Report of a
Case
A 67-year-old
man with a long-standing history of snoring noted that, in recent years,
the snoring had worsened so much that his wife banned him from their
bedroom. Since his retirement, he gained 20 pounds, and knee
problems reduced his physical activity. His nasal allergies also had
worsened. He noted increased fatigue, daytime sleepiness, and some trouble
concentrating. He reported following a medication regimen as treatment
for hypertension, but he otherwise denied having any medical problems.
He had a tonsillectomy and adenoidectomy as a child and had no history
of thyroid disease.
Physical
examination showed nasal congestion with moderately swollen, pale turbinates
and no purulent discharge. The septum was midline. Oropharyngeal examination
showed no tonsils and a low soft palate with elongated uvula that tended
to collapse against the posterior aspect of the pharynx and abutted
the base of tongue. Fiberoptic laryngeal examination showed a normal
larynx with moderate collapse of the lateral pharyngeal walls in "blocked"
inspiration (a reverse Müller's maneuver whereby the patient holds
his nose, closes his mouth, and attempts to breathe inward). He had
a short, thick neck and was overweight.
The working
diagnosis was obstructive sleep apnea.
Diagnosis of
Obstructive Sleep Apnea
The reference
standard for diagnosis of sleep disorders is to perform polysomnography
(a sleep study), during which the sleeping patient is observed for oxygen
saturation level, amount of oral and nasal airflow, degree of respiratory
effort, electrocardiographic measurements, body position, and overall
body movement. This examination can be done both "inhouse"
in a sleep laboratory and with home sleep studies for which the patient
is connected to monitors and observed in the patient's natural sleep
environment.
On the
basis of the apnea-hypopnea index, the severity of sleep apnea is categorized
as mild, moderate, or severe. Mild sleep apnea is defined by an apnea-hypopnea
index score anywhere from 5 to 14, oxygen saturation level of at least
86%, and minimal daytime disability. Moderate sleep apnea is defined
by an index score anywhere from 15 to 30 or an oxygen saturation level
of 80% to 85% and clinically significant dysfunction at work or socially
because of daytime somnolence and loss of concentration. Severe sleep
apnea is defined by an index score >30 or an oxygen saturation level
of <79% and incapacitation caused by the sleep disorder.
Common
causes of obstructive sleep apnea include obesity or excessive weight
gain (fatty tissue in the throat tissue narrows and blocks the airway
when the muscles relax), age (loss of muscle mass and tone in the upper
airway), gender (men tend to have narrower airways than women), irregular
sleep hours, anatomic abnormality (nasal obstruction, enlarged tongue,
elongated soft palate, large tonsils and adenoids), use of alcohol and
sedatives (relaxes the musculature), smoking (causes inflammation and
swelling of the upper airway), and severe reflux (gastroesophageal reflux
disease). Snoring is a common symptom of sleep apnea and results from
obstruction, usually by the soft palate and uvula (Figure 1).1
However, snoring itself does not involve cessation of breathing, and
many "snorers" have normal results of sleep studies.
Figure
1. Diagram shows anatomic structures involved in snoring. Adapted
and reproduced by permission from: Abeloff D. Medical art: graphics
for use. Baltimore: Williams & Wilkins; 1982.1 |
Treatment of
Obstructive Sleep Apnea
Where "sleep
classes" are available, most patients are referred to these classes,
group appointments at which patients receive educational material on
snoring and sleep apnea. This material advises patients to eliminate
their use of alcohol, tobacco, and sedatives, to sleep on their side
instead of their back, and to regularize their sleep hours. Overweight
patients receive a plan for weight reduction and appropriate exercise
to maintain mobility. Physicians prescribe intranasal steroid medication
and nonsedating antihistamine drugs for nasal allergies.
Patients
with moderate to severe sleep apnea are treated with continuous positive
airway pressure (CPAP). This therapy requires the patient to wear a
mask over their nose during sleep, when the pressure is adjusted to
keep the airway open at night. Although CPAP therapy is the most effective
treatment for obstructive sleep apnea, this therapy is often unsuccessful
because of patient noncompliance: Some studies have reported compliance
rates lower than 70%.2 The patient described in the present
case report was treated with CPAP and noted substantial reduction in
both fatigue and daytime somnolence.
Obstructive
sleep apnea has been treated with many surgical procedures: uvulopalatopharyngoplasty
(UPPP), a procedure which removes soft tissue at the back of the throat--uvula,
tonsils (if present), and part of the redundant soft palate--but does
not address problems originating at the base of tongue or hypopharynx;
tonsillectomy and adenoidectomy (effective in some children); mandibular
and hyoid advancement procedures (operations which are difficult, risky,
and inconsistently successful); and radiofrequency ablation procedures
(effective treatment for snoring but inconsistently successful for treating
sleep apnea). All of these treatments have substantial risks and are
only moderately successful. Tracheostomy is the most effective treatment
because it bypasses the upper airway completely; however, this procedure
is also the least popular and is technically challenging in the morbidly
obese patient. For most patients, the postoperative care necessitated
by tracheostomy makes this option untenable as an elective procedure.
Conclusion
Snoring
is part of the spectrum of sleep-disordered breathing that may be a
symptom of obstructive sleep apnea, but not all patients who snore have
clinically significant sleep apnea. Snoring may be present in 30% to
50% of the general adult population, whereas 2% of women and 4% of men
have clinically significant (moderate to severe) obstructive sleep apnea.3
Complications
of untreated obstructive sleep apnea can include cardiovascular changes
such as hypertension, ventricular dysfunction, or pulmonary hypertension.
To determine the proper intervention required to reduce these complications,
patients should receive a polysomnogram, either on an outpatient ("home"
study) basis or in a sleep laboratory with a technician in attendance.
Severity of sleep apnea does not always correlate with anatomic findings
or with medical history; therefore, patients who snore should receive
at least a nocturnal screening test measuring oxygen saturation and
airflow, and patients with daytime somnolence or symptoms suggestive
of sleep apnea should receive a full sleep study.
Patients
with sleep apnea have an increased risk of airway problems after general
anesthesia and should be observed carefully during the perioperative
period. In addition, use of opioid and sedative drugs should be minimized
for these patients to prevent airway compromise and desaturation.
To splint
and keep the upper airway patent during sleep, the most effective treatment
for sleep apnea is CPAP given at a level determined by results of a
titration study; variations of this treatment include bi-level positive
air pressure (BIPAP, a procedure in which expiratory pressure is lower
than prescribed inspiratory pressure if high pressure is required) or
auto titration (self-adjusting pressure).
Treatment
for snoring may include weight loss, avoidance of supine sleeping position,
sleeping with head elevated, avoidance of alcohol or sedatives at night,
and treatment of nasal symptoms. Patients who snore may opt to use a
dental appliance at night or may consider various procedures for treating
snoring--eg, radiofrequency ablation of the palate (somnoplasty), a
procedure designed to stiffen the soft palate or to increase airway
patency. These procedures are considered cosmetic and thus are not covered
either by the Kaiser Foundation Health Plan or by other insurance providers,
but many Head and Neck Surgery Departments will soon offer snoring treatment
procedures on a fee-for-service basis.
References
- Abeloff
D. Medical art: graphics for use. Baltimore: Williams & Wilkins;
1982.
- Flemons
WW. Clinical practice. Ostructive sleep apnea. N Engl J Med 2002 Aug
15;347(7):498-504.
- Young
T, Palta M, Dempsey J, et al. The occurrence of sleep-disordered breathing
among middle-aged adults. N Engl J Med 1993 Apr 29;328(17):1230-5.
Recommended
Reading
- Dart
RA, Gregoire JR, Gutterman DD, Woolf SH. The association of hypertension
and secondary cardiovascular disease with sleep-disordered breathing.
Chest 2003 Jan;123(1):244-60.
- Dreher
A, de la Chaux R, Klemens C, et al. Correlation between otorhinolaryngologic
evaluation and severity of obstructive sleep apnea syndrome in snorers.
Arch Otolaryngol Head Neck Surg 2005 Feb;131(2):95-8.
- Iseri
M, Balcioglu O. Radiofrequency versus injection snoreplasty in simple
snoring. Otolaryngol Head Neck Surg 2005 Aug;133(2):224-8.
- Riley
RW, Powell NB, Li KK, Troell RJ, Guilleminault C. Surgery and obstructive
sleep apnea: long-term clinical outcomes. Otolaryngol Head Neck Surg
2000 Mar;122(3):415-21.
- Sher
AE, Schechtman KB, Piccirillo JF. The efficacy of surgical modifications
of the upper airway in adults with obstructive sleep apnea syndrome.
Sleep 1996 Feb;19(2):156-77.
