What is Snoring and Sleep Apnea?

In order to understand what snoring and obstructive sleep apnea are, you first need to understand that both represent upper airway obstruction. In other words, something is obstructing the free flow of air somewhere between the openings of the nose and into the trachea (wind pipe). Moreover, many believe that if left unchecked, snoring will, in a great number of individuals, lead to significant obstructive sleep apnea syndrome.

Depending upon the degree of obstruction, the patient either exhibits partial collapse of the soft tissues of the upper airway and produces a noise, which we refer to as snoring, or with total obstruction of any portion of the collapsible airway, can experience a condition called apnea (total cessation of breathing for 10 seconds or longer), or hypopnea (50% or greater decreased in air exchange for 10 seconds or longer).. 

As a direct consequence of obstruction, the C02 in the blood increases and the oxygen level in the patient’s blood decreases proportionate to the severity of the airway obstruction. This disruptive pattern of breathing generates disruptive sleep patterns, the consequences of which being that those individuals exhibit increased fatigability, lethargy, decreased ability to concentrate, increased irritability, and morning headaches. Basically, those individuals are extremely tired due to their inability to get a good night’s sleep. 

The immediate consequences of obstructive sleep apnea are readily recognizable. However, not so easily recognizable are the long-term cardiovascular effects secondary to obstructive sleep apnea that lead to an estimated 30,000 to 40,000 cardiovascular/cerebrovascular deaths per year. Untreated obstructive sleep apnea ultimately leads to an increased incidence of pulmonary and systemic high blood pressure and ventricular hypertrophy (thickening of the heart muscle). Moreover, significant decreases in the oxygen saturation of the blood during apneic episodes can lead to potentially lethal arrhythmia (alteration in the rhythm of the heart). 

How is Sleep Apnea/Hypopnea Diagnosed?

Snoring, sleep apnea/hypopnea, sleep arousals, periodic leg movements, parasomnias, REM sleep behavior disorders are classically evaluated by a diagnostic sleep study typically carried out in a hospital or free-standing sleep laboratory. The objective data derived from that study is then used to help the clinician formulate a plan of treatment for the individual patients' needs.

Because approximately 85% of the patients evaluated in a sleep center are individuals who have airway obstruction, there have been developed home monitoring devices that can aid the patient clinician in the diagnosis of sleep apnea (i.e. airway obstruction). Although not as thorough or sophisticated as a sleep lab polysomnogram (i.e. sleep study), these home studies are less expensive, user friendly (carried out in the patients' home) and provide clinically important data upon which a treatment plan can be formulated.

Once the diagnosis of clinically significant obstructive sleep apnea/hypopnea is made, medical treatment is initiated. Recommendations are almost invariably made for exercise, weight loss, avoidance of alcoholic beverages before sleep, etc. The patient is then scheduled for either CPAP titration in a sleep lab or AutoPAP at home. The titration process is designed to ascertain the necessary level of pressure to be delivered by a modified bedside respirator (i.e., CPAP, Bi¬PAP, AutoPAP or VPAP) needed to bypass the individual patient's level of airway obstruction. If, for example, 10 cm of water pressure is determined to be the necessary pressure to open up the apneic patient's airway, that level of pressure will be programmed into the patient's CPAP for use at home. Every apneic patient is initially started on CPAP, AutoPAP, etc. in order to treat the obstruction. These units are very effective in opening up the patient's airways. Problems with CPAP, etc. are encountered with patient compliance. Long-term patient acceptance of CPAP, etc. has been and continues to be a major stumbling block in utilizing this treatment modality.

Consequently, as you appreciate the short and long-term effects of airway obstruction and disruptive sleeping, you can readily appreciate why these problems need to be corrected either medically or surgically. As you begin to realize that snoring may represent more than just a noisy bed-time social inconvenience, you begin to understand why many individuals who snore need to be evaluated for clinically significant obstructive sleep apnea. It has been estimated that virtually all apneic patients snore, and of the obnoxious snorers, two thirds have already developed apnea. Fully 50% of individuals with obstructive sleep apnea will eventually develop systemic high blood pressure. Approximately 25% of the patients with essential hypertension (high blood pressure) already have obstructive sleep apnea. Furthermore, the estimated risk of myocardial infarction (heart attacks) is 8 to 10 times higher for individuals with obstructive apnea than for non-apneic individuals.

Estimates vary widely; however, it is felt that approximately 45% of normal adults snore at least occasionally, and 25% snore habitually. Further estimates are that 50% of men and 25% of women snore and 4% of men and 2% of women have clinically significant obstructive sleep apnea. Additionally, up to 33% of obese individuals have obstructive apnea and 75% of apneic patients are greater than 120% of their ideal body weight. Many of the factors surrounding these two problems of snoring and apnea seem obvious; however, as obvious as they may seem, it makes correction no less complex.

Predisposing factors that lead to the development of snoring and obstructive apnea are excessive fatigue (i.e. irregular work/sleep schedules), neuromuscular conditions leading to decreased tone of the upper airway musculature, increasing age, obesity, gender (male greater than female by a ratio of 3-10:1), alcohol consumption particularly close to bedtime, smoking, tranquilizers or sedative medications, allergies, upper airway infections or nasal polyps, upper airway tumors, large tonsils and adenoids in children, deformities of the nose or nasal septum, and congenital malformations of the upper airway and facial skeleton. These represent most, but certainly not all, of the causes leading to the development of snoring and apnea.

When an individual snores habitually and in particular if the snoring is combined with morning headaches, excessive daytime sleepiness, increased irritability, personality changes, sexual impotence (up to 28%), a thorough medical evaluation is indicated. Moreover, if that history and physical examination is clinically significant, a Sleep Study (polysomnography) is required in order to quantify the severity of the problem. An objective RDI (i.e. Respiratory Disturbance Index, which is an average per hour summation of apneas and hypopneas) is obtained in order to justify the type of treatment protocol being offered the patient. As most individuals today realize, there are many more options available to treat these conditions than just five years ago. The appropriateness of these treatment options depends upon the severity of the upper airway obstruction and the area or areas of airway involvement. Multilevel airway obstruction is recognized to be involved in at least 80% of individuals with clinically significant obstructive sleep apnea syndrome. Therefore, it comes as no surprise that uvulopalatopharyngoplasty or laser assisted uvulopalatoplasty although successful 80% of the time in rectifying the problem of simple snorers, is no better than 40% to 50% effective in patients with obstructive sleep apnea.

Medical or surgical treatment options are generally available for most of the areas of upper airway obstruction with the retrolingual and hypopharyngeal areas being the most problematic.

If you are concerned about sleep apnea, please start by answering the questions found on the Screening Tool for Sleep Apena. Click HERE to download.

For information about the Pillar Palatal Implant System, click HERE

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This page was developed by
John M. O'Day, M.D., F.A.C.S., Medical Director
Head and Neck Specialty Group of New Hampshire
Board Certified Otolaryngologist, Head and Neck Surgeon
Fellow American Academy of Otolaryngology Head and Neck Surgery
Fellow American College of Surgeons
Fellow American Academy of Facial Plastic & Reconstructive Surgery
Fellow American Academy of Otolaryngic, Allergy and Immunology
Member of American Academy of Sleep Medicine
Board Certified, American Board of Medical Specialties
in Sleep Medicine

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