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    Snoring and Obstructive Sleep Apnoea (OSA)

    Overview
    Causes
    Symptoms
    Risk Factors
    Diagnosis
    Treatment
    Where To Seek Treatment
    Singapore General Hospital
    Contributed by Dept of Otolaryngology
    Singapore General Hospital

    Overview

    Sleep-disordered breathing (SBD) is used to describe snoring and obstructive sleep apnoea (OSA) syndrome. Snoring and OSA are common medical conditions that affect between 15-50% of the adult population worldwide.

    Snoring, due to vibration of tissues in the throat, can be a symptom of partial upper airway obstruction. The partial obstruction can lead to complete airway obstruction – a medical condition called obstructive sleep apnoea (OSA). In Singapore, about 15% of adults have OSA.

    Medical and Socioeconomic

    Consequences Studies have shown that OSA presents a huge economic burden to society. Individuals with untreated OSA use more healthcare resources, are associated with poor work performances and occupational injuries and are involved in more traffic accidents.
     
    Studies have also shown that compared to normal individuals, untreated and inadequately treated OSA can lead to increased risk of :

    • High blood pressure
    • Heart attack
    • Cardiac arrhythmias
    • Sudden death
    • Premature death in the long run
    • Stroke

    Causes

    Individuals with OSA have a narrower upper airway and repeated upper airway obstruction during sleep, leading to poor sleep quality, sleep deprivation and cardiovascular abnormalities that put tremendous stress on the heart and body. The upper airway obstruction leads to decreased oxygen supply to the brain, heart and other organs, causing the heart to work harder to provide oxygen to the tissues, leading to medical consequences in the long run.


    Symptoms

    excessive daytime sleepinessSomeone with OSA can present with :

    • Snoring
    • Excessive daytime sleepiness
    • Choking or gasping episodes during sleep
    • Feeling unrefreshed, even after supposed ‘enough hours’ of sleep

    Other symptoms include falling asleep while driving, depression, irritation, decreased libido and morning headaches.


    Risk Factors

    Anatomic abnormality. Snoring and OSA occur because of anatomic abnormality in the upper airway leading to obstruction.

    The sites involved include the :

    • Nose (enlarged turbinates, deviated nasal septum, and nasal polyps)
    • Oropharynx (long, redundant and thick palate and uvula, large tonsils)
    • Hypopharynx/base of tongue (lingual tonsillar hypertrophy, fl oppy epiglottis, and bulky tongue) and throat

    Genetics. Genetic predisposition leading to facial and jaw abnormalities are known predisposing risk factors.

    Medications / Alcohol. Mild or intermittent snoring may be a result of medications (like sedatives to help you sleep) or alcohol that induce relaxation of the upper airway muscles.

    Weight. Weight gain can contribute to snoring and OSA. Excessive fat accumulation in the upper airway can amplify an existing anatomic narrowing that was causing mild obstruction previously.

    Gender and Age. The male gender and increased age are risk factors.


    Diagnosis

    Individuals who snore persistently (night after night) should be referred to a Otolaryngologist, who will perform a comprehensive clinical evaluation including an endoscopic upper airway evaluation to determine an appropriate treatment plan. This evaluation includes a sleep study/ polysomnogram as the patient’s own history of apnoea or sleepiness may be inaccurate, and patients with OSA almost always snore.


    Treatment

    Treatment of both snoring and OSA requires a multidisciplinary and logical approach.

    1. Treatment for Snoring

    Conservative treatment
    This includes eliminating outside factors that may be playing a role. These include :

    • Weight loss
    • Avoidance of alcohol or other medications
    • Treatment of nasal congestion with medications

    In patients with significant snoring, these efforts are rarely successful. An evaluation by an Otolaryngologist is needed to rule out sleep apnoea.

    Surgical treatment
    If a person wants treatment, several options exist that are directed at the soft palate, nasal and base of tongue. Most treatments are directed at the soft palate (soft tissue at the back of the roof of the mouth) since this is the most common site of snoring.

    Surgery of the soft palate is effective in 80-90% of cases and can be associated with postoperative pain for 7-10 days.

    In the nose, normal structures called turbinates may be enlarged from allergic rhinitis causing airflow blockage. Reduction of the turbinates using radiofrequency or surgical reduction (turbinectomy) may be performed. The septum that divides the nose into two sides may also be crooked and needs to be straightened.

    The base of tongue and lingual tonsils (lymphatic tissues at the back of the tongue) may be enlarged and impede airflow during sleep. Obstruction at these sites can be treated by a variety of methods depending on severity.

    2. Treatment for Obstructive Sleep Apnoea (OSA)

    Indications for treatment of OSA include excessive daytime sleepiness with altered daytime performance, moderate to severe OSA, decreased blood oxygen saturation level, and cardiovascular complications (hypertension, ischaemic heart disease, cardiac arrhythmias and stroke).

    Treatment of OSA can prevent cardiovascular complications and improve daytime sleepiness, decrease OSA-related road traffic accidents and work-place accidents and improve quality of life. Current treatment options include conservative and surgical methods.

    Conservative treatment
    OSA conversative treatmentThis includes eliminating outside factors that may be playing a role. Other factors to consider include :

    • Weight loss
    • Avoiding alcohol or other medications
    • Treatment of nasal congestion with medications

    You will be advised to sleep on the side rather than on your back. In someone with significant snoring, these efforts are rarely successful.

    Continuous positive airway pressure (CPAP) is the first treatment option. It is applied via a nasal or face mask and works by providing an ‘air stent’ to keep the airway open during sleep. It is effective so long as it is used as directed and has been shown to decrease the medical consequences of OSA. Long-term compliance may be a problem.

    Dental splints may be suitable for some and has to be worn every night. Cost concerns as well as dental and temporomandibular joint side-effects may prevent compliance.

    Surgical treatment
    Surgery is recommended if someone is unable or unwilling to use the CPAP device and conservative methods are unsuccessful.

    Pre-surgical assessment
    pre-surgical assessmentPre-surgical assessment should include
    :

    • Polysomnography
    • A detailed history with head and neck physical examination
    • Fiber-optic endonasopharyngoscopy
    • Appropriate imaging study and sleep endoscopy

    They will enable the surgeon to have enough information to help in individualising surgical treatment depending on the severity and sites of obstruction. The surgeon will not rely on a single test or procedure to decide on the treatment.

    Successful surgical therapy for treating OSA is based on identifying the levels of airway obstruction, usually in multiple sites, which may include regions of the nose, soft palate and tongue base. No single surgical procedure can guarantee success.

    Surgical procedures serve to remove or reposition tissues that partially or completely block the upper airway during sleep. These procedures have been used for years and clinical outcomes have verified their use.

    Types of Surgeries

    Tracheostomy
    Tracheostomy involves creating a hole in the trachea, directly bypassing the upper airway obstruction. It is used in people with refractory base of tongue obstruction and in the morbidly obese with medical conditions that contraindicate surgeries that are more extensive. Though the success rate is 100%, this option is usually not accepted by patients and with the introduction of CPAP, it is seldom used to treat OSA.

    Nasal Surgery
    Nasal airway obstruction caused by bony, cartilaginous or enlarged tissues can interfere with nasal breathing during sleep. An open nasal airway establishes normal breathing and minimises mouth breathing. Mouth breathing in OSA individuals worsens the posterior airway by allowing the tongue to fall back. Establishing an open nasal airway passage can improve CPAP tolerance and compliance. Techniques include straightening the septum, turbinectomy and nasal valve reconstruction.

    Palatal Surgery
    Abnormal structures at the palate level include large tonsils, redundant lateral pharyngeal mucosal, thick and long soft palate and hypertrophied posterior tonsillar pillar muscles and mucosal. All these contribute to a narrow airway at the palatal level.

    The traditional Uvulopalatopharyngoplasty (UPPP) and many variations of it can be used. Most surgeons have shied away from the traditional UPPP in favour of modified techniques and surgical flaps (like uvulopalatal flap, extended uvulopalatal flap, lateral pharyngoplasty) as these have fewer complications, are less ablative and have a higher success rate.

    In carefully selected patients, the success rate may be 50-60% but falls to a low of 5-30% in unselected patients. This is because of the failure to address tongue base and hypopharyngeal obstruction.

    Hypopharyngeal and Base of Tongue Surgery
    Compared to the nasal and oropharyngeal level, obstruction at the hypopharyngeal (base of tongue) level is a very complex issue as the large tongue base tissue collapses easily during sleep. Obstruction at this level may be bypassed via a tracheotomy or by either increasing airway size to make more room for the tongue or reducing the tongue size. Both soft tissue techniques and skeletal work may be required. Soft tissue work involves removing the midportion of the tongue (median glossectomy, lingualplasty or volumetric reduction by radiofrequency). Skeletal advancements techniques can increase the airway size and tension on the tongue so that even if the tongue falls back during sleep it does not obstruct the airway. This procedure includes inferior sagittal mandibular osteotomy and genioglossus advancement and hyoid procedures.

    Maxillomandibular Advancement Surgery
    Maxillomandibular advancement surgery is a more aggressive procedure, usually saved for when the more conservative surgery fails. It involves the forward movement of the lower jaw and midface and gives the tongue more room, opens the airway more and places additional tension on the tongue base. The individualised use of staged soft tissue and skeletal procedures for upper airway reconstruction ensures that the most conservative treatment is offered and the possibility of unnecessary surgery reduced.

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