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Roentgenographic dimensions of the upper airway in snoring patients with and without obstructive sleep apnea.

The purpose of this study was to examine whether a simple test, such as routine roentgenographic views of the upper airway, is useful in identifying anatomic narrowing of the airway in patients with sleep apnea. To accomplish this, we prospectively studied a group of 117 patients (95 male and 22 female subjects) referred for evaluation of heavy snoring and possible obstructive sleep apnea. All patients had full nocturnal polysomnography, including measurements of snoring. Lateral view of the airway obtained after swallowing contrast material was used to measure pharyngeal diameters at three sites along the airway. All measurements were performed with the patients standing and supine. We used three different definitions of sleep apnea (apnea/hypopnea index of 10, 20, and 40), and compared airway diameters between the apneic and nonapneic snorers. Only when sleep apnea was defined as greater than 40 apneas plus hypopneas per hour of sleep was there a significant difference in airway diameter at the tip of the palate and 1 cm distal to it between apneic and nonapneic snorers. Both groups of patients demonstrated a significant reduction in the retropalatal distance on assumption of the supine posture. Stepwise, forward, multiple linear regression analysis showed that the retropalatal distance and airway diameter at the tip of the palate and 1 cm distal to it were significant predictors of snoring, but not apnea. We conclude that (1) airway diameters account for some of the variability in snoring, and (2) they do not differentiate between apneic and nonapneic snorers.

Adult↗

Snoring and nocturnal oxygenation. Is there a relationship?

OBJECTIVE: To test the hypothesis that snoring, independently of sleep apnea, is a significant determinant of nocturnal oxygen saturation. DESIGN: Prospective study. SETTING: Sleep disorders clinic, university teaching hospital. PATIENTS: Six hundred twenty-five nonapneic snorers referred to the clinic. METHODS: Nocturnal polysomnography, which included objective and simultaneous measurement of snoring and oxygen saturation, was performed in all patients. Pulmonary function tests and smoking history were also obtained. RESULTS: Multiple stepwise linear regression analysis demonstrated that age, body mass index, and pulmonary function were the most important determinants of nocturnal oxygen saturation, accounting for 20 to 30% of its variability. Snoring was a significant, although weak (partial r2 = 0.073, p < 0.001) determinant of lowest, but not mean, nocturnal oxygen saturation. When mild snorers were matched one-for-one for body mass index to a group of severe snorers, only the lowest, not the mean, nocturnal oxygen saturation was significantly different between the groups. CONCLUSIONS: Snoring is not associated with sustained nocturnal hypoxemia, but it is weakly related to lowest nocturnal oxygen saturation.

Adult↗

High prevalence of allergic sensitization in children with habitual snoring and obstructive sleep apnea.

STUDY OBJECTIVE: To determine whether allergic sensitization occurs frequently in children with habitual snoring and whether allergy predicts the occurrence of obstructive sleep apnea syndrome (OSAS) in snoring children. DESIGN: Prospective study of 39 children with habitual snoring who were referred for polysomnography. SETTING: Pediatric pulmonary sleep disorders clinic in a tertiary referral center. MEASUREMENTS: Subjects underwent a complete history and physical examination. To assess for the presence of allergic sensitization, a multiantigen radioallergosorbent test (RAST) was performed on serum samples. Subjects then underwent nocturnal polysomnography to determine the presence and severity of OSAS. RESULTS: Fourteen subjects (36%) demonstrated sensitivity to allergens; this is higher than expected for the general pediatric population. The frequency of OSAS was increased in subjects with positive RAST results compared to those with negative RAST results (57% vs 40%; chi 2 = 9.11; p < 0.01). CONCLUSION: Allergy is frequently present in pediatric patients with habitual snoring. Furthermore, the presence of allergy is associated with an increased risk of OSAS in this population.

Child↗

Inspiratory flow-volume curve in snoring patients with and without obstructive sleep apnea.

We analyzed the flow-volume curves of 50 patients with complaints of snoring and daytime sleepiness in treatment at the Pneumology Unit of the University Hospital of Brasília. The total group was divided into snorers without obstructive sleep apnea (OSA) (N = 19) and snorers with OSA (N = 31); the patients with OSA were subdivided into two groups according to the apnea/hypopnea index (AHI): AHI < 20/h (N = 14) and AHI > 20/h (N = 17). The control group (N = 10) consisted of nonsmoking subjects without complaints of snoring, daytime sleepiness or pulmonary diseases. The population studied (control and patients) consisted of males of similar age, height and body mass index (BMI); spirometric data were also similar in the four groups. There was no significative difference in the ratio of forced expiratory and inspiratory flows (FEF50%/FIF50%) in any group: control. 0.89; snorers, 1.11; snorers with OSA (AHI < 20/h), 1.42, and snorers with OSA (AHI > 20/h), 1.64. The FIF at 50% of vital capacity (FIF50%) of snoring patients with or without OSA was lower than the FIF50% of the control group (P < 0.05): snorers 4.30 l/s; snorers with OSA (AHI < 20/h) 3.69 l/s; snorers with OSA (AHI > 20/h) 3.17 l/s and control group 5.48 l/s. The FIF50% of patients with severe OSA (AHI > 20/h) was lower than the FIF50% of snorers without OSA (P < 0.05): 3.17 l/s and 4.30 l/s, respectively. We conclude that 1) the FEF50%/FIF50% ratio is not useful for predicting OSA, and 2) FIF50% is decreased in snoring patients with and without OSA, suggesting that these patients have increased upper airway resistance (UAR).

Humans↗

Results of uvulopalatopharyngoplasty in snoring.

Twenty-one patients (4 females and 17 males) with very annoying snoring were subjected to UPPP with CO2-laser technique. All patients were overweight (bodymass index average 30.3 kg/m2). In 71%, narrowing were found at the naso/oropharyngeal border. All had either abnormal uvula or soft palate. In 17 patients, snoring was reduced to a degree no longer socially annoying. Three were annoying to some extent. In only one patient, snoring was completely unchanged. UPPP is not very difficult to perform and we did not notice any troublesome sequelae. We think that UPPP is an effective operation for severe snoring, although it does not eliminate the symptom.

Female↗

Snoring children: factors predicting sleep apnea.

Many snoring children present obstructive symptoms according to their parents. The seriousness of the symptoms and the possibility of the obstructive sleep apnea syndrome (OSAS) in these children may be difficult to judge on the basis of the clinical findings and the patient's history only. In order to evaluate snoring children's relative risk (RR) to have OSAS, their symptoms and signs, as reported by the parents, and clinical findings were compared with the results of overnight polysomnography (PSG). An obstructive apnea index (AI) > or = 1 in PSG was regarded as the criterion for OSAS. The mean AI was 1.55 (range 0-15), and 29 children had a pathological AI, while 49 had a normal PSG recording. Apneic episodes every night detected by the parents was the most important single risk factor for OSAS (RR 3.6, 95% confidence interval (CI) 1.7-7.7). The RR ratio decreased when apneas appeared less frequently, but any detected apnea was still a single risk factor (RR 1.4, CI 1.2-1.8). The other risk factors of night-time symptoms were constant snoring (RR 1.5, CI 1.0-2.1) and restless sleep (RR 2.1, CI 1.1-4.0). Of the daytime symptoms, absence of excessive sleepiness was a protective factor against OSAS (RR 0.3, CI 0.1-1.0). Previous adenoidectomy was found to be a risk factor (RR 1.7, CI 1.1-2.7), as was tonsillar enlargement (RR 1.4, CI 1.1-1.8). These two findings suggest that the epipharyngeal space does not play a central role in the development of OSAS in children. OSAS cannot be reliably diagnosed without PSG, which is the most important examination for snoring children with obstructive symptoms. For clinical decisions, the consideration of risk factors is essential.

Adenoidectomy↗

Adults who snore.

Snoring is a common finding in adults and may signal sleep-disordered breathing. Careful history taking and physical examination may identify patients who require polysomnography. Any snoring that is disruptive to a patient's life or accompanied by symptoms suggesting obstructive sleep apnea requires further evaluation. Ambulatory polysomnography may be adequate in asymptomatic snorers (i.e., those without witnessed apneic episodes, daytime sleepiness, or significant associated disease processes) who seek treatment for social reasons. Split-night testing is a promising diagnostic protocol for symptomatic snorers. All snorers benefit from instruction on behavior modification. The best treatment option (fitting of an oral appliance, surgical intervention, CPAP) depends on whether apneic episodes accompany snoring and on patient preference. More studies are needed to determine the most reliable and cost-effective approach to symptomatic snoring.

Adult↗

["Restricted ablation" of elongated uvula mucosa by the injection of the ethanol/steroid mixture: a new treatment for snoring and OSAS].

We developed a "Submucosal Ethanol/Steroid (E/S) Injection Method (SEIM)" using an injection prepared by dissolving steroid with powerful antiinflammatory effect, which has the excellent effect of contractile reduction in oral tissues. In this clinical trial, the ablation effect of SEIM on the abnormally elongated uvula and the soft palate was examined in each one clinical case of obstructive sleep apnea syndrome (OSAS) and simple snoring. In the OSAS, we found that the uvula was reduced from 15 to 10mm, the visual analog scale (VAS) of snoring was reduced from 10 to 4 points, and the respiration disturbance index of the apnea-hypopnea index (AHI) improved from 35.3 to 26.1 after treatment. In simple snoring, the uvula was reduced from 11 to 8.5mm and VAS was relieved from 7 to 2 points after treatment. Our approach will produce a great clinical significance for not only OSAS or simple snoring but also treatment of the allergic rhinitis, etc, because the contractile tissue reduction can be attained safely in these diseases without open surgical wounds and unnecessary deformation or destruction of the mucosal structure.

Adult↗

Habitual snoring, OSA and craniofacial modification. Orthodontic clinical and diagnostic aspects in a case control study.

BACKGROUND: This research aims to analized the clinical and diagnostic aspects of OSA in the orthodontic research field. METHODS: Through a case control study, the presence of early craniofacial modifications in a study group constituted of 13 children with long history of habitual snoring and obstructive sleep apnea syndrome (mean age 54 months, range 36-103) and in a control group constituted of 13 children with no history of snoring (mean age 60 months, range 55-67), is analyzed. Clinical neurological and orthodontic examination, cefalometrics analysis and MESAM 4 has been performed to each single child. RESULTS: Neurological clinical examination and diurnal polysomnography or nocturnal ambulatory monitoring of snoring (MESAM 4) showed that this pathology started very early in the childhood: snoring onset was 22.7 months, the apnea onset was 34.7 months. Moreover 23% of the children showed a failure to thrive. The cephalometric results revealed that OSA children showed different cranio-facial features: a maxillo-mandibular micrognathia and or retrognathia, an increment of divergency associated with an increase in the vertical development of the face and a reduced perviety of the upper airway space caused by a mechanical obstruction due to enlarged adenoids. The orthodontic clinical examination revealed that OSA patients showed posterior cross-bite, anterior open-bite and lip-incompetence. CONCLUSIONS: These results suggest that oral breathing, that is present in sleep apnea patients, is responsible of different cranio-facial anomalies. For this reason these features must be recognized, as soon as possible, in order to start an early treatment of this pathology.

Age Factors↗

[Diagnosis and therapy of primary snoring].

Snoring, excessive daytime sleepiness and nocturnal apnoea are among the leading symptoms of the obstructive sleep apnoea syndrome (OSAS). Primary snoring without upper airway obstruction is a more common and normal phenomenon in sleep and has to be distinguished from OSAS. Patients with primary snoring are often suffering and complain of great distress and social embarrassment and therefore request professional help. Therefore, the otorhinolaryngologist has to be aware of the different treatment options that are possible and sensible. Apart from behavioral changes and general measures (weight loss, reduction of alcohol consumption, sleep position training), there are different conservative and surgical treatment options. In this article, the pathophysiology, diagnosis and treatment of primary snoring will be discussed.

Endoscopy↗

[Snoring and upper airway resistance syndrome].

Snoring is an inspiratory noise caused by vibration of soft palate and posterior faucial pillars. Snoring corresponds to partial obstruction of upper airway, and complete obstruction is followed by an apnea. Heavy snoring is practically always present in obstructive sleep apnea syndrome. Upper airway resistance syndrome (UARS) was first used by Guilleminault and colleagues to describe a subgroup of patients with conditions that were formerly diagnosed as idiopathic hypersomnia or CNS hypersomnia. These terms used to describe excessive daytime sleepiness without a cause that was clearly defined by a nocturnal polysomnogram or the multiple sleep latency test. The clinical importance of snoring and UARS is reviewed in this article.

Airway Obstruction↗

Recent advances in surgery for snoring-somnoplasty (radiofrequency palatoplasty) a pilot study: effectiveness and acceptability.

A prospective study was designed to investigate the effects of Somnoplasty (Radiofrequency palatoplasty) in patients with snoring. A group of 22 patients fulfilling the inclusion and exclusion criteria outlined underwent somnoplasty performed by a single surgeon. Every patient completed a standard questionnaire containing visual analogue scales at six weeks post operatively. The parameters assessed were post-operative pain, change in snoring score, effects on sleep of the patient and bed partner, speech and swallowing, alteration in weight, acceptance of the procedure and recommendation to friends and family. Results of improvement in snoring score were correlated to body mass index (BMI) kg/m2. We conclude that somnoplasty is an effective procedure in elimination of snoring and the success is closely linked to BMI. Best response is obtained in those with BMI < 25 and moderate response is obtained in those with BMI between 25-30. Obese (BMI > 30) patients are more likely to have a poor response. Morbidity associated with the procedure is minimal and patient acceptance is 100%. The long-term success of this procedure needs to be confirmed with further follow up.

Adult↗

[Snoring and obstructive sleep apnea].

Snoring and obstructive sleep apnea are similar disorders in etiology, with differences in clinical presentation and treatment. 5-20% of young and 40-50% of older population are affected by either of these disorders. Etiology of snoring should be sought in the anatomic irregularities of commencing portions of the upper respiratory and gastrointestinal tracts, obesity, alcohol abuse, use of some medications as well as in the sleep architecture disturbance. Treatment success depends on correctly established diagnosis and precise localisation of anatomic irregularity implicated in snoring. A wide array of diagnostic tests exist some of which are mandatory while the others are used on a case-by-case basis. Treatment is either conservative or surgical. The success rate is 30-90% depending on the type and the management of disorder. An algorithm for diagnosis and treatment of snoring and obstructive sleep apnea is shown at the end of the paper.

Humans↗

[Efficiency of intraoral applicator UPLH-01 in snore and obstructive sleep apnea].

Tolerance, subjective and objective effectiveness of domestic intraoral applicator UPLH-01 were studied in the treatment of snoring and obstructive sleep apnea (OSA). In 44 patients with uncomplicated snoring the above parameters were assessed using questionnaire, in 20 patients with uncomplicated snoring and OSA paired polysomnographic investigations were made. Tolerance of the treatment was 50%. Subjective positive effect was registered in 65% of the patients. The applicator was found effective in the majority of patients with uncomplicated snoring. In mild and moderate OSA the applicator was effective only in a few cases. In severe OSA no effect was found. Patients with chronic disorders of nasal breathing exhibited deterioration of respiration and blood saturation with oxygen. Thus nasal obstruction is a contraindication to applicator use.

Adult↗

Mandibular advancement splint improves indices of obstructive sleep apnoea and snoring but side effects are common.

AIM: To assess the efficacy of a mandibular advancement splint (MAS) in the treatment of obstructive sleep apnoea syndrome (OSAS). METHODS: Nineteen patients using a MAS for symptomatic OSAS underwent polysomnography, with MAS use randomised to one half of the night. Indices of snoring and OSAS were compared. Side effects, compliance and treatment response were evaluated by questionnaire. RESULTS: Use of the MAS improved total respiratory disturbance index (RDI) from 22.2 +/- 19.8 (SD) events per hour to 16.5 +/- 21.4/hr (p = 0.03), supine RDI (30.8 +/- 23.8/hr to 18.8 +/- 22.1/hr, p = 0.01), arousal index (25.2 +/- 18.9/hr to 19.3 +/- 14.2/hr, p = 0.01) and snoring intensity (52.7 +/- 4.1 to 50.7 +/- 2.7 dB, p = 0.02) but not total snore frequency (p > 0.05). Using polysomnographic criteria, MAS treatment was completely successful in four (21%) patients, partially successful in ten (52.6%) and a failure in five (26.3%). Treatment over a median of 6.5 weeks (range 2-48) was perceived as beneficial by ten of eleven partners. Fifteen patients (79%) reported side effects, 9 (46%) did not use the device every night and four (21%) used the device less than three nights per week. CONCLUSION: The use of the MAS resulted in significant reductions in indices of OSAS and snoring. However, a significant number of patients had difficulty tolerating and regularly using the device.

Adult↗

Anterior mandibular positioning device for treatment of snoring and obstructive sleep apnoea.

The aim of this study was to determine the severity of side effects and the influence on snoring and the AHI (apnoea-hypopnoea index = number of apnoeas and hypopnoeas per hour recording) of an anterior mandibular positioning device (AMP device) for treatment of snoring and obstructive sleep apnoea. Questionnaires were mailed to a consecutive series of 30 patients who had started treatment with an AMP device. The mean follow-up interval from receiving an AMP device to answering the questionnaire was 22 months. The perceived degree of sore teeth increased statistically significantly (p < 0.01) as a result of the AMP device treatment, but there was no increase in the degree of facial pain, salivation, or temporomandibular joint pain. The AMP device treatment resulted in a statistically significant reduction (p < 0.01) of the mean AHI and of the mean percentage of the recording time with loud snoring (p < 0.05). Twenty-two patients out of 30 were still using the device at the time of follow-up. In conclusion, AMP device treatment was associated with only mild side effects and resulted in a statistically significant reduction of the AHI and of the percentage of the recording time with loud snoring.

Adult↗

Long-term results of uvulopalatopharyngoplasty for snoring.

Snoring is a disease of listeners and one which can cause significant disruption in an otherwise peaceful household. Uvulopalatopharyngoplasty (UPPP) was initially described in 1981 for the treatment of obstructive sleep apnea, and since that time only one large series has evaluated it as a treatment for snoring. Various therapeutic strategies have been described for the treatment of snoring, but UPPP seems to hold the most promise. A retrospective review was undertaken of over 100 patients undergoing UPPP since 1984 to evaluate the efficacy of the procedure in controlling the symptom of snoring. The group of patients who will benefit most from this procedure is identified.

Adult↗

Snoring, sleep apnea syndrome, and stroke.

Increasing evidence suggests that snoring and sleep apnea are associated with cerebrovascular diseases. Several other factors may be involved in this association because many established or potential risk factors for stroke are related to snoring and sleep apnea. These include arterial hypertension, coronary heart disease, age, obesity, smoking, and alcohol consumption. Recent epidemiologic and clinical studies indicate, however, that snoring can increase the risk of stroke independently of these confounding factors. Accumulating epidemiologic evidence of long-term harmful effects of the obstructive sleep apnea syndrome appears to be related to increasing vascular morbidity and mortality. Potential mediators among snoring, obstructive sleep apneas, and stroke include cardiac arrhythmias and other hemodynamic disturbances, increased levels of catecholamines, and disturbances in cerebral blood flow caused by sleep apneas, as well as hypoxemic periods that may potentiate atherosclerosis.

Cardiovascular Diseases↗