SLEEP APNEA & 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.
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.
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.
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.
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.
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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