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Snoring and Sleep Apnea

People who snore very loudly tend to be jeered at and also become the target of elbow-thrusts while they are asleep. However, it must be understood that snoring is not a laughing matter. Loud snoring is definitely a social problem that can strain relationships. But for a number of men, women & children, loud snoring might signal Obstructive Sleep Apnea (OSA), which is a potentially life-threatening disorder.

Snoring Is Not Necessarily Sleep Apnea

It is very important to be able to differentiate between snoring & OSA. A lot of people snore. It is estimated that approximately 30% -50% of the United States’ population snore at some point in their lives; some more significantly than others. We all have heard stories about people who snore so loudly that they can be heard rooms away from where they are. This kind of snoring can cause a number of problems such as sleep disturbances, marital discord & waking episodes that are at times caused by the person’s own snoring. 

Non-Medical Treatments

However, it has to be understood that snoring does not necessarily always equal OSA. In most cases it is not more than a social inconvenience. But, a social inconvenience too may require treatment and there are a number of options that are available for chronic snorers. Certain non-medical treatments that might alleviate snoring are:

Weight loss - Shedding even upto 10 pounds can sometimes be enough to make a distinct difference
Changing the sleeping position - A person tends to snore when he/she sleeps on their back. Sleeping on the side might be helpful
Avoid caffeine, alcohol & heavy meals - This, especially within 2-hours of bedtime
Avoid sedatives - Since these can relax throat muscles, they increase the tendency for airway-obstruction which is related to snoring 

Other Treatments

Your doctor can provide you various other treatment options, such s:

Radio Frequency (RF)- Radio waves are used to shrink the tissue inside  the throat/tongue. This increases the area in the throat & makes airway obstruction less likely. With progressive treatments the inner-tissue shrinks and the outer tissue remains untouched. Several treatments might be required, but it has not yet been determined whether this procedure has any long-term success

Laser-Assisted Uvuloplasty (LAUP)- This is a surgical procedure which is used to remove the uvula & its surrounding tissue- It opens the airway just behind the palate. Generally, this procedure is used to relieve snoring & can be performed in the Oral & Maxillofacial Surgeon's office and local/general anesthesia will be used

Identifying and Treating OSA

Unlike just simple snoring, OSA is a potentially life-threatening condition and requires medical attention. There are some risks to undiagnosed OSA such as:

  • - Heart attack
    - High blood pressure,
    - Stroke
    - Irregular heartbeat
    - Heart disease
    - Decreased libido

In addition, Obstructive Sleep Apnea also causes daytime drowsiness. This can result in lost productivity, accidents, and problems in interpersonal relationships. The symptoms could be mild/moderate/severe.

Common Condition

Sleep apnea is quite a common condition and 1 in 5 adults has  some type of  mild sleep apnea while 1 in 15 adults will have moderate sleep apnea. Obstructive Sleep Apnea also affects 1%-3% of children. When a person is sleeping, the upper airway can get obstructed by large nostrils, a large tongue and/or excess tissue. The airway muscles are another contributing factor to the problem. These tend to relax & collapse when a person is asleep. The apnea or cessation of breathing that these factors bring about initiates various impulses from the brain and awaken the person just long enough to restart the actual breathing process.

This type of cycle keeps repeating a number of times, right through the night. It can result in severe sleep deprivation as well as a number of health issues. Generally, sleep apnea is defined as- The presence of 30 or more apneas during a 7-hour sleep.  In very severe cases, the “not-breathing” periods can last for as long as 60-90 seconds & may recur upto 500 times every  night.

Sleep Apnea Symptoms

People who have Obstructive Sleep Apnea are generally unaware of this  condition & they  think they sleep very well. In most cases, it is a bed partner or a family member that  notices the symptoms. Other symptoms include:

  • - Snoring with many pauses in breathing (apnea)
    - Poor judgment/cannot focus
    - Gasping/choking during sleep
    - Excessive daytime drowsiness
    - Problem with mental function
    - Memory loss
    - Restless sleep
    - High blood pressure
    - Quick to anger
    - Depression
    - Nighttime chest pain
    - Reduced libido
    - Excess weight
    - Morning headaches
    - Large neck (more than17" around in men & more than 16" around in women)
    - Airway crowding
    - Frequent trips to the washroom at night

Diagnosing Sleep Disorders

If you exhibit a number of OSA symptoms, it is very important for you to visit your Oral & Maxillofacial Surgeon for a thorough examination & accurate diagnosis.

- During the  first visit, your doctor will first take a medical history.

- He/she will perform a head & neck examination and look for problems that can contribute to the sleep-related breathing problems.

- At times, the doctor may even have an interview with your family members/your bed partner, about your sleeping & waking behavior.

- If your doctor suspects any type of sleep disorder, you will then be referred to a good sleep clinic. They will monitor your night-time sleep patterns through polysomnography, a special test.

- You are required to sleep at this clinic overnight  and a video camera will monitor  your sleep pattern. It  gathers data about the total number & length of every breathing cessation/other problems which disturb your sleep.

- In many cases, a "split night" study will be done. In this study, a C-PAP (continuous positive-airway pressure) device is utilized.

- During polysomnography, all efforts are made to limit the disturbances to your sleep.

Treating Sleep Apnea

It is possible to effectively treat sleep apnea. Based whether your condition is mild/moderate/severe, the doctor will decide which treatment  is best for you:

Behavior Modification- In case you  have been  diagnosed only with mild sleep apnea, the doctor might suggest that you employ non-medical treatments that are recommended to reduce the snoring. In mild cases, all these practical interventions might improve/cure snoring & sleep apnea:

  • - Weight loss
    - Avoiding caffeine, alcohol & heavy meals within 2-hours of bedtime
    - Change of sleeping positions
    - No sedatives

Oral Appliances – In  case you have mild-moderate sleep apnea/ cannot use C-PAP, some recent studies have indicated  that an oral appliance can be used as  first-line therapy. This  oral appliance is essentially a molded device which has to be  placed in the mouth before you go to sleep.

It holds the lower jaw & brings the tongue forward. In doing so, the appliance elevates the soft-palate/retains the tongue and keeps it from falling backwards into the airway & blocking breathing. Though this methods isn’t as effective as the (C-PAP) systems, these oral appliances are generally indicated for use in the patients who:

  • Have mild-moderate OSA
    - Prefer oral appliances
    - Don’t respond to C-PAP
    - Aren’t appropriate candidates for C-PAP
    - Fail behavioral changes/ C-PAP treatment attempts

Patients who use an oral appliance should always have regular follow up  visits with their Oral & Maxillofacial Surgeon and the compliance will be monitored. This is done to ensure that the appliance is functioning as it should &  and to ensure that their symptoms aren’t worsening.

C-PAP (Continuous Positive-Airway Pressure) & Bi-PAP (Bi-Level) - The C-PAP device is a very effective treatment for the patients who suffer from moderate OSA. It is also used as a first-line treatment for  individuals who have been diagnosed to be suffering from severe sleep apnea. Via a specially-fitted mask that fits  just over  the patient's nose, the constant & prescribed flow of pressured air that the C-PAP allows, prevents the airway/throat from collapsing. In certain cases the Bi-PAP device, that blows air at 2 different pressures, might be used.

While the C-PAP & Bi-PAP devices effectively keep the throat open & prevent snoring & interruptions in breathing, they are not a cure for the condition. If you discontinue using the C-PAP/Bi-PAP, the symptoms will return. In most cases, C-PAP & Bi-PAP are the preferred treatments, they can be quite difficult for certain patients to accept & use. If you feel that you can’t use these devices comfortably, speak with your doctor before you discontinue using them. Your Oral & Maxillofacial Surgeon can then suggest some other effective treatments.

Surgery for Sleep Apnea

Surgical intervention might be a viable option for certain OSA patients; however, it’s important to understand that surgical procedures are not always universally successful. Each patient has a different-shaped nose & throat; therefore, before any surgery is considered your Oral & Maxillofacial Surgeon will first measure the airway at different points & check for abnormal flow of air from your nose to the lungs. The different surgical procedures are:

Uvulopalatopharyngoplasty (UPPP) – In case the airway collapses at the soft-palate, the UPPP procedure might be helpful. This is generally performed on patients who are can’t tolerate the C-PAP. The Uvulopalatopharyngoplasty procedure shortens & stiffens the soft-palate by partly removing the uvula & reducing the soft palate’s edge.

Hyoid Suspension - If a collapse occurs at the base of the tongue, a hyoid suspension might be used. The hyoid bone is the U-shaped bone that is positioned in the neck just above the thyroid cartilage (Adam's apple) level. It  has attachments to the tongue-muscles &  other muscles as well as the soft tissues just around the throat. The procedure effectively secures this hyoid bone to the thyroid’s cartilage & helps stabilize this section of the airway

Genioglossus Advancement (GGA) – This was specifically-developed to treat OSA &  is designed to open the upper-breathing passage and it tightens the front tongue-tendon. Resultantly, it reduces the degree of  tongue displacement in the person’s throat. In most cases, this operation is  performed along with one UPPP /hyoid suspension

Maxillomandibular Advancement (MMA) – This procedure surgically moves the upper & lower jaws forward. Since the bones are surgically-advanced, the tongue & palate soft tissues also move forward, and open the upper airway. In some individuals, Maxillomandibular Advancement is the only technique which can create the required air passageway to successfully treat their OSA condition.

Talk With Your Doctor

Sleep apnea is quite a serious condition and people with OSA might not be aware that  they have this problem. If a family member or someone who is close to you has noticed that you wake up very abruptly & gasp for air, or if they have heard you snore loudly, you should consult your Oral & Maxillofacial Surgeon.

© 2006-2012 American Association of Oral and Maxillofacial Surgeons (AAOMS). All rights reserved.

Reprinted with permission from American Association of Oral and Maxillofacial Surgeons.