Snoring and Obstructive Sleep Apnea
- Noisy breathing, a rough, rattling inspiratory noise produced by vibration of pendulous soft palate or occasionally of vocal cords, during sleep.
- Snoring indicates some obstruction in upper airway and represents a continum of the similar pathology as of Obstructive Sleep Apnea (OSA), where snoring is on one end and OSA on the other.
- Management of snoring without Obstructive Sleep Apnea.
- Uvulopalatoplasty-Laser Assisted Uvulopalatoplasty (LAUP) or Bovie-Assisted Uvulopalatoplasty (BAUP).
- It is cessation of Airflow for atleast 10 seconds.
Types of Apnea:
- Central:no airflow as no respiratory effort.
- Obstructive:no airflow despite respiratory effort
- Mixed:combination of central and obstructive apnea.
OBSTRUCTIVE SLEEP APNEA AND ITS ETIO-PATHOPHYSIOLOGY.
- There is partial obstruction to the airway during inspiration due to partial collapse of relaxed soft tissues of Oropharynx and Supraglottis.
- This results in vibration of indrawn soft tissues of the oropharynx and Supraglottic Larynx.
- Physical obstruction with narrowing of the oropharynx,Supraglottic Larynx and Hypopharynx may be produced by Hypertrophic tonsils and Adenoids,Receding mandible,long soft palate,long uvula,large tongue,tumors of the Nasopharynx/Oropharynx/Supraglottis,base of Tongue and neck
- Nasa and Nasopharyngeal Obstruction by Deviated Nasal Septum,Hypertrophic Turbinates,polyps,etc
- It is diagnosed when the Apnea index exceeds 5 episodes per hour.
- Prolonged obstruction to airway results in hypoxia leading to polycythemia and later Cor-pulmonale.
- Decreased oxygen availability may result in leg edema, hypertension, morning headaches, cardiac arrhythmias, and stroke in patients with obstructive sleep apnea
- More common in midddle aged people
- More common in males
- Associated with excessive alcohol consumption,tobacco
CLINICAL FEATURES OF OBSTRUCTIVE SLEEP APNEA
- Loud snoring
- Excessive daytime sleepiness and tiredness
- Morning headache
- Personality changes
- Nocturnal Enuresis
- Difficulty in concentration
INVESTIGATION IN A CASE OF OBSTRUCTIVE SLEEP APNEA
- Fibreoptic Endoscopy-of nose,pharynx.larynx-to find the level of obstruction
- CT scan to detect soft tissue or bony obstructions.
- Pulmonary function tests may reveal Hypoxia
- Sleep latency time is less then 4 minutesin these patients.
- Nocturnal Polysomnography test
MANAGEMENT IN A CASE OF OBSTRUCTIVE SLEEP APNEA
- Weight reduction
- Alcohol consumption and smoking stopped
- Avoiding sedating drugs.
- Drugs like Modafinil may help in the treatment for day-time sleepiness.
- CPAP-Continuous Positive Airway Pressure
- Continuous positive airway pressure (CPAP) is effective for both moderate and severe disease. It is the most common treatment for obstructive sleep apnea.
- Prosthesis to hold tongue forward
- Surgery depending on the level of obstruction
- Nasal Surgery-polypectomy,septoplasty,etc
- Tonsil-Adenoid removal
- Mandibular Advancement,Hyoid bone suspension and expansion,base of tongue resection
- Tracheostomy in severe cases
- The most probable diagnosis in a 45 year old male patient complaining of frequent tiredness and headache,loud snoring and physical examination revealing leg edema,hypertension, and cardiac arrhythmia is Obstructive sleep apnea.
- Modafinil is an FDA approved drug in the treatment of obstructive sleep apnea, shift work disorder and narcolepsy.
- Snoring is treated by laser-assisted uvulopalatoplasty.
- OSA is associated with >5 episodes of apnea per hour.
- OSA is commonly associated with Hypertension.
- OSA is more common in males as compared to females.
- OSA is commonly found in patients with receding jaw,Obesity and Acromegaly.
- Next line of management in a 36 years old obese man who is a known smoker suffering from hypertension and snoring with > 5 apnea/hyperapneas episodes per hour found in sleep test and given antihypertensives and advised to quit smoking is Weight reduction and diet plan.