Snoring and Sleep Apnea – October 2010

With the rise in body weight in our nation, there are a multitude of diseases that are related directly to obesity that are at epidemic proportions. Hypertension, degenerative joint disease, diabetes, heart disease, stroke and a variety of cancers are more prevalent in obese individuals. Obstructive Sleep Apnea Syndrome (OSAS) is a silent killer that often goes undiagnosed, and with few exceptions, is related to body fat content, as well as other anatomic abnormalities.

Simple “snoring” without symptoms detailed below can usually be managed simply with nonsurgical treatment, conservative weight loss, or some simple surgical procedures. A dental device worn at night can be made to advance the jaw, and on occasion, can alleviate benign snoring.

The typical symptoms of sleep apnea include heavy snoring interrupted by periods where the person seems to be “breath-holding” (“apneas”). These patients may report they fall asleep all too easily, but their nights are restless. Typically, the bed or room partner of these patients cannot tolerate the disturbing, loud noises made by the sufferer. During daytime hours, the sleep apnea patient often struggles to stay alert and may inadvertently nap throughout the day. Some patients are so severely effected they routinely fall asleep behind the wheel. Untreated sleep apnea may give rise to high blood pressure, heart disease, depression, alteration in mood and depressive symptoms, and loss of sexual drive. Children with sleep apnea snore heavily and have restless sleep, but during day hours, instead of being overly tired, may become agitated, restless and have behavioral changes that have on many occasions been confused for Attention Deficit Disorder.

In my opinion, all patients suspected of having this disorder should be examined by an ENT specialist (“otolaryngologist’). I say this not out of pride for my specialty, but because the anatomy of upper airway blockage in the nose or throat is understood best by our field. It is common that patients suspected of having OSAS are referred to a “pulmonary” specialist, although they have no formal training in the examination of the upper airway.

Adults with suspected OSAS should therefore undergo a thorough ENT evaluation, and if their history and physical is suspicious for the disease, should have a formal overnight sleep study which we order routinely. Simple measurement of oxygen levels by  “finger probe” oximetry overnight is often very misleading:  not all patients with low blood oxygen levels at night have sleep apnea, and not all patients with sleep apnea demonstrate significant decreases in oxygen levels during sleep. Children with typical symptoms of sleep apnea, in my opinion, do not require any form of sleep study unless they have unusual findings on exam.

Treatment for adults with OSAS falls into two broad categories. Regardless of which approach is chosen, if body weight is an issue, aggressive weight loss is mandatory for a satisfactory outcome.

  1. Use of Continuous Positive Airway Pressure (CPAP) by nasal or facial mask (usually the patient will be introduced to this during the overnight sleep study if they are found to have OSAS).
  2. Multilevel surgery, including procedures to open the obstructed nose, remove excess tonsil tissues, reconstruct or “lift” the palate” (“UPPP”), and on occasion, reduce bulk of, or advance the base of the tongue. An alternative to surgery at the tongue base is the use of a simple dental splint which can be worn to hold the tongue off the back of the throat.

Frequently, aggressive weight loss alone can cure OSAS. Unfortunately permanent weight loss of this magnitude takes time, and must be undertaken under supervision. In these instances, during the weight loss period, I recommend these patients use CPAP so we protect them from progression of disorders associated with OSAS as best as possible, and also so that they feel more energetic and are able to undertake an exercise program.

Very often, patients who start on CPAP masks fail to tolerate this treatment, and conversely, some patients choosing a surgical option fail to achieve complete resolution of their symptoms. It is therefore vital the patient and doctor remain flexible and realistic, and are willing to accept alternative treatments if the first choice fails.

Children with sleep apnea almost always are cured by simple removal of enlarged tonsils and adenoid tissues. On rare occasions, a child will have OSAS related strictly to body weight, or a separate, unusual anatomic feature of their airway.

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