CCENT offers diagnostic and treatment options for sleep disorders. Our physicians and staff are highly qualified and ready to assess your sleep concerns. Below is some information on Obstructive Sleep Apnea and Snoring. If you feel you are in need of a physician for your sleep concerns, please contact our office.

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Obstructive Sleep Apnea

Obstructive sleep apnea, or OSA, is a serious condition affecting more than twelve million Americans. This condition is due to blockage of air flow through the throat while sleeping.  OSA leads to decreased oxygen delivery to the body, termed oxygen desaturation.

If gone untreated, sleep apnea can cause:

  • High blood pressure
  • Loud snoring
  • Cardiovascular disease
  • Weight gain
  • Memory problems
  • Impotency
  • Headaches
  • Depression
  • Irritability
  • Dry mouth upon awakening
  • Nocturnal snorting, gasping, choking (may wake self up)
  • Insomnia
  • Chest retraction during sleep in Young Children (chest pulls in)

DEFINITION OF OBSTRUCTIVE SLEEP APNEA

The term apnea describes a complete stop or pause in breathing, while hypopnea describes a slowdown in breathing.  Apnea can be further defined as central or peripheral.  In central apnea, the nervous system fails to adequately control breathing, thus leading to irregular sleep patterns and decreased oxygen levels.  In contrast, peripheral apnea is due to the tissues (tongue, tonsils, and palate) blocking the airway leading to decreased oxygen levels.  This blockage, or obstruction, is the cause of obstructive sleep apnea.

The character and severity of your obstructive sleep apnea can be determined via a sleep study.  The sleep study yields information regarding sleep cycles, oxygen levels, and the number and length of the apneic and hypopneic episodes.  This information is used to determine the Respiratory Distress Index, or RDI, and the degree of oxygen desaturation.

  • The Respiratory Distress Index is defined as the number of breathing pauses (apneas) and the number of breathing slowdowns (hypopneas) per hour.  Normal RDI is less than 10 events per hour.  An RDI of 16 or greater is considered diagnostic for OSA.
  • The oxygen desaturation is the degree in which blood oxygen levels drop due to decreased breathing.  Maximal oxygen saturation is 100%, with normal patients maintaining saturations greater than 90% while asleep.  In contrast, patients with OSA experience significant oxygen desaturations, with levels falling well below 90%.

Obstructive sleep apnea is thus defined as peripheral obstruction leading to decreased oxygen levels, and is defined by abnormalities in the RDI and percentage of oxygen saturation.

WHO GETS OBSTRUCTIVE SLEEP APNEA, AND WHAT ARE THE SYMPTOMS?

Obstructive sleep apnea is most commonly seen in middle-aged men.  While the condition is made worse with obesity, it can occur in thin people.  Most people with OSA state they are tired in the morning when awakening.  They have trouble making it “through the day” and are very tired in the afternoon.  While not all patients who snore have obstructive sleep apnea, almost all patients with obstructive sleep apnea are very loud snorers.  The spouse or partner of the OSA patient will have observed the apneic episodes, and often report needing to shake or nudge the patient to “get them to breathe.”

OSA patients will frequently wake up throughout the night.  They may get out of bed to get a drink or go to the bathroom multiple times.  They may also have six or seven awakenings in which they do not get out of bed.  Finally, patients with OSA often report having trouble at work.  They may have decreased memory and concentration.  They may have trouble operating machinery, and in particular have trouble driving the car secondary to fatigue. 

CAUSE OF OBSTRUCTIVE SLEEP APNEA

The exact cause of OSA is not known.  While OSA is made worse with obesity, certainly not all obese people have obstruction.  A long palate, large tonsils, and a large or high-riding tongue are commonly found in patients with OSA and contribute to the obstruction.  Furthermore, people whose chins do not protrude or project may have tongues positioned farther back in the throat, leading to OSA.

DETERMINATION OF OBSTRUCTIVE SLEEP APNEA

If the patient has symptoms consistent with obstructive sleep apnea, then a sleep study, or polysomnogram, is performed.  This study can be carried out either in a sleep lab or at home.  The study determines the number of apnea episodes, hypopnea episodes, and the degree of oxygen desaturation.  It will look at changes in brain waves and the various sleep cycles.  It will determine if you have significant leg movements or spasms, which may cause irregularity of sleep.  It will also determine whether abnormal brain waves occur, as some patients’ apparent sleep deprivation may actually be caused by nighttime seizures.

  • Ultimately the sleep study will determine your Respiratory Distress Index.  Patients with significant symptoms have RDIs in the 30 to 40 range.  RDIs can be very severe, however, and it is not uncommon to see patients with RDIs as high as 100. 
  • The sleep study will also determine the degree of oxygen desaturation, the second important indicator of OSA.  While patients with OSA may have recurrent apnea episodes (and thus an elevated RDI), it is the length of the episodes that ultimately determine how low the oxygen saturation falls.  Many short episodes may result in no significant desaturation, and the medical consequences of the apnea on the body may be minimal.  However, if significant desaturation occurs, then a significant long-term effect on the brain, heart and lungs may be experienced.
  • The sleep study will determine the effects of obstruction on the sleep cycles.  Your total REM (rapid eye movement) time, or deep sleep time, is determined.  Normal REM time is approximately 25% of the total sleep.  In contrast, patients with OSA often have REM sleep times less than 5%.  This is one reason why OSA patients are so tired when awakening in the morning.

I’VE BEEN TOLD I HAVE OBSTRUCTIVE SLEEP APNEA – NOW WHAT?

If you have been examined and a sleep study has shown that you have OSA, then treatment is available.  If the degree of OSA is mild and you are overweight, then a weight loss program may be of great benefit.  If the degree of OSA is moderate to severe, however, then Continuous Positive Airway Pressure (CPAP) or surgical intervention may be offered.

CPAP.  CPAP is a padded mask worn while sleeping which fits over the mouth or nose.  The machine senses each time you stop breathing and provides a breath of air.  There are multiple kinds of CPAP machines, masks, and settings.  Once a sleep study has determined that you have obstruction, a “CPAP titration study” is carried out.  This repeat sleep study is performed with the CPAP mask in place to determine the optimal mask settings to overcome your obstruction.

Surgery.  Surgery is reserved only for patients who are absolutely intolerant of CPAP therapy.  Surgery is a “protocol” or series of well-defined surgical steps to open up the airway.  The protocol is comprised of uvulopalatopharyngoplasty, or UPPP, in addition to temperature controlled radiofrequency ablation of the tongue base, or TCRFA.  Note that TCRFA is not carried out in one treatment, but is delivered in four treatments spaced eight weeks apart.

CPAP vs UPPP/TCRFA
Some patients have difficulty comparing surgical versus CPAP treatment.  It is important, however, to understand that all patients are started on CPAP prior to being offered surgery.  Often patients who think they could never wear a CPAP mask while sleeping actually do quite well.  Furthermore, once a “good night’s sleep” is obtained using CPAP, many patients remain highly motivated to stay with the mask.  This is because CPAP, when used properly, is almost 100% effective in eliminating obstructive sleep apnea.  CPAP has few complications other than those that may occur due to the pressure of the mask on the face or due to the drying effects of the pressurized air.  The mask is “reversible”, and can be removed at any time.  There are some portability issues, but most masks come in a suitcase style box and can be taken on vacation.  If the required pressures are relatively mild, it is comfortable to wear. 

In contrast, surgery is reserved for patients who cannot tolerate CPAP.  The surgical protocol is only 70-80% effective in treating OSA, and therefore some patients completing the entire protocol may still have significant obstructive sleep apnea.  It is important, therefore, to understand that not all patients respond to surgery.  Surgery is also time consuming and expensive.  The protocol is comprised of four surgeries conducted under general anesthesia, with the first surgery (UPPP with TCRFA) requiring an overnight hospital stay.  The first surgery also requires you to be off work at least two weeks.  The three additional tongue treatments (TCRFA alone) will require at least a few days off for each procedure.  There are also potential serious risks to these procedures, as is the case with all operations.  Furthermore, the effects of surgery are not reversible, unlike the mask.  Therefore, for the above reasons, an earnest attempt at the use of CPAP is highly advocated.

Snoring

Doctor, Please Explain Snoring

Insight into sleeping disorders and sleep apnea

Forty-five percent of normal adults snore at least occasionally, and 25 percent are habitual snorers. Problem snoring is more frequent in males and overweight persons, and it usually grows worse with age. Snoring is an indication of obstructed breathing. Therefore, it should not be taken lightly. An otolaryngologist can help you to determine where the encumbrance may be and offer solutions for this noisy and often embarrassing behavior.

What causes snoring?

The noisy sounds of snoring occur when there is an obstruction to the free flow of air through the passages at the back of the mouth and nose. This area is the collapsible part of the airway where the tongue and upper throat meet the soft palate and uvula. Snoring occurs when these structures strike each other and vibrate during breathing.

In children, snoring may be a sign of problems with the tonsils and adenoids. A chronically snoring child should be examined by an otolaryngologist, as a tonsillectomy and adenoidectomy may be required to return the child to full health.

People who snore may suffer from:

  • Poor muscle tone in the tongue and throat. When muscles are too relaxed, either from alcohol or drugs that cause sleepiness, the tongue falls backwards into the airway or the throat muscles draw in from the sides into the airway. This can also happen during deep sleep.
  • Excessive bulkiness of throat tissue. Children with large tonsils and adenoids often snore. Overweight people have bulky neck tissue, too. Cysts or tumors can also cause bulk, but they are rare.
  • Long soft palate and/or uvula. A long palate narrows the opening from the nose into the throat. As it dangles, it acts as a noisy flutter valve during relaxed breathing. A long uvula makes matters even worse.
  • Obstructed nasal airways. A stuffy or blocked nose requires extra effort to pull air through it. This creates an exaggerated vacuum in the throat, and pulls together the floppy tissues of the throat, and snoring results. So, snoring often occurs only during the hay fever season or with a cold or sinus infection.

Also, deformities of the nose or nasal septum, such as a deviated septum (a deformity of the wall that separates one nostril from the other) can cause such an obstruction.

Why is snoring serious?

Socially—It can make the snorer an object of ridicule and causes others sleepless nights and resentfulness.

Medically—It disturbs sleeping patterns and deprives the snorer of appropriate rest. When snoring is severe, it can cause serious, long-term health problems, including obstructive sleep apnea.

What is obstructive sleep apnea?

When loud snoring is interrupted by frequent episodes of totally obstructed breathing, it is known as obstructive sleep apnea. Serious episodes last more than ten seconds each and occur more than seven times per hour. Apnea patients may experience 30 to 300 such events per night. These episodes can reduce blood oxygen levels, causing the heart to pump harder.

The immediate effect of sleep apnea is that the snorer must sleep lightly and keep his muscles tense in order to keep airflow to the lungs. Because the snorer does not get a good rest, he may be sleepy during the day, which impairs job performance and makes him a hazardous driver or equipment operator. After many years with this disorder, elevated blood pressure and heart enlargement may occur.

Is there a cure for heavy snoring?

Heavy snorers, those who snore in any position or are disruptive to the family, should seek medical advice to ensure that sleep apnea is not a problem. An otolaryngologist will provide a thorough examination of the nose, mouth, throat, palate, and neck. A sleep study in a laboratory environment may be necessary to determine how serious the snoring is and what effects it has on the snorer's health.

What treatments are available?

Treatment depends on the diagnosis. An examination will reveal if the snoring is caused by nasal allergy, infection, deformity, or tonsils and adenoids.

Snoring or obstructive sleep apnea may respond to various treatments now offered by many otolaryngologist—head and neck surgeons:

  • Uvulopalatopharyngoplasty (UPPP) is surgery for treating obstructive sleep apnea. It tightens flabby tissues in the throat and palate, and expands air passages.
  • Thermal Ablation Palatoplasty (TAP) refers to procedures and techniques that treat snoring and some of them also are used to treat various severities of obstructive sleep apnea. Different types of TAP include bipolar cautery, laser, and radiofrequency. Laser Assisted Uvula Palatoplasty (LAUP) treats snoring and mild obstructive sleep apnea by removing the obstruction in the airway. A laser is used to vaporize the uvula and a specified portion of the palate in a series of small procedures in a doctor's office under local anesthesia. Radiofrequency ablation—some with temperature control approved by the FDA—utilizes a needle electrode to emit energy to shrink excess tissue to the upper airway including the palate and uvula (for snoring), base of the tongue (for obstructive sleep apnea), and nasal turbinates (for chronic nasal obstruction).
  • Genioglossus and hyod advancement is a surgical procedure for the treatment of sleep apnea. It prevents collapse of the lower throat and pulls the tongue muscles forward, thereby opening the obstructed airway.

If surgery is too risky or unwanted, the patient may sleep every night with a nasal mask that delivers air pressure into the throat; this is called continuous positive airway pressure or "CPAP".

Do you recommend the use of over-the-counter devices?

More than 300 devices are registered in the U.S. Patent and Trademark Office as cures for snoring. Some are variations on the old idea of sewing a sock that holds a tennis ball on the pajama back to force the snorer to sleep on his side since snoring is often worse when a person sleeps on his back. Some devices reposition the lower jaw forward; some open nasal air passages; a few others have been designed to condition a person not to snore by producing unpleasant stimuli when snoring occurs. But, if you snore, the truth is that it is not under your control. If anti-snoring devices work, it is probably because they keep you awake.

Self-help for the light snorer

Adults who suffer from mild or occasional snoring should try the following self-help remedies:

  • Adopt a healthy and athletic lifestyle to develop good muscle tone and lose weight.
  • Avoid tranquilizers, sleeping pills, and antihistamines before bedtime.
  • Avoid alcohol for at least four hours and heavy meals or snacks for three hours before retiring.
  • Establish regular sleeping patterns
  • Sleep on your side rather than your back.
  • Tilt the head of your bed upwards four inches.

Reprinted with permission of the American Academy of Otolaryngology-Head and Neck Surgery Foundation, copyright © 2006. All rights reserved.


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