Snoring & Obstructive Sleep Apnea Syndrome (OSAS)

Snoring It is estimated that between 25-50% of the adult population snores, and although it is not as common in children, this age group certainly is not immune. When mild or infrequent it may not be a significant issue. However, snoring is a major social problem for the individual sharing the bed with the snorer. It can lead to sleeping in another room and even puts pressure on relationships.

Snoring Education Obstructive Sleep Apnea Sleep Apnea Surgery OSA in Children

Most importantly however, is that snoring is an indication that the individual’s airway is partially obstructed. Over time partial obstruction can become total obstruction. In some patients this may be the only sign or symptom that this obstruction is leading to a medical condition known as sleep apnea, which can have significant side effects.

There certainly can be many causes for mild or intermittent snoring. Any medication that may induce relaxation or the muscles may play a role. The most common culprit is alcohol, especially when it is consumed right before bed. Other medications such as sleeping aids can also aggravate snoring.

Weight gain also can contribute to snoring. This may simply amplify an existing anatomic problem which was causing mild obstruction previously.

The most common cause, however, is simply an anatomic abnormality leading to obstruction. The most common sites are the roof of the mouth (palate, uvula, and tonsils), throat, and nose. Although certain temporary changes can aggravate these problems, such as allergies or a cold causing swelling in the nose, most conditions are actually longstanding and simply worsen with age.

The diagnosis is usually apparent to the patient- or more commonly the patient’s family. However, habitual (night after night) snoring is truly a medical problem. If it is persistent, full evaluation by a physician is necessary. This examination may include a polysomnogram (sleep study) to determine if sleep apnea is present. This is important since the patient’s own history of apnea or fatigue has been shown to be an inaccurate source of information, and sleep apnea may be present in as many as 80% of all habitual “heroic” snorers.

Treatment

Treatment may include eliminating those outside factors that may be playing a role. This may include weight loss, the avoidance of alcohol or other medications, or even the treatment of nasal congestion with medication or nasal dilating strips. However, these efforts are rarely successful in those patients with significant snoring. Evaluation by a physician is indicated to rule out sleep apnea. If the patient is a “simple snorer” (intermittent) and still desires treatment, several options exist. Most treatment is directed at the soft palate since this is the most common site of snoring. Traditional surgery of this area (known as uvulopalatopharyngoplasty or UPPP) is effective in 80-90% of cases, but can be associated with postoperative pain for 7-10 days. Alternatively, radiofrequency reduction of the palatal tissue is appropriate for some patients. It can be performed as an outpatient and results in less discomfort.

The other sites of obstruction that may contribute to snoring are the nose and the base of tongue, and should also be evaluated. In the nose a deviated (crooked) septum, the bone and cartilage wall which divides the nose internally into sides, may cause obstruction. In addition, normal structures known as turbinates protrude from the lateral wall and if chronically enlarged can also block airflow. The base of tongue also can be enlarged and impede airflow during sleep. Obstruction at these sites can be treated by a variety of methods depending on the severity.

Habitual snoring can also be a significant social issue. However, at times it may be the only sign of the more important medical condition of sleep apnea. A comprehensive examination can identify the cause of the problem and determine what options are appropriate for treatment.

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Obstructive Sleep Apnea

Obstructive Sleep Apnea Syndrome is a debilitating breathing disorder which occurs during sleep. While sleeping, the body's muscles relax; this can cause excess tissue in the upper airway (back of the mouth, nose and throat) to collapse and block breathing. When breathing is interrupted by an obstruction in the airway, the brain reacts by waking the body slightly to restore muscle tone and breathing starts again.

These events, called arousals, may occur hundreds of times each night but do not fully awaken the patient, who remains unaware of the loud snoring, choking and gasping for air that are typically associated with Obstructive Sleep Apnea Syndrome. Obstructive Sleep Apnea Syndrome sufferers seldom get "a good night's sleep" because repeated apneas and arousals deprive patients of REM and deep-stage sleep, leading to chronic daytime fatigue, sleepiness and increased risk of high blood pressure, heart attack and stroke.

What are the health implications of Obstructive Sleep Apnea Syndrome?

Obstructive Sleep Apnea Syndrome has a profound impact on an individual's health. Excessive daytime sleepiness caused by disruption of normal sleep patterns leads to loss of productivity and ability to concentrate. It also leads to a significant increase in the rate of accidents, including a sevenfold increase in automobile accidents. Obstructive sleep apnea is also associated with greater risk of cardiovascular diseases such as hypertension, heart attack and stroke. The National Commission on Sleep Disorders Research estimates that 38,000 cardiovascular deaths occur each year due to sleep apnea.

The National Commission on Sleep Disorders Research estimates that 38,000 cardiovascular deaths occur each year due to sleep apnea.

Loud snoring and breathing interruptions can also affect the quality of sleep of the Obstructive Sleep Apnea Syndrome patient's bed-partner. Witnessing an apnea (apnea is defined as a cessation of breathing for 10 seconds or greater) can be a frightening experience because the Obstructive Sleep Apnea Syndrome patient appears to be suffocating. Frequently, it is a sleep-deprived bed partner who convinces the patient to seek medical help.

Who suffers from Obstructive Sleep Apnea Syndrome?

Although Obstructive Sleep Apnea Syndrome is commonly associated with obesity, male gender and snoring, it affects a broad cross-section of the population including children. It is estimated that twenty-four percent of adult men and nine percent of adult women, or more than 20 million Americans, have some degree of Obstructive Sleep Apnea Syndrome. Of these, six million are estimated to have cases severe enough to warrant immediate therapeutic intervention. However, Obstructive Sleep Apnea Syndrome was not well understood or recognized by primary care physicians until recently and only a fraction of these 20 million Obstructive Sleep Apnea Syndrome patients have been diagnosed and treated. With increased awareness, a growing number of new patients are expected to be identified for treatment in the next few years. (Back to Top)

What are some of the treatments for Obstructive Sleep Apnea Syndrome?

Available treatments for Obstructive Sleep Apnea Syndrome include medical and surgical therapy. Medical therapy consists of nightly use of continuous positive airway pressure devices (CPAP). During sleep, CPAP patients wear a face mask connected to a pump that forces air into the nasal passages at pressures high enough to overcome obstructions in the airway and stimulate normal breathing. In general, CPAP should be worn for at least 6-8 hours a night and 7 nights per week to maximize its benefit. Although CPAP is effective, some patients find the mask very uncomfortable, claustrophobic or embarrassing. CPAP patients often suffer from side effects related to forced air delivery including nasal dryness, congestion, sore throat, sore eyes, headaches and abdominal bloating. A significant number of CPAP patients do not use the device nightly and may discontinue treatment on their own. Since CPAP is not a cure and must be used every night for life, non-compliant patients experience a full return of Obstructive Sleep Apnea Syndrome and related symptoms.

A Dental Oral appliance is also a form of medical therapy. The dental device causes the lower jaw to protrude forward while the patient is asleep. This treatment is supposed to enlarge the airway opening at the back of the tongue. The problem with this treatment is that it may be ineffective, and even when the patient experiences some benefit, the long-term use of such device may lead to drooling, tooth movement and jaw joint (TMJ) pain.

Surgical therapy for treating Obstructive Sleep Apnea Syndrome is based on identifying the sites of airway obstruction including the nose, soft palate and tongue. The procedures that are effective in clearing specific areas of blockage include nasal reconstruction, uvulopalatopharyngeoplasty (UPPP), mandibular osteotomy with genioglossus advancement, hyoid myotomy and suspension, and maxillomandibular advancement. Nasal reconstruction improves the opening inside the nose by straightening the nasal septum and shrinking the fleshy tissue inside the nose (turbinate), thus improving nasal airway. UPPP involves the removal of the uvula, part of the soft palate, tonsils and possibly other excess tissue in the throat. Mandibular osteotomy with genioglossus advancement as well as hyoid myotomy and suspension clear the obstruction in the back of the tongue. Maxillomandibular advancement is a very effective surgical technique to clear significant upper airway obstruction by moving the upper and lower jaws forward.

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