Sleep
Apnea and Snoring
Snoring and sleep apnea are
common problems. They are both caused by excess tissue in the throat.
The primary obstructed areas are the soft palate and the base of
the tongue. A long palate vibrating while breathing causes most
snoring. Apnea is the cessation of breathing and may be due to an
obstructive cause or to a central cause. Central sleep apnea results
when the brain fails to tell the body to breathe. Obstructive sleep
apnea results from excess soft tissue in the palate, base of tongue,
and rarely, the sides of the throat collapsing in and blocking
breathing. Obstructive sleep apnea occurs in the deeper stages of
sleep when the body becomes very relaxed. Both types of apnea are
relieved when the oxygen concentration in the blood drops low enough
that the person feels starved for air and wakes up to breath. These
brief waking episodes may occur hundreds of times a night and are not
usually remembered by the patient. The result is a poor night's rest.
Symptoms include daytime sleepiness, morning headaches, falling asleep
at the wheel, irritability and short temper, and problems with
concentration and memory. There is also an association with health
problems such as high blood pressure, heart attack, and stroke.
TREATMENT
- Medical Treatment
Medical treatment is generally recommended as the initial
treatment for all but the most severe cases of sleep apnea. For
obstructive sleep apnea, continuous positive airway pressure (CPAP)
is used as the initial treatment. In this form of treatment, a
mask is worn at night and a machine blows air into it. This
creates pressure in the airway thus supporting the tissues and
preventing blockage. CPAP is an effective treatment for those
patients who tolerate it. If CPAP is not effective or if the
patient does not tolerate it surgery may be considered.
- LAUP
The laser-assisted uvulopalatoplasty is an office procedure
performed under local anesthetic. It is a highly effective
treatment for snoring. At this time, it does not have a role in
the treatment of sleep apnea. In this procedure, excess tissue is
trimmed off the soft palate and uvula with a laser. This reduces
or eliminates snoring by reducing the amount of tissue, which can
vibrate. This procedure is repeated in the office until the
desired result is obtained. It may take from two to five
treatments to alleviate the problem. The treatments are spaced 6
to 8 weeks apart. It is performed in a serial fashion to avoid
taking to much palate. This increases the safety of the procedure.
In our practice, this procedure has been replaced by injection
snoreplasty.
- Injection Snoreplasty
This is the latest procedure used to
treat snoring. It is
performed in the office using local anesthesia and results in
minimal discomfort after the procedure.
A small amount of sclerosing solution (sodium tetradecyl
sulfate) is injected into the soft palate.
This causes scarring and stiffening which in turn results
in less noise being produced.
- UPPP
Uvulopalatopharyngoplasty is also an operation to trim
excess tissue from the palate and also from the tonsil area. It is
similar to the LAUP except that tissue is also removed from the
sides of the throat. The tonsils are removed in conjunction if
they are still present. This is an effective operation for snoring
and is effective for obstructive sleep apnea resulting from
obstruction at the level of the palate. This operation requires
overnight hospitalization.
- Tongue Base Advancement
In cases where collapse of the tongue base is obstructing
breathing, operations may be performed to pull the tongue forward.
The tongue is attached to the lower jaw in the midline just below
and behind the front teeth. If this attachment is separated or
loose, the tongue can flop backwards and block the airway. The genioglossus
advancement is a surgical procedure designed to pull the
tongue forward towards its attachment to the lower jaw.
The very lowest part of the base of
tongue is pulled forward in a procedure known as the hyoid
suspension. In this procedure, the base of
the tongue is pulled forward and suspended over the top of the voice
box. This prevents collapse of the
base of the tongue.
These two procedures are usually
performed together to maximize suspension of the tongue
- Bimaxillary Advancement
This procedure pulls both the upper and lower jaw forward, thus
pulling both the tongue and the palate away from the back of the
throat. It is a very effective procedure for sleep apnea however
it is quite extensive and is usually reserved for those cases
which fail more conservative approaches. In this procedure, the
teeth bearing portions of the upper and lower jaws are cut free
and surgically suspended in a more forward position.
- Evaluation and Management
Protocol
The patient with a snoring and/or sleep apnea problem is evaluated
in a systematic fashion. The patient's history is the most
important indicator of problems. A complete ear, nose and throat
examination is performed. A sleep study, also known as a
polysomnogram, is usually obtained. The sleep study may be
screening test which can be done at home if the suspicion of sleep
apnea is low and treatment of snoring is all that is desired. A
more detailed sleep study, performed in a sleep lab may be
required if the screening test is abnormal or if sleep apnea is
strongly suspected.
Once sleep apnea is ruled out in
the snoring patient, an injection snoreplasty may
be performed for snoring. Sometimes chronic nasal obstruction
contributes to snoring and/or sleep apnea and may require medical
or surgical treatment.
Once sleep apnea is documented to
exist with a sleep study the initial treatment is usually medical.
This treatment takes the form of Continuous Positive Airway
Pressure (CPAP). If CPAP is not effective or if the patient
does not tolerate it surgery may be considered.
When surgery is considered, the
object of the evaluation is to determine the level where the
obstruction is occurring. A complete head and neck
examination is performed. In addition, a small flexible
scope is passed through the nose to evaluate the base of the
tongue. An x-ray is also obtained of the base of the tongue
region.
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