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
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)
  
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