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PubMed2000

Craniomandibular status and function in patients with habitual snoring and obstructive sleep apnoea after nocturnal treatment with a mandibular advancement splint: a 2-year follow-up.

The aim of the investigation was to evaluate the status and function of the temporomandibular joint (TMJ) and masticatory system in patients with habitual snoring and obstructive apnoea after 2 years nocturnal treatment with a mandibular advancement splint. Thirty-two patients participated in the study, ranging from 43.0 to 79.8 years of age (mean 54.4 years, SD 8.78) at the start of treatment. All patients had been referred from the ENT department for treatment with a mandibular advancement splint. The acrylic splint advanced the mandible 50-70 per cent of maximal protrusion, opened 5 mm vertically, and was used 6-8 hours per night and 5-7 nights per week. Overjet, overbite, and molar relationship were measured on dental casts. The patients were asked to answer a questionnaire concerning symptoms of craniomandibular dysfunction (CMD). They were also clinically examined in a standardized manner, including registration of range of mandibular movements, TMJ sounds, pain on movement, and palpatory tenderness of the TMJ and the masticatory muscles. None of the patients showed more than five symptoms of dysfunction either at the start of or after 2 years of treatment. A decrease in the frequency of headache was found for nine of those 18 patients that reported headache (P = 0.004). A minor, but significant decrease in overjet and overbite was found and the molar relationship was also changed. It was concluded that 2 years' treatment with a mandibular advancement splint had no adverse effects on the craniomandibular status and function, but the observed occlusal changes requires further evaluation.

Adult↗
PubMed2003

Validation of measurements of mandibular protrusion in the treatment of obstructive sleep apnoea and snoring with a mandibular protruding device.

The aims of this study were to compare the maximum range of protrusion determined with a ruler with measurements made using a George Gauge (GG) and to validate the methods of measurement (ruler and GG) of the advancement established by mandibular protruding devices (MPDs), using cephalograms as the gold standard. The study comprised 77 patients (63 males, 14 females, mean age 54 years, range 31-73 years) with obstructive sleep apnoea (OSA) (n = 50) or complaints of snoring (n = 27). After a medical examination that included an overnight somnographic registration and a dental and stomatognathic examination, each patient was given a MPD. Measurements of the maximum range of protrusion with the GG and a ruler were compared. Pairs of upright cephalograms were taken with and without the MPD. The position of the mandible on the cephalograms was compared with ruler measurements of the device-induced protrusion in the incisor and premolar regions, the vertical opening in the anterior region, and GG construction bite registration. The maximum range of protrusion was significantly greater with GG than ruler measurements, on average +1.2 mm (P < 0.001). The mandibular position as measured in the incisor or premolar region with a ruler or on the cephalogram was not significantly different. GG values, however, were higher and differed significantly from ruler and cephalometric measurements (P < 0.001). The degree of anterior mandibular advancement with a MPD measured with a ruler in the incisor or premolar regions compared well with corresponding cephalometric measurements. The ruler and cephalometric measurements of the vertical opening with the MPD coincided well in the incisor region. The GG overestimated the maximum range of protrusion compared with ruler measurements.

Adult↗
PubMed1997

Intensity pattern of snoring sounds as a predictor for sleep-disordered breathing.

The relationship between a new operational definition of sleep sounds and apnea was examined in a population of 69 patients referred for overnight evaluations in a sleep disorders center. The sample contained 18 women (mean age 53.6 years) and 51 men (mean age 48.4 years). Subjects underwent polysomnography (PSG) with concurrent graphical recording of sleep sound intensities throughout the night. An acoustical signature event (ASE) was defined as a loud sound preceded by at least 10 but no more than 90 seconds of silence. Multiple regression was performed using known correlates of apnea and ASE to predict PSG levels of respiratory disturbance. Of the commonly known correlates, only self-reported estimate of snoring and apnea severity explained significant variance to the respiratory disturbance index (RDI; R2 = 0.24, p < 0.0001). ASE was entered into the equation as the last step, significantly improving explained variance (R2delta = 0.54, p < 0.0001). The final equation R2 was 78% (p < 0.0001). An alternative analysis compared ASE findings to polysomnographic findings in each matched 30-second interval (60,231 observations) in an analysis of receiver's operating characteristics. This analysis resulted in d' = 2.67, indicating acceptable accuracy for screening.

Adult↗
PubMed2006

Practice parameters for the treatment of snoring and Obstructive Sleep Apnea with oral appliances: an update for 2005.

These practice parameters are an update of the previously published recommendations regarding use of oral appliances in the treatment of snoring and Obstructive Sleep Apnea (OSA). Oral appliances (OAs) are indicated for use in patients with mild to moderate OSA who prefer them to continuous positive airway pressure (CPAP) therapy, or who do not respond to, are not appropriate candidates for, or who fail treatment attempts with CPAP. Until there is higher quality evidence to suggest efficacy, CPAP is indicated whenever possible for patients with severe OSA before considering OAs. Oral appliances should be fitted by qualified dental personnel who are trained and experienced in the overall care of oral health, the temporomandibular joint, dental occlusion and associated oral structures. Follow-up polysomnography or an attended cardiorespiratory (Type 3) sleep study is needed to verify efficacy, and may be needed when symptoms of OSA worsen or recur. Patients with OSA who are treated with oral appliances should return for follow-up office visits with the dental specialist at regular intervals to monitor patient adherence, evaluate device deterioration or maladjustment, and to evaluate the health of the oral structures and integrity of the occlusion. Regular follow up is also needed to assess the patient for signs and symptoms of worsening OSA. Research to define patient characteristics more clearly for OA acceptance, success, and adherence is needed.

Continuous Positive Airway Pressure↗
PubMed2006

Oral appliances for snoring and obstructive sleep apnea: a review.

We conducted an evidence-based review of literature regarding use of oral appliances (OAs) in the treatment of snoring and obstructive sleep apnea syndrome (OSA) from 1995 until the present. Our structured search revealed 141 articles for systematic scrutiny, of which 87 were suitable for inclusion in the evidence base, including 15 Level I to II randomized controlled trials and 5 of these trials with placebo-controlled treatment. The efficacy of OAs was established for controlling OSA in some but not all patients with success (defined as no more than 10 apneas or hypopneas per hour of sleep) achieved in an average of 52% of treated patients. Effects on sleepiness and quality of life were also demonstrated, but improvements in other neurocognitive outcomes were not consistent. The mechanism of OA therapy is related to opening of the upper airway as demonstrated by imaging and physiologic monitoring. Treatment adherence is variable with patients reporting using the appliance a median of 77% of nights at 1 year. Minor adverse effects were frequent whereas major adverse effects were uncommon. Minor tooth movement and small changes in the occlusion developed in some patients after prolonged use, but the long-term dental significance of this is uncertain. In comparison to continuous positive airway pressure (CPAP), OAs are less efficacious in reducing the apnea hypopnea index (AHI), but OAs appear to be used more (at least by self report), and in many studies were preferred over CPAP when the treatments were compared. OAs have also been compared favorably to surgical modification of the upper airway (uvulopalatopharyngoplasty, UPPP). Comparisons between OAs of different designs have produced variable findings. The literature of OA therapy for OSA now provides better evidence for the efficacy of this treatment modality and considerable guidance regarding the frequency of adverse effects and the indications for use in comparison to CPAP and UPPP.

Humans↗
PubMed1996

Screening for obstructive sleep apnea in patients presenting for snoring surgery.

Excessive mortality is associated with obstructive sleep apnea (OSA). Therefore it is important to diagnose OSA in patients presenting for snoring surgery. A prospective study was performed to develop screening models to detect OSA compared with universal polysomnography for sensitivity and cost. Multivariate analysis of 150 consecutive patients was based on clinical data, questionnaire data, and polysomnography. Two screening models obtained 100% sensitivity and reduced the need for polysomnograms. Cost savings of screening based on clinical data was projected to be $35 to $80 per patient using reported prevalence rates of OSA among snorers. A screening model for OSA using clinical data alone is more cost-effective than one that combines these data with pulse oximetry data, but savings over universal polysomnography were modest.

Adult↗
PubMed1997

A cost-effective and rational surgical approach to patients with snoring, upper airway resistance syndrome, or obstructive sleep apnea syndrome.

The past decade has seen several innovations in the surgical techniques available for treatment of patients with sleep-disordered breathing. Outpatient techniques such as laser-assisted uvulopalatoplasty (LAUP) and more aggressive procedures designed to address hypopharyngeal and base of tongue obstruction (genioglossus advancement and hyoid myotomy) have been developed and proven successful. We describe the efficacy of LAUP for snoring (72.7%), upper airway resistance syndrome (81.8%), and mild (mean [+/-SD] respiratory disturbance index [RDI] = 12 +/- 8.1) obstructive sleep apnea (41.7%) in 56 patients who underwent 132 LAUP procedures in a 26-month period. Thirty-two patients with more significant obstructive sleep apnea (mean RDI = 41.8 +/- 23.1) underwent multilevel pharyngeal surgery consisting of genioglossus advancement and hyoid myotomy combined with uvulopalatopharyngoplasty. The surgical success rate in this group of patients was 85.7% when commonly accepted criteria were applied. We recommend a stratified surgical approach to patients with sleep-disordered breathing. Progressively worse airway obstruction marked by multilevel pharyngeal collapse and more severe sleep-disordered breathing is treated with incrementally more aggressive surgery addressing multiple areas of the upper airway.

Adult↗
PubMed1991

Intrapalatine resection (IPR) in the treatment of sleep apnea and snoring.

A conservative surgical technique is proposed as an alternative to the classical uvulopalatopharyngoplasty (UPPP) for the treatment of obstructive sleep apnea and snoring. The resection is strictly intrapalatine, and careful suturing in three planes seems to lead to complete disappearance of the often unbearable postoperative pain. The soft palate is shortened but nonetheless still resembles a normal soft palate. Uvulopalatopharyngoplasty (UPPP) was described by Ikematsu in 1952. This method has taken on a new lease of life in recent years. Its efficacy is generally accepted, and its use, especially in cases of obstructive sleep apnea syndrome, is the only treatment of the palatal velum at present practiced. In addition to aesthetic problems, this method generally gives rise to complications in the shape of temporary--but sometimes considerable--pain, nasal regurgitation, and a nasal voice. In a small percentage of patients, some of these disorders may prove irreversible. In my series of eight patients, five were obese and presented with hypertension. Three of them also were suffering from obstructive sleep apnea syndrome. The three others were ordinary snorers who caused considerable inconvenience to sleeping partners.

Humans↗
PubMed2005

Sleep endoscopy versus modified Mallampati score in sleep apnea and snoring.

OBJECTIVES/HYPOTHESIS: The aim of this study is to quantify the correlation between a large tongue classified by the modified Mallampati score (MMS) and obstruction at the tongue base observed during sleep endoscopy in patients with socially unacceptable snoring (SUS) and obstructive sleep apnea syndrome (OSAS). STUDY DESIGN: Prospective. METHODS: One hundred twenty-seven patients with obstructive sleep apnea and SUS underwent sleep endoscopy. Patients were classified into four specific groups according to their MMS. After intravenous administration of midazolam, obstructive events in the upper airway were classified. The level of obstruction was expressed as palatal (2), palatal and to a lesser degree base of the tongue/laryngeal level (2), tongue base/laryngeal level and to a lesser degree palatal (3), and tongue base/laryngeal level (3). The degree of correlation between the level of obstruction and the MMS was analyzed by means of Spearman's rank-order correlation. RESULTS: No linear association between the level of obstruction and MMS could be found. A large tongue (MMS 3 or 4) does not predict obstruction at the base of the tongue. Patients classified as MMS 1 or 2 did not frequently show obstruction at the base of the tongue (9 of 38, 23,6%). The majority of the population showed retropalatal obstruction. A large tongue (MMS 3 or 4) was often accompanied by retropalatal obstruction, 76% of the cases (64 of 89). CONCLUSIONS: No positive correlation exists between a large tongue and obstruction at tongue base level. In both groups, retropalatal obstruction occurred more often than retrolingual obstruction. Sleep endoscopy provides qualitative insight into important changes during sleep in patients with SUS and OSAS. In addition, anatomic aberrations are clearly visualized in a dynamic setting. Classification of the size of the tongue, as assessed by the MMS, may be of great importance as well.

Airway Obstruction↗
PubMed1991

Sleep nasendoscopy: a technique of assessment in snoring and obstructive sleep apnoea.

It appears that uvulopalatopharyngoplasty (UVPP) is a reliable procedure for reducing snoring, but much less reliable when used as a treatment for OSAS. This is thought to be because of poor patient selection in that the site of the problem is not always the site of the operation. We present the technique of sleep nasendoscopy which allows direct visualization of the site or sites of obstruction in a sleeping patient. Our study has shown that there are patients with obstructive sleep apnoea syndrome (OSAS) in whom the only site of pharyngeal obstruction is at the velopharynx. These patients should do well with the relatively simple procedure of UVPP. This is not true for many other OSAS patients in whom we found that obstruction was multisegmental. This helps to explain the frequently poor results of UVPP in OSAS patients. We feel that this form of preoperative assessment will avoid unnecessary surgery.

Adult↗
PubMed2004

Massive transient pulmonary air embolism during pacemaker implantation under mild sedation: an unrecognized hazard of snoring.

We present a case of a massive pulmonary air embolism during permanent pacemaker lead implantation under mild sedation in a 73-year-old woman. We used a peel-away sheath that is devoid of a hemostatic valve. The air embolism occurred after deep inspiration associated with loud snoring sounds and resolved after short chest massage and administration of adrenaline. Temporary closure of the intravenous entrance route of the peel-away sheath before inserting the lead may prevent this potentially lethal complication.

Aged↗
PubMed2003

Snoring in infancy.

Obstructive sleep apnoea (OSAS) in infants is a risk factor for sudden infant death (SIDS). Snoring in a young child should raise suspicion of OSAS, and according to recent AAP guidelines, evaluation and polysomnographic studies are recommended in selected cases as the diagnostic test of choice. However, infants under 1 y of age are excluded from the guidelines, and interventions to prevent SIDS based on respiratory monitoring remains a matter of controversy. As often happens, the evidence we need most is usually scarce.

Humans↗
PubMed1982

Alcohol, snoring and sleep apnea.

We studied the effect of alcohol ingestion on sleep-induced breathing abnormalities and arterial oxyhaemoglobin saturation in seven patients with a range of sleep-induced upper airway occlusion. The characteristics of each patient's sleep-induced breathing abnormality was established on one or more control all-night studies, and then a further all-night study was done immediately following alcohol ingestion. Alcohol increased the duration and frequency of the occlusive episodes in five patients with obstructive sleep apnoea, and resulted in a marked increase in the degree of hypoxaemia in the first hour of sleep. In two patients with benign chronic snoring, alcohol induced frank obstructive sleep apnoea during the first hour of sleep. We suggest that the increased tendency to develop obstructive apnoea after alcohol is the result of alcohol-induced oropharyngeal muscle hypotonia, while the increased duration of obstructive apnea is the result of alcohol-induced depression of arousal mechanisms.

Adult↗
PubMed2004

Operating characteristics of the negative expiratory pressure technique in predicting obstructive sleep apnoea syndrome in snoring patients.

BACKGROUND: This study examines the operating characteristics of the expiratory flow response to a negative pressure (NEP) applied to the mouth in the prediction of obstructive sleep apnoea syndrome (OSAS) in snoring patients. METHODS: Two hundred and thirty eight patients with normal spirometric values were studied. Full laboratory polysomnography was performed and an NEP of -5 cm H(2)O was applied in the sitting and supine positions. RESULTS: A significant correlation was found between the degree of flow limitation measured by NEP in both positions (expressed as the percentage of the expired tidal volume over which NEP induced flow did not exceed spontaneous flow) and the apnoea-hypopnoea index (AHI). This correlation was significantly higher in the supine position (p<0.0001) where an expiratory flow limitation cut off value of >/=27.5% of the tidal volume produced a sensitivity of 81.9% and a specificity of 69.1% in predicting OSAS. CONCLUSION: These findings show that the degree of instability of the upper airway measured by NEP is correlated with the severity of OSAS. NEP had moderate sensitivity and specificity and may be useful in predicting OSAS in a clinic based population.

Adult↗
PubMed1992

Habitual snoring with and without obstructive sleep apnoea: the importance of cephalometric variables.

BACKGROUND: The obstructive sleep apnoea syndrome is characterised by an increased apnoea-hypopnoea index and a reduction in the minimal arterial oxygen saturation (SaO2) values during sleep. The extent to which these variables can be predicted by cephalometric and otorhinolaryngological variables was tested. METHODS: One hundred consecutive habitual snorers (84% male), with a mean (SD) age of 50.1 (10.1) years, were studied. The 45 patients with less severe sleep apnoea, with an apnoea-hypopnoea index of 10 or less (group A), were compared with the 55 with an index above 10 (group B). RESULTS: Body mass index, some cephalometric variables, and some otorhinolaryngological variables differed significantly between group A and group B, in particular the soft tissue measures PNS-P (posterior nasal spine to palate), MP-H (mandibular plane to hyoid bone), degree of oropharynx stenosis, and tongue size. In a multiple regression correlation analysis MP-H, SNB (angle from sella to nasion to subspinale point), SNA (angle from sella to nasion to supramentale point), PAS (posterior airway space), tongue size, and body mass index contributed significantly to the equation explaining the severity of sleep apnoea. Nevertheless, these variables together explained only 33% of the variance of the apnoea-hypopnoea index in the total sample; they were more important for patients with moderate to severe stages of the disease. CONCLUSION: The lack of association between cephalometric variables and mild sleep apnoea suggests that the differences in these variables (soft tissue measures) may be the consequence rather than the cause of habitual snoring and the obstructive sleep apnoea syndrome.

Adult↗
PubMed1998

Evaluation of some velar functions before and after surgical treatment of snoring.

The aim of this prospective study was to evaluate velar function before and after uvulopalatopharyngoplasty for isolated snoring and for sleep apnoea. It is based on the analysis of oral and nasal airflow during phonation by an EVA workstation of 24 patients before and after the surgical intervention. The results show (1) quantitative and qualitative airflow abnormalities before the operation, (2) an increase in the percentage of nasal airflow flow after the operation, and (3) a change in the airflow sequence, which is improved after the surgical procedure. In conclusion, this work confirms a modification of velar function after uvulopalatopharyngoplasty and raises the problem of contra-indications to this intervention.

Adult↗
PubMedDate not supplied

Side effects after surgical treatment of snoring.

In a questionnaire study detailed side effects after snoring surgery were examined in 415 individuals 2-8 years after surgery. Three years later a new questionnaire was answered by those with side effects affecting taste, smell and voice (n = 74). At the first follow-up 255 had side effects of globus, regurgitation, taste, smell and voice. The globus was the most common (40%). In all spheres except the globus, a significant improvement was seen 3 years later. However, pharyngeal dryness and phlegm had a reported frequency of nearly 60%. No significant differences were seen between the uvulopalatopharyngoplasty and laser uvulopalatoplasty methods. Taste disturbances might be due to surgical damage to the nerves or oral dryness. The olfactory impairment present in 7 patients still needs to be explained.

Female↗
PubMed1996

Upper airway patency and nocturnal desaturation in habitual snoring and obstructive sleep apnea: pathogenesis of sleep-related breathing disorders.

Sixty patients, 53 men and 7 women, referred for excessive snoring or suspected sleep apnea syndrome were analyzed by polysomnography, Mueller maneuver, cephalometric roentgenography, and pulmonary function testing, to evaluate the contribution of static and dynamic upper airway obstruction in the pathogenesis of sleep-related breathing disorders and OSAS. Desaturation index and maximal desaturation were used in the analysis as indicators of severity of sleep-related breathing disorders. Body Mass Index, increased collapsibility at the base of the tongue by the Mueller maneuver, increased distance between hyoid and mandibular plane, and increased soft palate diameters by cephalometry as well as a decreased peak inspiratory flow by pulmonary function testing were found to be related to increased oxygen desaturation parameters. In a multivariate analysis the significant obstruction parameters could explain only 37% of the variability of maximum desaturation and 31% of the variability of desaturation index, 63 and 69%, respectively, must therefore be explained by other mechanisms. We conclude that instability of respiratory and muscular control, possibly enhanced by sleep-phase-related changes, is more important in the pathogenesis of sleep-related breathing disorders than pure anatomic narrowing of the airway.

Adult↗