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Patients with stable cardiac failure who snore may present sleep hypopnea and cardiac arrhythmias. Nasal continuous positive airway pressure (CPAP) may worsen the disordered breathing. Nasal bilevel positive airway pressure (BiPAP), however, may help alleviate the breathing problem and eliminate sleep-related arrhythmias.
Oral breathing causes changes in pulmonary mechanics as well as in the pressure of arterial blood gases. In response to increased nasal obstruction oro-nasal breathing occurs. The level of oro-nasal partitioning maintains an adequate level of respiratory resistance. Sleep disordered breathing, although not only related to oral breathing, is a common disorder. When upper airway resistance is increased limitation of flow occurs. Snoring indicates a mild degree of reduced airflow. Sleep apnea occurs when upstream pressure falls below a critical pressure (Pcrit). The mechanisms are reviewed.
For ten years, uvulo-palato-pharyngoplasty has become the preferred surgical treatment for snoring. Techniques, variations, postoperative followings, complications, results are reported. For sleep apnea syndrome, other surgical procedures can also be considered: tracheotomy, adenoido-tonsillectomy, nasal surgery, hyo-tongue surgery, maxillomandibular surgery. In children, adenoido-tonsillectomy is usually the adequate treatment.
The history of snoring can be divided into three major periods. First, there was a prehistoric phase during which everything was ignored and in which there was no interest in knowing anything. We call this "le repos du guerrier'. Sleep was regarded mainly as a phase of recovery, and there was no question of related problems. A second period began about the beginning of this century: they still did not know anything, but it was felt that something needed to be done. Multiple types of therapy were attempted. This was a time in which research extended in all directions. Modern times began in the middle of this century with the first serious work of medical scientists who discovered and defined the sleep apnea syndrome, the UPPP, the CPAP, etc.
Over the past three years, surgery was performed on 149 patients (55 children and 94 adults) who complained of snoring and symptoms related to sleep apnea syndrome, at Fujita Health University's Second Hospital. Treatment in children was adeno-tonsillectomy. Treatment in adults was uvulo-palato-pharyngoplasty, and midline laser grossectomy or nasal surgery, or both. The apnea hypopnea index was (AHI) was defined as the frequency of apneic and hypopneic events per hour. Pathological apnea (sleep apnea syndrome) was defined as an AHI of 10 in adults and an AHI of 5 in children. Marked improvement was defined as a 75% reduction in AHI or a postoperative AHI below 10 in adults and below 5 in children. Improvement was defined as a 50% to 74% reduction in AHI. Slight improvement was defined as a 29% to 49% reduction in AHI. No improvement was defined as a reduction in AHI of less than 25%. Of the 55 children, the AHI in 35 was above 5:30 (86%) improved markedly with the treatment; 3 (8%) improved; 1 (3%) improved slightly, and 1 (3%) did not improve. Of the 94 adults, the AHI in 84 was above 10:40 (48%) improved markedly with the treatment; 12 (14%) improved; 14 (17%) improved slightly and 18 (21%) did not improve.
1. A careful history and favorable physical exam is mandatory for consideration of LAUP. 2. Concurrent diseases must be addressed for optimal results. 3. A sleep study should be recommended with any evidence suggestive of sleep apnea. 4. LAUP cures snoring. 5. Primary treatment of severe sleep apnea is nasal continuous positive airway pressure (NCPAP). 6. Mild sleep apnea with appropriate physical exam can be expected to have acceptable results when treated by LAUP. 7. LAUP should be considered for moderate to severe sleep apnea only if NCPAF intolerance is intractible.
Laser-assisted uvulopalatoplasty (LAUP) is an effective surgical procedure for treating habitual snoring. It is performed under local anesthesia as an outpatient procedure and consists of enlarging the oropharyngeal air space and restructuring the uvula, velum, and pharyngeal pillars. We used LAUP in 112 patients with upper airway resistance syndrome (UARS) (Lipman grade II) over the last three years and achieve a care rate of 87.5%.
We present a retrospective analysis of the initial results of our institution's evaluation of a new procedure designed to help relieve snoring, as well as having the potential to assist in the treatment of obstructive sleep apnea. The ambulatory, in-office CO2 laser procedure is performed with a local anesthetic. It is a serial procedure that achieves the same end-result as conventional uvulopalatopharyngoplasty, but without many of the associated problems. The indications for the procedure are reviewed, and detailed technical aspects of its performance, including use of new instrumentation, are discussed. Detailed analysis of the first 20 patients to undergo the procedure in the United States is presented. This is the first series of patients presented in the American literature who have undergone this procedure and who have had long-term follow-up of more than five years. A 90% success rate was achieved. The complication rate, patient tolerance, relative costs, indications and contraindications are discussed.
Stock intra-oral vestibular shields of a heat malleable, semiflexible ethylene vinyl-acetate material were adapted at chairside to the mouths of 77 chronic snorers. The effectiveness of the shield in controlling snoring was assessed eight to ten weeks after fitting. 77.9 per cent of subjects benefitted from wearing the device. Of the subjects who failed to benefit nine (11.7 per cent) appeared to have nasal or naso-pharyngeal obstruction. A further five (6.5 per cent) abandoned the clinical trial due to poor self-motivation while two subjects (2.6 per cent) were unable to tolerate the shield in the mouth. The potential of the device in the management of obstructive sleep apnoea warrants further investigation.
Reports of snoring are common among serviceman in the armed forces. Continuous positive airway pressure (CPAP) is usually an inappropriate modality for servicemen, but surgery, although requested, is very painful. In an attempt to reduce the pain, a laser has been used to perform uvulopalatopharyngoplasty and the more conservative uvulopalatoplasty has also been performed. Before proceeding to a randomized trial, this retrospective study was performed by questionnaire comparing these operations with conventional uvulopalatopharyngoplasty. Fifty-two completed replies from 63 patients were analysed. The results have to be interpreted with caution because of the small sample sizes; however, the results in the three groups were similar. The study suggests that each operation works well, but that any reduction in pain from performing uvulopalatoplasty or by using a laser is likely to be small. The study also found that the incidence of dryness as a complication is much higher than previously estimated.
Two treatments are habitually proposed for snoring without obstructive sleep apnea syndrome: the surgical pharyngotomy, and the treatment by laser done in the office. Our study analyses retrospectively, by telephone questionnaire, a group of 168 snorers, without obstructive sleep apnea syndrome, treated by pharyngotomy (n = 71) or CO2 laser (n = 97) between 1989 and 1993. Results after a mean follow-up of 5 years, with a minimal of 3 years, show for the two procedures the same efficacity, and an equivalent prevalence of side effects. The rate of satisfaction for the patient and her bed-partner is about 50%, in relation to a degradation of therapeutic effect in the long run. We propose to precisely the results and the indications of the surgery and the laser for treatment of uncomplicated rhonchopathy.
We studied the effectiveness of uvulopalatopharyngoplasty under general anesthesia and classical surgery in 26 patients treated surgically for chronic snoring (CS) and obstructive sleep apnea syndrome (OSAS). Our technique is a variation of the Fujita and Quesada technique that involves partial resection of the palate and uvula with endonasal microsurgery. The criteria for inclusion were age 35 to 47 years and desire to do without C-PAP or Bi-PAP. This device, although effective, produced poor physical and psychological tolerance. After a postoperative follow-up of 3 years, good results were found in all cases.
Oral appliances have been developed that are effective in snoring patients and in patients with mild to moderate sleep apnea. This article reviews the types of appliances that are available, their possible modes of action, and their efficacy. In addition, the clinician is provided with guidelines on how to choose the appropriate patient for this therapy.
The number and kind of oral appliances have proliferated in recent years as dentists have responded to the challenge to develop more sophisticated devices for the control of socially disruptive snoring and obstructive sleep apnea. Sleep-disordered breathing is now recognised as being a highly prevalent problem which carries increased social, economic, cognition and health risks. The popular mandibular-advancement devices have a greater level of acceptance by patients than the standard nasal continuous positive airway pressure (CPAP) treatment in recent head-to-head studies. It is important that these patients be followed by sleep clinicians as these appliances are less successful in controlling sleep apnea when the level of severity is high. Research is needed to determine the patients most appropriate for an oromandibular treatment and when CPAP is the treatment of choice. Potential sequences of treatments are suggested.
STUDY OBJECTIVE: To compare the MMPI responses between nonapneic primary snoring (PS) and obstructive sleep apnea (OSA). DESIGN: Cross sectional with matched samples. SETTING: University sleep disorders center. PATIENTS: All PS patients (n = 49) available in a series of 428 clinical referrals to a sleep disorders center, and age and gender-matched OSA patients (n = 49) selected from the 199 available OSA patients in the series. INTERVENTIONS: Not applicable. MEASUREMENTS AND RESULTS: Subjects completed the MMPI prior to overnight diagnostic polysomnographic assessment and multiple sleep latency test (MSLT). OSA patients exhibited a mean of 2.3 elevated MMPI scales, which was significantly more than the PS mean of 1.6 elevations, and attributable to higher OSA scores on Depression (D) and Hypochondriasis (Hs). Approximately twice as many OSA patients than PS patients showed disturbed scores on D (49% vs. 25%, p < .05) and Hy (35% vs. 16%, p < .05). On nine of the ten MMPI clinical scales, both patient groups exceeded the elevation rate expected in nondistressed individuals. Among OSA patients, but not PS patients, number of MMPI elevations had a significant negative correlation with sleep efficiency and average blood saturation during NREM, and a significant positive correlation with wake time after sleep onset. CONCLUSIONS: Compared to patients with PS, those with OSA have more intense depressive symptoms (e.g., pessimism, inactivity, guilt) and somatic concerns. General psychopathology is associated with blood oxygen saturation only among OSA patients. Nonetheless, PS patients show psychological maladjustment that is qualitatively similar, but quantitatively less severe, than that characterizing OSA.
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