Snoring and Obstructive Sleep Apnea

SNORING
  • Noisy breathing, a rough, rattling inspiratory noise produced by vibration of pendulous soft palate or occasionally of vocal cords, during sleep.
  • Snoring indicates some obstruction in upper airway and represents a continum of the similar pathology as of Obstructive Sleep Apnea (OSA), where snoring is on one end and OSA on the other.
  • Management of snoring without Obstructive Sleep Apnea.
  • Uvulopalatoplasty-Laser Assisted Uvulopalatoplasty (LAUP) or Bovie-Assisted Uvulopalatoplasty (BAUP). 
APNEA
  • It is cessation of Airflow for atleast 10 seconds.
  • Types of Apnea:
  1. Central:no airflow as no respiratory effort.
  2. Obstructive:no airflow despite respiratory effort
  3. Mixed:combination of central and obstructive apnea.
OBSTRUCTIVE SLEEP APNEA AND ITS ETIO-PATHOPHYSIOLOGY.
  • There is partial obstruction to the airway during inspiration due to partial collapse of relaxed soft tissues of Oropharynx and Supraglottis.
  • This results in vibration of indrawn soft tissues of the oropharynx and Supraglottic Larynx.
  • Physical obstruction with narrowing of the oropharynx,Supraglottic Larynx and Hypopharynx may be produced by Hypertrophic tonsils and Adenoids,Receding mandible,long soft 
  • palate,long uvula,large tongue,tumors of the Nasopharynx/Oropharynx/Supraglottis,base of Tongue and neck
  • Nasa and Nasopharyngeal Obstruction by Deviated Nasal Septum,Hypertrophic Turbinates,polyps,etc
  • It is diagnosed when the Apnea index exceeds 5 episodes per hour.
  • Prolonged obstruction to airway results in hypoxia leading to polycythemia and later Cor-pulmonale.
  • Decreased oxygen availability may result in leg edema, hypertension, morning headaches, cardiac arrhythmias, and stroke in patients with obstructive sleep apnea
  • More common in midddle aged people
  • More common in males
  • Associated with excessive alcohol consumption,tobacco
  • Obesity
  • Acromegaly
  • Drugs:Sedatives,tranqulizers.
CLINICAL FEATURES OF OBSTRUCTIVE SLEEP APNEA
  • Loud snoring
  • Excessive daytime sleepiness and tiredness
  • Morning headache
  • Personality changes
  • Nocturnal Enuresis
  • Difficulty in concentration
INVESTIGATION IN A CASE OF OBSTRUCTIVE SLEEP APNEA
  • Fibreoptic Endoscopy-of nose,pharynx.larynx-to find the level of obstruction
  • CT scan to detect soft tissue or bony obstructions.
  • Pulmonary function tests may reveal Hypoxia
  • Sleep latency time is less then 4 minutesin these patients.
  • Nocturnal Polysomnography test
MANAGEMENT IN A CASE OF OBSTRUCTIVE SLEEP APNEA
  • Weight reduction 
  • Alcohol consumption and smoking stopped
  • Avoiding sedating drugs.
  • Drugs like Modafinil may help in the treatment for day-time sleepiness.
  • CPAP-Continuous Positive Airway Pressure
  • Continuous positive airway pressure (CPAP) is effective for both moderate and severe disease. It is the most common treatment for obstructive sleep apnea.
  • Prosthesis to hold tongue forward
  • Surgery depending on the level of obstruction
  1. Nasal Surgery-polypectomy,septoplasty,etc
  2. Tonsil-Adenoid removal
  3. UPPP-Uvulopalatopharyngoplasty
  4. Mandibular Advancement,Hyoid bone suspension and expansion,base of tongue resection
  5. Tracheostomy in severe cases
Exam Question
  • The most probable diagnosis in a 45 year old male patient complaining of frequent tiredness and headache,loud snoring and physical examination revealing leg edema,hypertension, and cardiac arrhythmia is Obstructive sleep apnea.
  • Modafinil is an FDA approved drug in the treatment of obstructive sleep apnea, shift work disorder and narcolepsy.
  • Snoring is treated by laser-assisted uvulopalatoplasty.
  • OSA is associated with >5 episodes of apnea per hour.
  • OSA is commonly associated with Hypertension.
  • OSA is more common in males as compared to females.
  • OSA is commonly found in patients with receding jaw,Obesity and Acromegaly.
  • Next line of management in a 36 years old obese man who is a known smoker suffering from hyperten­sion and snoring with > 5 apnea/hyperapneas episodes per hour found in sleep test and given antihypertensives and advised to quit smoking is Weight reduction and diet plan.

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