomnography.Lancet 1992;1:347-350.

14-Pringle MB and Croft CB. A grading system for patients with obstructive sleep apnea based on sleep nasendoscopy.Clin Otolaryngol 1993; 18:840-848.

15-Haavisto L.Complications of uvulopalatoplasty Clin Otolaryngol 1993; 19:243-247

16-Kamami YV.Outpatient treatment of snoring with CO2 laser:Laser assisted uvulopalatoplasty.J Otolaryngol 1994;23 (6):391-395.

17-Coleman J and Rathfoot MC.Oropharyngeal Clin North Am 1999; 32 (2):263-276.

18-Aimino G,Davi G. Principles of radiofrequency in oculoplastics. In:Occuloplastic surgery with radiofrequency firest  ed. Full image,Milano,Italy 1998:13-27.

 

Dr: Shaban mourtaga

Msc. ENT

 

  وزارة الصحة - مركز المعلومات - قسم النشر الالكتروني - 2005