Sleep Medicine: Diagnostic and Therapeutic Options for Snoring and Sleep Apnea
"Sleep disorders affect up to 70 million people in the United States. This costs about $100 billion each year in accidents, medical bills and lost work." (Statistic from Brain Facts, Society for Neuroscience, 2002)
Sleep disordered breathing is a common problem in the American household. Snoring, for instance, is estimated to occur in over 20 percent of males and 5 percent of females by the age of 30. This number increases dramatically by the age of 60, to 60 percent of males and 40 percent of females. Sleep apnea is a condition where frequent apneas and or hypopneas occur while sleeping, with subsequent gasping for air when carbon dioxide levels rise. While apnea occurs at a much lower percentage than snoring, the medical implications associated with this disorder can be serious.
Snoring and sleep apnea disturbs a restful night's sleep. Snoring disturbs other people's sleep, while sleep apnea disturbs the sleep not only of others, but of the apneic person as well. This leads to frequent extreme daytime fatigue and somnolence. Although snoring is frequently considered a cosmetic disorder, it may have greater social implications. Anyone who has slept near a loud snorer can attest to this. Preliminary studies also are starting to show some evidence of unilateral hearing loss and quality of life disturbances in the bed partners of loud snorers.
People with sleep apnea not only face the same stigmas that snorers face, but may also suffer serious medical problems as well. Medical conditions with direct causative links to sleep apnea include memory loss, depression, anxiety, erectile dysfunction, high blood pressure, accidents caused by excessive daytime fatigue and mental fogginess, cerebral vascular accidents, diabetes, and decreased seizure thresholds.
Potential indicators of sleep apnea include loud snoring and apneic episodes, obesity with collar size of >17 inches in males and >16 inches in females, intractable daytime fatigue and mental clouding, male gender, age greater than 40, a Mallampati classification greater than 3, and a retrognathic or micrognathic jaw with a low, posterior based hyoid bone.
The work-up of snoring and sleep apnea involves a thorough history followed by a detailed physical exam focusing on the pathologic anatomical features associated with these disorders. Evaluation of the nasal airway, soft palate, base of tongue, lateral pharyngeal wall, hyoid position and mandibular projection is performed. This includes studies such as nasal endoscopy and cephalometric exams. If the history and physical exam suggests evidence of sleep apnea, then an overnight split sleep study with CPAP titration is essential.
Treatment for snoring without apnea involves initially trying simple modalities such as weight loss, sewing a tennis ball to the back of the pajamas to avoid sleeping on the back, avoidance of alcohol and other muscle relaxants, and elevating the head of the bed. If these treatment modalities fail, then surgical options focusing on the main cause of snoring, the elongated soft palate, are considered. This involves stiffening the soft palate to decrease its tendency to vibrate. This can be accomplished in a number of ways. Surgical resection, laser stiffening, injection of sclerosing agents, insertion of stiffeners, and radiofrequency induced stiffening are all procedures that decrease sound producing vibrations of the soft palate. If, during the examination, a large vibrating tongue base is seen, radiofrequency shrinking of the base of tongue can also be performed. All work quite well in the ultimate treatment of snoring.
The initial treatment for sleep apnea is a trial of CPAP. Unfortunately, recent studies have shown that while effective, compliance in using this device remains at less than 50 percent. The main goal for the surgical treatment of sleep apnea is widening of the upper airway to decrease airway resistance while sleeping. This involves a focused approach of delineating the cause of the upper airway obstruction and eliminating or decreasing it. Frequently, this requires a tonsillectomy, shortening of the soft palate, and improving nasal breathing. In addition to this, if tongue base size is an issue, radiofrequency ablation is performed to decrease the size. Other procedures can be included in the treatment, depending on anatomical factors, sleep apnea severity, or failure of previous procedures. These adjunct procedures include hyoid suspension, genioglossus advancement, application of electrical stimulators to the tongue musculature to prevent backwards collapse during sleep, maxillomandibular advancement to improve airway patency, and a tracheostomy. With these added Phase II procedures, a greater than 90 percent efficacy rate of the treatment of severe sleep apnea can be obtained.