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 7 th 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

Situation

3 =

High

chance of dozing 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