Snoring and Obstructive Sleep Apnea

Snoring and Obstructive Sleep Apnea

SNORING

•  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). 

APNEA

• 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
• Obesity
• Acromegaly
• Drugs:Sedatives,tranqulizers.

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
• UPPP-Uvulopalatopharyngoplasty
• Mandibular Advancement,Hyoid bone suspension and expansion,base of tongue resection
• Tracheostomy  in severe cases

 Exam Question

• 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.