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Sleep Disorders/Snoring - Overview

Over the past several years there has been a significant interest and awareness of issues relating to sleep disturbances. The significance of obstructive sleep apnea (OSA) is becoming increasingly evident as we become more knowledgeable as to the major physiological impacts of the condition. The lay population is also becoming much more aware and informed regarding causes of snoring, and what it could indicate in regards to current and long term health. These sleep disorders represent a wide spectrum of severity and this leads to much confusion regarding treatment and evaluation options.

Sleep Apnea and Snoring

Obstructive apnea is essentially a condition where to a lesser or greater extent, an individual experiences a collapse of one or more regions of their airway at night. This results in either an outright stoppage of the breathing (apnea) or a significant "shallowing" of the breathing (hypopnea). If these episodes occur frequently enough and with a significant duration, then one may in fact spend a considerable percentage of their sleep time with inadequate breathing. In turn there may then be drops in the blood oxygen levels that may pose a long term and serious risk for heart disease, stroke, and hypertension. Additionally this leads to serious sleep disruptions that prevent restful sleep and lead to chronic daytime fatigue, possible poor job performance, possibly serious and risky fatigue while driving, and an assortment of other chronic problems. This represents a potentially major health risk that needs to be thoroughly evaluated and effectively treated/cured.

Within an individual’s sleeping environment, snoring is often an indicator of OSA. The vast majority of individuals who suffer from OSA have an identifiable region of the upper airway where the obstruction takes place. In the absence of organic brain disorders, "central" sleep apnea problems are exceedingly rare. We feel that there has been a significant degree of inconsistency in the evaluation and management of individuals with possible OSA. The treatment options given to individuals are often incomplete and potentially do not address the individual's specific problem. We feel that the rational evaluation of a potential OSA disorder must include a comprehensive assessment of the entire upper airway as well as the information obtained from a sleep study.

Evaluation

The evaluation of individuals with suspected OSA needs to start with a detailed history from the patient and if possible from the bed partner. We utilize a comprehensive questionnaire to assist in this. The next essential element is a comprehensive head and neck exam with specific emphasis on the upper airway. We feel that a thorough fiber optic evaluation of the upper airway is essential to the exam and often will identify the source of obstruction.

A sleep study is often the next important element in the evaluation. This may consist of a study performed in a sleep lab or a home based study. Over the past several years the technology for performing outpatient, at home, sleep studies has progressed to the extent that an accurate and comprehensive study can be routinely achieved. The at home study we perform utilizes the state of the art system which records up to 6 data channels. We monitor SaO2 (blood oxygen levels), EKG, respiratory effort, actual nasal and oral airflow, patient position, and sound produced. The correlation between this study and inpatient studies at a lab is extremely close and in fact we feel that given the far more typical sleep environment at the patientís home vs. a lab, the home sleep study findings are possibly more valid. The costs of a home study are a small fraction of the sleep lab fees- often even less than the deductible payment for a lab based study. The diagnosis of OSA is confirmed by observing an elevated RDI (respiratory distress index) and possible correlation with associated episodes of de saturation of SaO2 (decrease in blood oxygen values).

Sites of Obstruction and Therapeutic options

There are many options of therapy once a diagnosis of OSA has been made. These include:

    Weight loss

    Some individuals clearly do benefit from weight management, and for the appropriate individual this is an important adjuvant measure. It is however important to note that obesity in and of itself is not necessarily the cause of the problem. Obese individuals may have no element of obstruction due to the obesity, and certainly we see many patients with severe OSA who have very low body fat. On a practical note, it is obviously difficult and fairly rare for the obese individual to achieve a sustained weight loss.

    Orthognathic appliances

    A number of appliances have been devised to attempt to deal with OSA. These are intended to either pull the tongue forward or create a forward thrusting of the lower jaw. This type of therapy is potentially limited in that only a modest number of patients are able to tolerate the device on a long-term basis. Additionally there are potential adverse affects on the teeth and jaw joints.

    CPAP

    The use of CPAP has become increasingly popular in the treatment of OSA. The device acts essentially as a pneumatic "splint" to the airway thus alleviating the obstruction. The use of CPAP is effective in the majority of patients with OSA; the most significant benefit is that this offers a non-surgical option. There are a number of concerns which arise however.

    CPAP is a LIFETIME commitment. It will not be acceptable to discontinue its use in the absence of definitive resolution of the source of the obstruction.

    There must be essentially 100% usage of the device while sleeping or napping. It is not acceptable to tolerate periods of significant drops in SaO2 at any time if we truly wish to eliminate the added risk of heart attack or stroke.

    It is clear that even the optimistic estimates of true compliance report only 60% or less for long term use.

    There is a self explanatory social problem associated with having to be connected to a device with a mask and hose every night.

    The long term costs of CPAP are significant when one considers numerous decades of use.

Surgical management

The goal of surgical management is the cure of OSA by elimination of the obstructive cause of the problem. Successful management is greatly dependent on appropriate patient selection. Identification of the precise sites of obstruction is essential to choosing and recommending the appropriate procedure. Successful surgery does in fact offer a cure for OSA. In essentially un-selected patients UPPP (uvulopharyngopalatoplasty- trimming of the soft palate) offers a 50% cure rate. In carefully selected patients (those with the likely source of obstruction at the level of the palate) the success rate is significantly improved. The major reason for incomplete success for the UPPP procedure is the frequent presence of obstruction involving the tongue base. Perhaps as many as 50% of individuals with moderate to severe OSA, in fact, have a significant element of tongue base obstruction. This area has been poorly managed with prior surgical techniques.

There has been a recent revolutionary change in this area of therapy with the advent and success of the radio frequency ablation technique for tongue base reduction-Somnoplasty of the tongue base. This technique now allows for a reliable, painless, and highly effective means of safely de-bulking the obstructive excess tissue and cure a great many individuals whose only prior option has been CPAP.

In the condition of sleep apnea, the site of obstruction may be anywhere from the nasal vestibule to the level of the trachea. The specific site then dictates the treatment alternatives. A given individual may be noted to have more than one anatomical site as a problem. The following is a list of sites and their treatment options:

    Nasal airway

    The nose is a frequent site of obstruction. Although rarely the only cause for OSA, nasal obstruction is very often an exacerbating cofactor in OSA. Specific sites include functional nasal valvular collapse due to anatomy and poor cartilage support, nasal septal deviation, and hypertrophy (enlargement) of the inferior turbinates. Treatment consists of rhinitis management and nasal airway restoration by surgical correction of the specific site.

    Sinus disorders

    Individuals with significant sinus disorders may present with polypoid tissue obstructive to the nasal or naso-pharyngeal airway. They may also produce excessive nasal secretions that contribute to obstruction. Evaluation might include a CT scan if clinically indicated. Treatment might require steroid sprays, antibiotics, and possibly functional endoscopic surgery.

    Oro/naso-pharyngeal

    This is the site of obstruction for 40- 50% of individuals we see with OSA. The specific problem may involve flaccidly and redundancy of the palate, uvula, and/or significant tonsillar encroachment. Treatment options include CPAP and surgical correction. The surgical correction involves performing a UPPP or its equivalent using a laser. This procedure does involve a 7-10 day recovery time related to a significant sore throat but it offers a permanent cure for those in whom this is in fact the area of obstruction. In select individuals, Somnoplasty of the palate may be effective as an alternative and highly conservative treatment option.

    Hypopharyngeal

    Obstruction at the hypopharyngeal region is seen in a number of individuals with OSA. The obstruction is related to the relative anatomical relationships between the tongue base and the hypopharyngeal structures. This anatomical problem has been the most difficult to correct in the past, and the majority with this level of obstruction would need CPAP therapy on a permanent basis. The advent of tongue base Somnoplasty has completely changed this concept allowing for a safe, virtually painless, and reliable means to cure this difficult area. We have had excellent success with this simple technique over the past 4 years.

    Glottic, subglottic and other laryngeal areas

    Rarely, the site of obstruction is due to problems referable to the glottic and periglottic structures. Bilateral vocal cord paralysis, glottic webs, laryngeal polyps or tumors, laryngoceles, laryngomalacia, valecular cysts, subglottic stenosis or webs, and tracheomalacia are all possible findings. A large goiter may also compromise the airway resulting in OSA. The treatment is of course directed by the specific site and includes correction of webs, removal of tumors and cysts, thyroidectomy, or potentially tracheotomy. CPAP may also play a role particularly in cases poorly amenable to correction.

    Tracheotomy

    This is one of the oldest therapies for OSA. It is 100% effective, does not require the use of added equipment, and is safe and permanent. The downside is having to manage a tracheotomy tube. This may still represent a realistic treatment option for a limited group of individuals.

    Snoring

    Snoring is an obvious problem for a substantial group of individuals. In the more extreme cases (heroic snorers), the sound can be so loud as to disrupt the sleep of another despite separate rooms and even earplugs. There is of course a wide spectrum of this disorder. A significant percentage of snorers also have OSA that must be evaluated and addressed. The source of sounds consistent with snoring is almost inevitably due to redundancy and flaccidity of the soft palate and uvula. Additionally nasal airway restriction may be an exacerbating factor. Treatment of the non-apnic snorer (no OSA) is generally directed to addressing the redundant soft palate and resolving any associated nasal obstruction. When the area vibrating is clearly seen to be the palate on endoscopic exam, then the Somnoplasty or Pillar procedure offers a 90-100% success rate in resolving the snoring (complete resolution or sufficient reduction in volume and frequency as to no longer pose any concerns).

Summary

Sleep disorders are common and fall within a wide spectrum of severity. Snoring is a strong indicator of issues with airway restriction. There are a number of modalities of therapy that are offered for individuals with snoring/OSA issues, often in a highly subjective fashion. We feel that it is important that a systematic approach be utilized in evaluation that then directs individuals to appropriate therapeutic options. As head and neck surgeons we offer the experience and expertise to be able to objectively evaluate the upper airway. We are also able to offer highly cost effective and accurate sleep studies. If treatment is necessary we are able to address essentially all options of therapy be they medical, surgical, or initiating the use of CPAP therapy. With carefully selected treatment options based on a thorough upper airway exam and objective testing, we are able to offer a high rate of resolution and patient satisfaction.