Understanding your Snore!

Table of Content

  1. Introduction
  2. What can cause Obstructive Sleep Apnea
  3. Potential Signs and Symptoms
    1. What are the symptoms of Obstructive Sleep Apnea
    2. Signs to identify patients at risk of apnea
  4. How to evaluate obstructive sleep anea?
  5. Management
  6. Association between Snoring and Cancer of the Head & Neck region
  7. Sleep Board

Introduction

As good night’s sleep might come easy to most people, but there are innumerable people whose restful sleep is disrupted due to either theirs or their partner’s snoring problem.

Snoring is frequently deemed a social nuisance, mainly not to the snorer, but to the bed partner. Most people dismiss snoring as a nuisance rather than a medical problem. It is estimated that snoring occurs in about 45% of men and 30% of women over 65 years of age. Habitual snoring is one of the symptoms of sleep disordered breathing. A population based longitudinal study found that 13% of adults developed habitual snoring over 14 years. The factors associated with habitual snoring include male gender, obesity, smoking, and asthma. In addition, snoring is strongly associated with increased all-cause mortality.

Snoring maybe a symptom of Sleep Apnea which can have long term health implications. It occurs from vibration of soft tissue in the mouth, which can include the soft palate, tonsils and tongue base. Whereas, Obstructive Sleep Apnea is a disorder where a person stops breathing momentarily many times during sleep. It is characterized by episodes of partial or complete obstruction of the upper airway during sleep, interrupting (apnea) or reducing (hypopnea) the flow of air, followed by transient awakening that leads to the restoration of upper airway permeability. Each apnea or hypopnea events usually last for about 10 seconds, A person can have repeated events in an hour of sleep.  It is also important to differentiate Obstructive Sleep Apnea from the less common Central Sleep Apnea, which is caused by an imbalance in the brain’s respiratory control centers during sleep. 

An Obstructive Sleep Apnea sufferer can experience dips in oxygen levels during sleep, which can indirectly stress the heart ns brain. If sleep apnea continues for long term, It can lead to high blood pressure, strokes, heart attacks and sometimes even sudden premature death.

Obstructive sleep apnea syndrome (OSAS) The syndrome can affect any age group, and is estimated to affect 2-4% of the adult population, though it is more common in middle aged males. One out of every 5 adults suffers moderate OSAS, and one out of every 15 presents moderate to severe OSAS. 

Hence, If a snorer is having un-refreshing sleep, feeling of choking, recurrent awakening from sleep, daytime fatigue, and change in personality, he/she has crossed the line of demarcation between snoring and potentially life-threatening disease. 

What can cause Obstructive Sleep Apnea:

Several factors are implicated in the development of OSAS . Sleep apnea occurs when there is not enough space to accommodate sufficient airflow in a portion of the upper airway during sleep. When muscle tone is decreased, the result is a repetitive total or partial collapse of the airway. In children, the most common cause of obstructive sleep apnea is enlarged tonsils and/or adenoids. In some infrequent instances, Altered upper airway anatomy can occur in children due to skeletal abnormalities . In adults, it is most commonly associated with obesity, male sex, and advancing age. There can also be discoordination between the inspiratory activity of the muscle and respiratory effort, which play an important role in progression of the disease.

Obese persons in particular, have alterations of the soft tissues of the neck, due to increased adipose tissue in the region of the neck with fat infiltration. Although obesity is regarded as a principal risk factor in the occurrence of OSAS, it has been shown that the neck perimeter is more closely correlated to severity of the syndrome than body mass index, though there is usually direct proportionality between obesity and neck perimeter. Obesity also contributes to airway narrowing through fatty infiltration of the tongue, soft palate, or other areas surrounding the airway.

The common sites of obstruction are located in the pharynx or throat. Airway failure often occurs when patients sleep on their back and the base of the tongue adheres to the posterior pharyngeal wall and soft palate. Elongated or excessive tissue of the soft palate, a large tongue, swollen uvula, large tonsils, facial malformations, micrognathia, macroglossia and redundant pharyngeal mucosa are the most common reasons of snoring and OSA. 

Potential Signs and Symptoms

The typical adult obstructive sleep apnea patient is overweight or obese middle-aged male or postmenopausal female with excessive daytime sleepiness and loud nightly snoring. They may also complain of waking to gasp for breath or choking, sleep maintenance insomnia, night sweats, night time reflux, and nocturia in the absence of excessive night time liquid intake. The syndrome can affect any age group, and is estimated to affect 2 – 4% of the adult population, though it is more common in middle aged males. One out of every 5 adults suffers moderate OSAS, and one out of every 15 presents moderate to severe OSAS.

A physical exam is typically notable for a larger than average neck circumference (17 inches in males) with crowded oropharynx (Mallampati 3 to 4) and large tongue. Retrognathism may be present. Patients with refractory atrial fibrillation, resistant hypertension, and history of a stroke should be screened for sleep apnea regardless of symptoms. 

Snoring is the most common symptom of OSAS (present in up to 95% of all patients). However, it is also very common in the adult general population, affecting 25- 30% of all women and 40-45% of all men on a regular basis. Patients who consult with suspected OSAS tend to have a long prior history of snoring that has become increasingly intense and irregular over time, often in connection with increased body weight, alcohol consumption or with menopause in women. Observed apneas (choking spells) are a frequent cause of consultation, since they often worry the spouse of the patient, describing them as respiratory pauses that interrupt snoring while the patient continues to make efforts to breathe. 

Sleepiness is the most important daytime symptom of OSAS, and is due to the fragmentation of sleep caused by recurrent electroencephalographic awakening that usually terminate the apneas and hypopneas. Daytime sleepiness is of scant diagnostic value, because a number of situations and disease processes can cause the same symptoms. Morning headaches, apathy, depression, concentration difficulties, memory loss and decreased libido are other characteristic daytime symptoms of patients with OSAS, all as a consequence of daytime sleepiness.

What are the symptoms of Obstructive Sleep Apnea:

  • Snoring
  • Excessive daytime sleepiness 
  • Choking or gasping at night 
  • Unrefreshing sleep
  • Fatigue on waking.
  • Night  Sweats
  • Neurocognitive impairment (impaired judgment and learning, slowed reaction time)
  • Heart Burn
  • Morning headaches 
  • Maintenance insomnia
  • Erectile dysfunction 
  • Nocturia 

Signs to identify patients at risk of apnea:

  • Increased daytime sleepiness – drowsy driving
  • Automobile or work-related accidents due to fatigue
  • Personality changes or cognitive difficulties related to fatigue
  • Hypertension
  • Nasopharyngeal narrowing
  • Pulmonary hypertension (rare)

How to evaluate obstructive sleep anea ?

A proper sleep history and physical examination including endoscopy of the airway, is required. It is also important to establish the profession of the patient, since in some professions OSAS constitutes a medical emergency.

Many tests are available for evaluating sleep and for diagnosing OSAS. The most widely used technique is Polysomnography (PSG). It involves the evaluation of sleep staging, airflow and ventilatory effort, arterial oxygen saturation, electrocardiogram, body position, and periodic limb movements. In addition, PSG records the distribution of the stages of sleep, the number of awakenings, the number of apneas or hypopneas, the starting time of sleep, and the hours of efficient sleep(hours asleep/hours in bed). PSG also provides the apnea / hypopnea index (AHI); in this context, apnea is very serious and can only be treated surgically when AHI >30, while AHI 15-30 defines moderate apnea, and an AHI score of < 15 indicates mild apnea. 

Management

Regarding the treatment of OSAS, emphasis firstly must be placed on the importance of behavioural or lifestyle  modifications on the part of patients with OSAS, including the adoption of a regular sleep schedule, ensuring a good environment for adequate sleep, not lying down without the need to sleep, and the avoidance of too much time in bed. Secondly, alcohol consumption and smoking should be avoided. In this context, smoking increases inflammation of the upper airway and implies a greater risk of snoring and OSAS. Alcohol consumption in turn is associated with exacerbation of the number and duration of apneas, arterial desaturation and sleep fragmentation.

First-line therapy for most patients with OSA continues to be the use of continuous positive airway pressure (CPAP). This therapy maintains adequate airway patency; it not only immediately reverses apnea and hypopnea, but it also decreases somnolence and increases quality of life, alertness, and mood.  However, patient compliance levels average only 50% to 60% because of the frustrations associated with CPAP machines, including mask leaks, nasal congestion, and sleep disruption 

A commonly implemented alternative to CPAP involves the use of oral appliances designed to advance the mandible forward. Such devices de- crease arousal and the apnea-hypopnea index while increasing arterial oxygen saturation.  Furthermore, patients tend to have a stronger preference for oral appliances. 

The American Association of Sleep Disorders has proposed the use of oral appliances in order to eliminate snoring or sleep apnea, classifying them as follows: mandible advancement appliances, lingual retainers, appliances that act upon the soft palate, and combined advancement and positive pressure appliances. Mandible advancement appliances are mostly manufactured with an advance of 80% of maximum protrusion . There are monoblock types and devices manufactured with two splints – no differences in success rate being observed between the two designs. According to the literature, the success of these appliances is associated with lower AHI scores as established by PSG. 

Regarding the side effects of these appliances, various authors have reported pain in the upper and lower incisors, joint discomfort, dental or facial muscle discom- fort, excessive salivation, dryness of the mouth, headache and bruxism, while other authors have reported only minimum dental and orthopedic effects following the use of these appliances.

Comparison of these appliances with continuous positive airway pressure (CPAP) shows them to be less effective in reducing the AHI score.
CPAP was introduced by Sullivan in 1981, wherein the patient wears a mask at night, attached to a machine that continuously impels air into the airway. This increases the air pressure in the pharynx; air forces the soft palate to move forwards against the tongue, and the upper airway thus receives pressure and does not collapse. This technique requires great effort on the part of the patient, but is also the most effective form of treatment, as it has been shown to reduce the AHI score to less than 5 events per hour in most patients – with improvements in both objective and subjective sleep, and in the cardiovascular results. However, while very effective, many patients cannot tolerate CPAP every night for life; its acceptance is therefore rather low. When non-surgical techniques for the treatment of OSAS fail or are unacceptable to patients, surgery is considered. 

For adults, the use of continuous positive airway pressure (CPAP) is the most effective treatment, and diligent adherence to nightly CPAP use can result in near complete resolution of symptoms. For patients unable or unwilling to use CPAP or those who will be unable to access electricity reliably, custom fitted and titrated oral appliances can be used to bring the lower jaw forward and relieve airway obstruction. This typically works best for candidates deemed to have appropriate dentition and mild to moderate sleep apnea. Severe obstructive sleep apnea can be treated with BiPAP as well and is better tolerated by patients who require higher pressure settings (greater than 15 cm to 20 cm H2O). For all patients, it is important to address any concomitant nasal obstruction with nasal steroids for allergic rhinitis or surgically for nasal valve collapse. 

Overweight patients should be encouraged to undergo a weight-loss regimen. Studies have shown that a 10% weight loss is associated with a 26% reduction in apnea-hypopnea index scores. For severely obese patients, bariatric surgery (i.e., gastric banding, gastric bypass, gastroplasty) may be considered, as studies have shown that symptoms of OSA can be relieved in up to 86% of patients undergoing such operations. 

Surgical treatments can be targeted at different anatomical regions in the upper airway. Nasal surgery such as septoplasty, functional endoscopic sinus surgery and turbinate reduction may be effective if there is nasal obstruction, and nasal abnormalities should be looked for in those who develop nasal symptoms during CPAP treatment. For obstruction or redundant tissue at an  oropharyngeal level,  Uvulopalatopahryngoplasty or Tonsillectomy is performed. In a patient with multiple sites of obstruction, or blockage which is diffuse and inaccessible, or a in category of skeletal malocclusion, Maxillo-Mandibular Advancement (MMA) is very helpful. This is a surgical procedure wherein,  the mandible is advanced forward, thereby repositioning the muscles of the tongue and floor of mouth. MMA helps in stretching the tongue forwards and away from the pharynx.

Association between Snoring and Cancer of the Head & Neck region

HNSCC patients may experience upper airway obstruction and poor sleep quality from the mass effect of a pre-treated or recurrent tumour itself, or from the anatomic and functional alterations related to RT, surgical ablation, and reconstruction. This significant anatomic and functional het 

Sleep disturbances are a common complaint in cancer patients with a reported incidence ranging from 30% to 75%. Sleep disturbances have been shown to decrease quality of life, decrease work productivity, increase utilization of health care resources, decrease mental health, and serve as a predictor of other complications in cancer patients. There are studies demonstrating that sleep disorders are common among head and neck cancer patients. However, the causes of sleep disturbances among head and neck cancer patients are unclear and have not been well studied. Head and neck cancer patients have a high prevalence of pain (70%) compared to other cancer sites (52%–60%), and pain is associated with insomnia.

Multiple studies suggest that head and neck cancer patients are predisposed to obstructive sleep apnea, although the data are far from conclusive. Theoretically, the presence of a tracheotomy would improve sleep in this patient group, which would not correlate with our findings assuming there was a significant prevalence of obstructive sleep apnea (which was not specifically evaluated). Although an upper airway obstruction may be bypassed, issues such as secretion management and suctioning requirements may adversely affect sleep.

Sleep Board

Despite substantial research effort, the goal of determining which patients will respond most favourably to certain treatment options ahead of time (i.e., CPAP vs. oral appliances vs. surgery) and the development of alternative treatments remains largely elusive. To achieve this goal, a clear understanding of the physiological causes of OSA on an individual patient basis may be required. As such, approaches that enable determination of the relative importance of the various physiological causes of OSA may lead to novel therapeutic treatment options for certain patients. 

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