Clinical significance of snoring

Habitual snoring, nocturnal apnea, and excessive daytime sleepiness are leading symptoms of the obstructive sleep apnea syndrome. However, simple snoring without apnea is a more common and normal phenomenon. In certain habitual snorers increased upper airway resistance during sleep may lead to sleep fragmentation and hypersomnolence even in the absence of frank apnea; this condition is termed upper airway resistance syndrome. There is no convincing evidence that snoring in the absence of sleep apnea is an independent risk factor for cardiovascular disease. The evaluation of symptomatic snorers includes a specific history and physical exam, followed by a sleep study if treatment is considered necessary. The choice of treatment modality for snoring is guided by the individual needs and symptoms of the patient. Weight loss, nocturnal application of continuous positive airway pressure, or intraoral appliances which hold the mandible in protrusion during sleep are non-surgical treatment options. According to the patients' subjective assessment conventional or laser-assisted uvulo-palato-pharyngoplasty (UPPP) has a high cure rate for snoring. However, objective documentation of the effect of these interventions on measured snoring noise is scant.     

Obstructive sleep apnea in Schwartz-Jampel syndrome

Schwartz-Jampel syndrome (SJS) is a rare entity characterized by myotonia and skeletal abnormalities. Death and respiratory distress have previously been reported in newborns and young children with SJS. We describe a patient with SJS and snoring in whom polysomnography demonstrated obstructive sleep apnea and hypoxia. Although tonsillectomy with laser palatoplasty significantly widened the oropharyngeal introitus, obstructive sleep apnea persisted. Ultimate improvement occurred only after the institution of home therapy with bi-level positive airway pressure during the night. We also discuss the specific structural and neuromuscular features of SJS that may be responsible for upper airway obstruction.     

Upper airway resistance syndrome

Many clinicians are familiar with the clinical symptoms and signs of obstructive sleep apnea (OSA). In its most blatant form, OSA is complete airway obstruction with repetitive, prolonged pauses in breathing, arterial oxyhemoglobin desaturation; followed by arousal with resumption of breathing. Daytime symptoms of this disorder include excessive daytime somnolence, intellectual dysfunction, and cardiovascular effects such as systemic hypertension, angina, myocardial infarction, and stroke. It has been recently recognized that increased pharyngeal resistance with incomplete obstruction can lead to a constellation of symptoms identical to OSA called "upper airway resistance syndrome" (UARS). The typical findings of UARS on sleep study are: (1) repetitive arousals from EEG sleep coinciding with a (2) waxing and waning of the respiratory airflow pattern and (3) increased respiratory effort as measured by esophageal pressure monitoring. There may be few, if any, obvious apneas or hypopneas with desaturation, but snoring may be a very prominent finding. Treatment with nasal positive airway pressure (NCPAP) eliminates the symptoms and confirms the diagnosis. Herein we describe two typical cases of UARS.     

Essential hypertension and abnormal upper airway resistance during sleep

The epidemiological, clinical, hereditary, biochemical, hematological, and physiological characteristics of essential hypertension (EH) and obstructive sleep apnea (OSA) are reviewed here. This extensive review shows that essential hypertension and sleep-disordered breathing--independently of whether it is OSA syndrome or upper airway resistance syndrome--share strikingly similar characteristics. The accumulated data obtained by many different researchers support the hypothesis that EH is mainly due to increased upper airway resistance during sleep. If this hypothesis is correct, treating disorders that cause increased upper airway resistance, particularly during sleep, would be an important part of the treatment of essential hypertension.     

Sleep apneas

In its most frequent form, in which obstructive apneas are predominant, the sleep apnea syndrome appears more and more as a frequent disorder. Clinically, it can be easily suspected in a patient presenting with snoring and daytime sleepiness, provided that these symptoms are systematically sought. A firm diagnosis relies on polysomnographic recordings. Beyond these symptoms, which are social and professional handicaps, the severity of the disorder is related to its cardiovascular long-term complications. The standard treatment is based upon nasal continuous positive airway pressure, which is safe and efficient but constraining. Surgical treatments, which are not as safe nor as efficient, can be proposed when continuous positive airway pressure is not accepted.     

Obstructive sleep apnea and related disorders

OSAS, a common cause of disrupted sleep and EDS, result from repetitive closure of the upper airway during sleep. It probably represents the most severe syndrome related to obstruction of the upper airway; less severe forms include UARS, a syndrome characterized by the need for increased effort to breath but no prominent apneas or hypopneas, and primary snoring. Initial clues to the presence of OSAS and related disorders are derived from the history and include loud snoring, EDS or insomnia, and witnessed apneas. Some patients, especially women, may complain mostly of tiredness or fatigue, and children may present with behavioral abnormalities. Obesity, a large neck circumference, and a crowded oropharynx are common on physical examination. Nonobese patients, in particular, often have retrognathia, a high-arched narrow palate, macroglossia, enlarged tonsils, temporomandibular joint abnormalities, or chronic nasal obstruction. The clinical suspicion of obstructed nocturnal breathing is confirmed by overnight polysomnography, and an MSLT may be used to assess sleepiness. Esophageal manometry during polysomnography facilitates diagnosis of UARS. Treatment most commonly consists of nasal CPAP or BPAP, although problems with compliance make surgical treatment preferable in some cases. Although UPPP eliminates sleep apnea only in a minority of patients, combining UPPP with maxillofacial procedures appears to improve outcomes. Other treatments such as the use of dental appliances or medications, weight loss, and positional therapy may be useful as adjunctive therapy for moderate to severe OSAS or as primary treatments for UARS or mild OSAS.     

A cost-effective and rational surgical approach to patients with snoring, upper airway resistance syndrome, or obstructive sleep apnea syndrome

The past decade has seen several innovations in the surgical techniques available for treatment of patients with sleep-disordered breathing. Outpatient techniques such as laser-assisted uvulopalatoplasty (LAUP) and more aggressive procedures designed to address hypopharyngeal and base of tongue obstruction (genioglossus advancement and hyoid myotomy) have been developed and proven successful. We describe the efficacy of LAUP for snoring (72.7%), upper airway resistance syndrome (81.8%), and mild (mean [+/-SD] respiratory disturbance index [RDI] = 12 +/- 8.1) obstructive sleep apnea (41.7%) in 56 patients who underwent 132 LAUP procedures in a 26-month period. Thirty-two patients with more significant obstructive sleep apnea (mean RDI = 41.8 +/- 23.1) underwent multilevel pharyngeal surgery consisting of genioglossus advancement and hyoid myotomy combined with uvulopalatopharyngoplasty. The surgical success rate in this group of patients was 85.7% when commonly accepted criteria were applied. We recommend a stratified surgical approach to patients with sleep-disordered breathing. Progressively worse airway obstruction marked by multilevel pharyngeal collapse and more severe sleep-disordered breathing is treated with incrementally more aggressive surgery addressing multiple areas of the upper airway.     

Linking postdoctoral general dentistry programs with managed care programs and settings

Sleep-disordered breathing is a chronic problem of the inappropriate mechanical collapse of the upper airway. Symptoms range from mild occasional snoring to severe obstructive sleep apnea. The standard of care for the diagnosis and treatment of sleep-disordered breathing by sleep medicine has been the use of the polysomnogram and continuous positive airway pressure. This approach is burdensome, costly, and ineffective due to lack of compliance with or rejection of treatment. Oral appliances are highly effective in managing the mild snorer to the moderate sleep apneic and are approaching the efficacy of continuous positive airway pressure with the severe apneic. The dentist can and should manage these patients. However, the dental practitioner must acquire sufficient training and knowledge to appropriately treat these patients.     

Obstructive sleep apnoea. Part II: Treatment with a customised dental appliance

The use of dental appliances in the treatment of patients with snoring and obstructive sleep apnoea is an important treatment modality for those patients not severe enough for continuous positive airway pressure (CPAP) or who cannot tolerate this form of treatment. A mandibular advancement splint has been specifically designed to eliminate snoring and obstructive sleep apnoea. The appliance's design parameters included ease of insertion, comfort, and maximum effectiveness. Customised appliances have been designed for dentate, semi-dentate, and edentulous patients. To date, over 100 appliances have been used with a symptomatic improvement in snoring and well-being in over 80 percent of patients. Dental appliances for the treatment of snoring and obstructive sleep apnoea are simple, cost effective, and reversible.     

Resolution of obstructive sleep apnoea with growth in the Robin sequence

A 12 year old female with the Robin sequence presented with a one year history of snoring, witnessed apnoeas and daytime sleepiness. Surgery in early childhood had consisted of cleft palate repair, tonsillectomy and adenoidectomy and, later, revision palatoplasty. Overnight polysomnography (PSG) demonstrated severe obstructive sleep apnoea syndrome with an apnoea/hypopnoea index (AHI) of 49 events x h(-1), and repetitive oxygen desaturations below 50%. Nasal continuous positive airway pressure (nCPAP) effectively controlled her sleep abnormalities. After 3 yrs of nCPAP therapy, she requested discontinuation and was fully reassessed. PSG without nCPAP revealed an AHI <5 events x h(-1) with no desaturations below 90% and normal sleep quality. A repeat lateral cephalometrogram showed increased mandibular length and posterior airway space and reduced soft palate length. The patient remains asymptomatic 9 months following nCPAP discontinuation. This case indicates that nasal continuous positive airway pressure is an effective nonsurgical therapy in children with obstructive sleep apnoea syndrome and the Robin sequence. It is likely that mandibular growth, increase in mandibular length and enlargement of the posterior airway space was responsible for the resolution of obstructive sleep apnoea syndrome in this case.     

The prevalence of high-level exercise in the eating disorders: etiological implications

Among 145 patients treated with recombinant human growth hormone (GH), four developed sleep apnea (two obstructive, two mixed) associated with tonsillar and adenoidal hypertrophy in three. These four patients had no local risk factors predisposing to upper airway obstruction (i.e., frequent pharyngitis or sinusitis). Clinical and/or polysomnographic features of sleep apnea improved following cessation of GH therapy in one patient, and following tonsillectomy and adenoidectomy in all patients. The present observations indicate that, albeit rarely, obstructive and/or central sleep apnea may occur in children treated with GH. Polysomnography should be considered if symptoms of snoring, interrupted sleep, daytime somnolence-particularly if associated with tonsillar hypertrophy-appear in children during GH therapy.     

Management of simple snoring in adults

The management of simple snoring in adults is reviewed. Snoring is associated with oscillations of the soft palate and adjacent structures, as a consequence of a critically reduced pharyngeal cross-sectional area under conditions of sleep-induced flow limitation. Anatomical and physiological factors resulting in upper airway collapse and snoring are reviewed. The conservative treatment of snoring encompasses weight loss, alcohol and sedatives avoidance, as well as smoking cessation. Nasal obstruction should be relieved, either medically or surgically. If these measures fail, polysomnography should be performed. Patients with obstructive sleep apnoea should be offered nasal continuous positive airway pressure therapy. Uvulopalatopharyngoplasty can be proposed to nonapnoeic snorers, with a good chance of success, as far as reported snoring is concerned. Unfortunately, this has not been confirmed by objective recordings, and long-term results have not been adequately studied.     

Expandable metallic stent placement in patients with benign esophageal strictures: results of long-term follow-up

Prosthetic mandibular advancement (PMA) was applied to nine patients with obstructive sleep apnea syndrome (OSAS) and its therapeutic usefulness, mechanism of action, and clinical indication were discussed based on polysomnographic findings and serial examination of upper airway before and during PMA treatment. Apnea hypopnea index significantly decreased during PMA treatment compared with the value before treatment (P < 0.01) and the rate of the treatment responder counted 78.1%. Cephalometric variables indicated forward and inferior advancement of mandible in our subjects. Magnetic resonance imaging of the upper airway during sleep revealed a marked improvement of velophanryngeal obstruction in most subjects. In addition, intraesophageal negative pressure during sleep decreased significantly. Our results confirmed the high therapeutic efficacy of PMA for OSAS and indicated forward advancement of the mandible and decrease of negative pressure loading on upper airway with PMA might suppress velopharyngeal collapse. Thus, PMA was regarded as one of the treatments of choice for OSAS occurring based on with velopharyngeal narrowing.     

Histological indications of a progressive snorers disease in an upper airway muscle

The etiology of upper airway collapsibility in patients with snoring and obstructive sleep apnea (OSA) remains unclear. Local muscular abnormalities, including neurogenic lesions, could be a contributory factor. The aim of this study was to histologically evaluate the hypothesis of a progressive snorers disease. Biopsies of palatopharyngeal muscle were obtained from 21 patients with habitual snoring and different degrees of upper airway obstruction (10 patients with OSA) and 10 nonsnoring control subjects. Morphological abnormalities, including neurogenic signs (e.g., type grouping), were blindly quantified. The degree of abnormality was significantly increased in patients compared with control subjects. The individual score of abnormalities was significantly correlated to the percentage periodic obstructive breathing but not to oxygen desaturation index. Analyses of the individual fiber-size spectra demonstrated a significantly increased number of hypertrophied and/or atrophied fibers in patients compared with controls. The subjects were also divided into three groups according to their type of nocturnal breathing, i.e., nonsnorers, patients with < 20%, and patients with > or = 45% obstructive breathing. These groups correlated significantly with the degree of abnormality and pathological fiber-size spectra. In conclusion, these results support the hypothesis of a progressive local neurogenic lesion, caused by the trauma of snoring, as a possible contributory factor to upper airway collapsibility.     

The acoustic properties of snores

This study was undertaken in an attempt to characterize the acoustic properties of snoring sounds in the time and frequency domains, and to correlate between these properties and the mechanical events underlying their production. Three experimental set-ups were used: 1) Dog model--six mongrel dogs, in which partial upper airway obstruction was created by an implanted supraglottic balloon. Flow, supraglottic pressure, and snoring sounds were recorded during different degrees of obstruction. Fifteen to 20 snores from each dog (total 100 snores) were analysed. 2) Simulated human snores--Six simulated snores from each of four subjects were recorded in two locations (trachea and ambient) with simultaneous airflow, and their correlations examined. 3) Snoring patients--snores were recorded with an ambient microphone from nine subjects with "heavy" snoring and no obstructive sleep apnoea (OSA). Forty to 50 snores from each subject were analysed (total of 400 snores). The snoring sound was analysed in the time (time-expanded waveform) and frequency (power spectrum) domains. After analysing these snores, we were able to identify two dominant patterns which are distinctly different from each other: the "simple-waveform" and the "complex-waveform". The complex-waveform snore is characterized by repetitive, equally-spaced, train of sound structures, starting with a large deflection followed by a decaying amplitude wave. In the frequency domain, it is characterized by multiple, equally-spaced peaks of power (comb-like spectrum). Simple-waveform snores have a quasi-sinusoidal waveform, with a range of variants, and almost no secondary internal oscillations. Their power spectrum contains only 1-3 peaks, of which the first is the most prominent. We developed a mathematical representation of these waveforms, which is presented along with its implications. The complex-waveform snores result from colliding of the airway walls and represent actual brief airway closure. Simple-waveform snores are of higher frequency and probably result from oscillation around a neutral position without actual closure of the lumen.     

Upper airway muscles and physiopathology of obstructive sleep apnea syndrome

Upper airway dilator muscle generate inspiratory pressure that balances subatmospheric pharyngeal pressure gene-rated by diaphragmatic contraction leading to reduce upper airway patency. Neural control of upper airway dilator muscles involve several categories of receptors such as vagal pulmonary receptors, upper airway mecanoreceptors, baroreceptors, chemoreceptors. Upper airway resistances increase during sleep and upper airway inspiratory muscle activity decrease especially during bursts of rapid eye movements in REM sleep. Sleep-related upper airway obstruction occurs when upper airway dilator pressure does not balance subatmospheric pharyngeal pressure. Several variables are involved in the pathophysiology of obstructive apneas such as upper airway anatomical factors, structural muscular dysfunction, changes in neural drive.     

Respiratory patterns during sleep in Down's syndrome:importance of central apnoeas

Obstructive sleep apnoea episodes have been reported repeatedly in Down's syndrome (DS) patients as a consequence of the presence of predisposing malformations or intercurrent pathology of the upper airways. There are no data on respiratory patterns of uncomplicated Down's syndrome subjects. In order to evaluate the eventual effects of central nervous system (CNS) impairment on respiration in DS, we studied the respiratory patterns during sleep of a group of 10 DS subjects, aged 8.6-32.2 y, without relevant upper airway pathology. In order to control the possible effects of sleep structure and mental retardation on the results obtained, we compared the findings in DS with those obtained from a group formed by subjects affected by fragile X syndrome (six males and one female, aged 10.0-15.42 y) another genetically determined type of mental retardation. Sleep structure was similar in both groups; however, DS subjects showed significantly higher indices of central sleep apnoea and of oxygen desaturation than fragile X patients (P < 0.005). As far as DS individuals were considered, a significant preponderance of central, as opposed to obstructive, sleep apnoeas was found (89.4% vs. 9.4%, respectively; 1.2% were mixed) which showed a significant age-related increase. Central respiratory pauses were mostly preceded by sighs, which occurred more frequently during sleep stages 1 and REM, and were often organized in long sequences of periodic-like breathing. During REM sleep, they were less frequently preceded by sighs and by body movements than during NREM sleep. Obstructive sleep apnoeas occurred more often during REM sleep and were more rarely preceded by sighs or by body movements. Both central and obstructive apnoeas induced significant oxygen desaturation in 50-69.6%. Sleep structure was not significantly modified by apnoeas and oxygen desaturation. We hypothesize that the increase in central sleep apnoeas is related to a dysfunction of the central respiratory control at a brainstem level in DS.     

Flow-regulatory function of upper airway in health and disease: a unified pathogenetic view of sleep-disordered breathing

Although the Starling resistor behavior of the upper airway during sleep has been well established in health and disease, its physiological implications have not been fully appreciated. The purposes of the present communication are to reassess the current state of knowledge within the framework of the Starling resistor concept and to examine the implications of the concept on homeostatic feedback respiratory control and the pathogenesis of the sleep apnea syndrome. The main inferences drawn from the assessment include: (1) Owing to the Starling resistor properties of the upper airway and the well-organized neurochemical control mechanism, the upper airway performs important homeostatic flow regulatory function; it appropriately dampens the potentially unstable breathing during sleep and prevents the PaCO2 from falling below the apneic threshold; (2) Under certain conditions, the upper airway flow regulatory function fails to achieve appropriate dampening, leading to development of a variety of sleep-related breathing disorders that include underdamping due to overly sensitive central chemoresponsiveness and/or excessive lung to chemoreceptor transport lag--central sleep apnea; overdamping due to upper airway obstructive dysfunction--obstructive sleep apnea and/or hypopnea; and, finally, conditions with mixed features of central underdamping with coexisting collapsible upper airway; and (3) Successful treatment of these conditions requires restoration of appropriate damping. The overdamping imposed by the faulty upper airway is effectively reduced by surgical and medical approaches, and by application of nasal continuous positive airway pressure (CPAP). Reduction of PaCO2 by use of acetalzolamide and/or aminophylline reduces the plant gain, thus effectively offsetting the underdamping of central origin. Owing to the dual effect of nasal CPAP on the upper airway and respiratory pump, use of nasal CPAP can also effectively reduce the plant gain, accounting for the therapeutic effect of nasal CPAP on the central sleep apnea.     

Cor pulmonale due to obstructive sleep apnoea

A 47 year old man with a long history of chronic loud snoring and daytime sleepiness presented with hypercapnic respiratory failure and right ventricular failure. The diagnosis of obstructive sleep apnoea (OSA) leading to the 'obesity-hypoventilation syndrome', was supported by the findings of an overnight cardio-respiratory monitoring during sleep. His symptoms and arterial blood gases improved following treatment with nocturnal nasal continuous positive airway pressure (CPAP).     

Identifying the patient with sleep apnea: upper airway assessment and physical examination

Since the final common pathway for obstructive sleep apnea is obstruction of the upper airway during nocturnal respiration, examination and assessment of the anatomy of the upper airway plays a central role in patient evaluation. Since the upper airway begins at the nose and lips and ends at the larynx, a complete assessment of the upper airway evaluates this entire length of this anatomic region including the bony framework and soft tissue. Though office assessment of these structures does not necessarily mimic the appearance of behavior of these structures during physiologic sleep, the office examination can give important information as to the site of obstruction during sleep that can help direct therapy.