Snoring and Sleep Disorders
Snoring is a very common problem that affects as many as 40% of men and 20% of woman older than age 50. This is most commonly caused by vibrations of the soft palate in the throat though other structures can contribute as well. During sleep when the muscles of the throat relax, these tissues can become floppy and collapse to cause intermittent obstruction. When the obstruction becomes severe enough, this can result in either partial reductions in airflow (hypopneas) or complete cessation of breathing (apneas). These disruptions in breathing can result in drops in blood oxygen levels, stress to the heart and lungs, and frequent micro-arousals in order to re-establish normal breathing. These micro-arousals may not be remembered, but they disrupt the normal sleep pattern preventing deeper stages of sleep, resulting in poor quality sleep. This condition is referred to as obstructive sleep apnea (OSA). Other sleep conditions can contribute to poor sleep as well (for example insomnia, difficulty falling or staying asleep), but OSA is one of the most common sleep disorders in the United States, affecting at least 2% of women and 4% of men, or roughly 22 million adults.
Adult Obstructive Sleep Apnea
OSA can affect people of any age, but the prevalence increases between middle and older age. Common symptoms include heavy snoring with witnessed pauses, gasping, or snorting during sleep, and excessive daytime sleepiness. About 80-90% of adult with OSA remain undiagnosed. Risk factors for adult OSA include obesity, large neck size, male gender, and being middle aged or older. If left untreated, OSA can result in chronic hypertension, increased risk of stroke, heart attack, and arrhythmia, diabetes, poor concentration, mood disturbance, and increased risk of deadly motor vehicle accidents. OSA can also have significant impacts on the quality of life for bed partners of those afflicted as well.
Risk Factors for Adult OSA:
- Overweight (Body Mass Index 25-29.9) or Obesity (Body Mass Index >30)
- Large neck size (>17 inches for men, >16 inches for women)
- Middle age or older, post-menopausal
- Craniofacial anomalies
- Down syndrome
Treatment of Adult OSA
- Positive Airway Pressure (PAP) therapy –first-line treatment
- Oral appliance therapy –alternative to PAP for those who fail or are unable to tolerate PAP therapy. Most effective for pts who are non-obese with mild-moderate OSA
- Surgery –alternative to PAP for those who fail or are unable to tolerate PAP therapy. A wide variety of surgical options have been developed targeting specific anatomic features that may be contributing to obstruction (see below).
To make an appointment for initial diagnosis of OSA, please contact the Sleep Disorders Program at 503 494-6066.
Surgery for OSA
Obstruction can occur throughout the upper airway, and multilevel obstruction is common. The parts of the upper airway most commonly contributing to OSA in adults are the nasal airway, the soft palate, and the back of the tongue. If the tonsils are present and large, these can also contribute to obstruction. Various surgical procedures have been developed over the years to target each of these areas. Surgery must be tailored to each patient's specific anatomy, and not every procedure or intervention will be appropriate for every patient.
Drug-Induced Sleep Endoscopy (DISE)
To help determine the optimal surgical approach, a common part of the evaluation process is a diagnostic procedure called drug-induced sleep endoscopy (DISE). In this procedure, the patient is placed under a sedated sleep, then a flexible fiberoptic endoscope is passed through the nose to the back of the throat to visualize the areas are collapsing and causing snoring and obstruction. Based on this evaluation, further surgery can be planned targeting the problem areas.
The following list of procedures are commonly performed for OSA. This is not a comprehensive list, and other interventions may be recommended or performed if deemed appropriate.
- Bilateral inferior turbinate reduction
- Endoscopic sinus surgery
Soft Palate/Pharyngeal Procedures
- Uvulopalatopharyngoplasty (UPPP
- Expansion pharyngoplasty
- Radiofrequency ablation of the soft palate
Base of Tongue Procedures
- Lingual tonsillectomy
- Posterior midline glossectomy
- Genioglossus suspension
- Radiofrequency ablation of the tongue base
- Transoral robotic surgery of the tongue base
Bony Skeleton Procedures
- Maxillomandibular advancement
- Mandibular distraction
- Sliding genioplasty
Upper Airway Stimulation
- Inspire Hypoglossal Nerve Stimulator (see below for further details)
Upper Airway Stimulation
Upper airway stimulation or hypoglossal nerve stimulation is the newest treatment available for obstructive sleep apnea. FDA-approved in 2014, this implanted device is essentially a pacemaker for your tongue. The device is implanted just beneath the skin of the right upper chest with two wires that are tunneled under the skin, one attached to the hypoglossal nerve that controls your tongue, and the other inserted into your chest wall between the ribs to sense the breathing pattern. Only activated during sleep, when the device senses that you are taking a breath in, it provides a small pulse of stimulation to your tongue to flex the tongue muscle enough to keep the airway open during inspiration, then relaxes during exhalation. This has been shown in multiple studies to be a highly effective treatment for OSA for people who meet the appropriate criteria. These criteria include a Body Mass Index <32, moderate to severe OSA, and failed trial of CPAP therapy. A good night's sleep is an article that gives more details.