How to Sleep With a Snorer
Gary Kroukamp
“Laugh and the world laughs
with you; snore and you sleep
alone.” anon.
Snoring
• 40% of men and 30% of women (30 to 60
years)
• Increases to 80% and 70% in 7th decade
• Self reporting and partner reporting are
inaccurate
Anatomical levels of obstruction
Oropharyngeal Abnormalities
Pathophysiology of snoring
Sounds of snoring originate in collapsible parts of
upper airway due to 3 factors:
• Reduction in pharyngeal muscle tone
muscle tone reduced in sleep and exacerbated by alcohol,
sedatives, hypothyroidism
• Space-occupying masses impinging on airway
tonsils/adenoids, obesity, long soft palate/uvula, retro- or
micrognathia, macroglossia, tumours polyps and cysts
• Restriction of nasal airflow
septal deviation, ostiomeatal and turbinate abnormalities,
allergic and vasomotor rhinitis
Definitions
• Snoring – undesirable sound due to Bernoulli
effect, alternating higher and lower airway
pressures due to narrowing, causes vibration
• Obstructive Sleep Apnoea Syndrome –
No airflow for more than 10 seconds, until a
“resuscitative gasp” occurs, more than 5 episodes
per hour, drop in sats of > 4%
Classification of disease severity
• Primary snoring – RDI < 5, normal sats, no
daytime sleepiness
• Upper Airway Resistance Syndrome – RDI
< 5, normal sats, excessive daytime
sleepiness
• Obstructive Sleep Apnoea Syndrome – RDI
>5, Sats < 90, excessive daytime sleepiness
THE EPWORTH SLEEPINESS SCALE
How likely are you to doze off or fall asleep in the situations described below, in contrast to just feeling tired?
Even if you haven’t done some of these things recently, try to work out how they would have affected you.
Use the following scale to choose the most appropriate number for each situation:
0 = Would never doze
1 = Slight chance of dozing
2 = Moderate chance of dozing
3 = High chance of dozing
Situation
Sitting and reading
Watching TV
Sitting, inactive in a public place (eg theatre or meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after lunch without alcohol
In a car, while stopped for a few minutes in the traffic
Chance of dozing
Thank you for your co-operation
Diagnosis
• Physical examination
• Vital signs and BMI/collar size
• Head and neck/upper airway examination
• Special Investigations
• Polysomnography (Sleep study) – Gold standard/mandatory,
determines AI, RDI, Sats
• Split night polysomnography
• Fibreoptic endoscopy (Mueller manoeuvre/Sleep endoscopy)
• Cephalometry
• CT/MRI
• Oximetry
• Thyroid function,Cardiac evaluation, CXR
Fibreoptic Endoscopy
• Good for nasal deformities
• Retroglossal or retropalatal obstruction
• Mueller manoeuvre
Endoscopy and Mueller Manoeuvre
Non-Surgical Treatment for
Snoring
• Nasal CPAP – first-line therapy, 50%
compliance
• Elimination of alcohol
• Oral/Dental appliances – 50% success rate
• Nasal appliances
• Positional devices – apnoea more common
when supine
• Weight loss – very difficult
Nasal CPAP
Surgical Treatment for Snoring
• Nasal procedures
• Adeno/Tonsillectomy
• Palatal procedures (LAUP, UPPP,
coblation,implants)
• Maxillo-facial procedures
What constitutes a successful
surgical outcome?
• 50% improvement in RDI
Nasal Surgery?
• If obvious nasal abnormality
• Neural reflex mechanism – apnoea on decreased
nasal afferent input
• Nasal obstruction causes negative inspiratory
pressure and may cause pharyngeal collapse
•
•
•
•
Nasal Valve surgery
Septoplasty
Turbinate surgery
Nasal Polypectomy/FESS
Palatal Procedures
• Uvulopalatopharyngoplasty (UPPP)
• Laser Assisted Uvulopalatoplasty
• Radiofrequency Volumetric Tissue
Reduction
• Pillar procedure
UPPP
•
•
•
•
•
Since 1952 - Japan
Reduction of excessive tissue
Includes tonsillectomy
General anaesthetic
40% to 80% effective in snoring
UPPP
Post-Operative View UPPP
Disadvantages of UPPP
• PAIN
• Over-resection of palatal tissue with incompetence
(of palate and surgeon!)
• Stenosis
• Haemorrhage
• Swallowing impairment
• Pharyngeal discomfort/dryness
• Speech disturbance
LAUP
•
•
•
•
•
•
•
Good for simple snoring – 95% initial success
Easy
Outpatient
Local anaesthetic
Multiple treatments
PAIN!!
Expensive equipment
Operative Technique - LAUP
Radiofrequency Volumetric
Tissue Reduction
•
•
•
•
•
•
•
Similar to LAUP
Tissue necrosis and healing by scarring
Outpatient procedure
Local anaesthetic
Multiple procedures required
Not painful
Promising early results in snoring
Pillar Procedure
•
•
•
•
Single procedure
Not painful
Local anaesthetic
FDA approved
Literature
Otorhinolaryngology – Head and Neck Surgery 2006
• Retrospective review 125 patients – not funded by
manufacturers
• Done alone and with Nasal/palatal/pharyngeal
procedures
• Snorers and mild/moderate OSAS
• Subjective “cure” – 88% (Partner VAS and
Epworth Sleepiness Scale)
• Objective “cure” – 34.4% (Sleep Study)
• Extrusion rate – 8%
Subjective Improvement in
Snoring
100
90
80
70
60
50
40
30
20
10
0
Pillar only
Pillar&Nasal
Pillar&
Pillar&UPPP