Dr. Stephen Schendel
Craniofacial and Maxillofacial Surgery
650-353-7352

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Obstructive Sleep Apnea

Snoring & Obstructive Sleep Apnea Syndrome


Overview

Studies have shown that up to 50% of adults snore. It is not very common in children, but it does occur. Snoring, when mild or infrequent, may not be a significant issue. Unfortunately, those that share a bed with the snorer do not feel the same way. Loud and frequent snoring can lead to nights on the couch, and put unneeded pressures on relationships.

Snoring is an indication that the airway is partially obstructed. Over time, this can become total obstruction. In some cases, snoring is the only sign that a patient has or is developing sleep apnea, which has many dangerous and life-threatening side effects.

Snoring has many causes, such as alcohol and certain medications like muscle relaxers and sleeping aids. Weight gain can also contribute to snoring. This may simply amplify an existing anatomic problem previously causing mild obstruction. The most common cause is 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, a cold or swelling in the nose, most conditions are actually longstanding and simply worsen with age.

The diagnosis is usually apparent, especially to the family of the patient. Snoring that occurs night after night is a key indicator of a medical problem. Outside influences, such as colds and allergies, should be discounted. If snoring persists after the factors are removed, the patient should seek the help of a physician. This examination may include a sleep study to confirm or rule out sleep apnea. This is important since sleep apnea may be present in as many as 80% of all habitual “heroic” snorers.

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

Treatment

Treatment varies, but is based on eliminating factors that may cause the snoring. This can include weight loss, alcohol avoidance or certain medications. These treatments rarely succeed in 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 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 procedure, and results in less discomfort.

Other sites of obstruction that may contribute to snoring are the nose and the base of the tongue. In the nose, a deviated (crooked) septum may cause an obstruction. In addition, normal structures known as turbinates can chronically enlarge and block airflow. The base of the tongue can also become enlarged and impede airflow during sleep. Obstruction at these sites can be treated by a variety of methods depending on severity.

Obstructive Sleep Apnea

This debilitating breathing disorder occurs during sleep. Essentially, the muscles in the body relax which causes excess tissue in the 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 start breathing again. This may happen several times during the night without the sufferer being aware of the snoring, choking and gasping for air associated with obstructive sleep apnea. These “arousals” interrupt REM sleep, which prevents a patient from getting a full cycle of sleep.

Some signs associated with sleep apnea include:

  • Excessive, nightly snoring
  • Waking up several times during the night
  • Chronic daytime fatigue
  • Sleepiness

These problems can lead to an increased risk of high blood pressure, stroke and heart attack. Witnessing an episode can be very frightening. The patient will appear to be suffocating and gasping for air. They will also sometimes wake up suddenly, and then fall back to sleep.

Who suffers from Obstructive Sleep Apnea Syndrome?

This is commonly associated with obesity, males and snoring but it affects a broad cross-section of the population including children. It is estimated that 25% of adult men and 9% of adult women have some degree of Obstructive Sleep Apnea Syndrome. About one third of these are estimated to have cases severe enough to warrant immediate therapeutic intervention.

Until recently, Obstructive Sleep Apnea Syndrome was not well understood or recognized by primary care physicians. Only a small fraction of the cases have ever 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.

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

Sleep apnea surgery as well as other medical therapy is available. The less obtrusive medical therapy consists of nightly use of a Continuous Positive Airway Pressure (CPAP) machine. Patients using a CPAP machine have to 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. This mask should be worn for 6-8 hours each night for maximum effect. CPAP patients often suffer from side effects 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, even when the patient experiences some benefit. Long-term use may lead to drooling, tooth movement and jaw joint (TMJ) pain.

Surgical therapy is based on identifying the sites of airway obstruction. This can include the nose, soft palate and tongue. The procedures that are effective in clearing specific areas of blockage include nasal reconstruction, uvulopalatopharyngoplasty (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. 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.