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Snoring
snoring.PNGSnoring is a problem that affects 67% of adults. It is conservatively estimated over 120 million people in the United States snore every night. Snoring can cause disrupted sleep for both snorers and their sleeping partners and it can lead to health problems.

Snoring is the harsh sound that occurs when the tissue at the back of the roof of the mouth vibrates against the back of the throat. During sleep, throat tissues, the tongue and the muscles that line the airway all relax, narrowing the airway. Air passing through the narrower airway cause the tissues to vibrate against each other and create the snoring sound that can grow louder during sleep. Snoring may also be an indication of a bigger health problem.

Sleep Apnea

sleepapnea.PNGObstructive sleep apnea is a condition in which the soft tissues at the back of the throat completely close off the airway so that air cannot flow into the lungs. This airway blockage can reduce the amount of oxygen reaching the brain and body. When that happens, the brain alerts the muscles in the airway to tighten up and unblock the air passage. This leads to a cycle of blocking and unblocking the airway and causes significant disruption of sleep.


The most common symptoms of obstructive sleep apnea are:
Loud snoring
Restless sleep
Periodic stoppages of breathing
Significant daytime sleepiness
Irritability or personality change
Difficulty concentrating and poor memory
Sleep apnea is a health problem that can be associated with high blood pressure, heart problems and stroke. It is important for patients to see a physician or a sleep disorder specialist if they are experiencing snoring and daytime sleepiness.

Note:
This information is intended to help individuals manage their snoring and/or sleep apnea. It is not to be used as a guide for self-diagnosis or to recommend a particular treatment. Dr. Polles recommends consulting a professional for appropriate diagnosis and treatment.



Sleep Diagnostic Center


Most hospitals have sleep diagnostic centers which are being run by sleep technicians working with physicians. Sleep centers have sophisticated equipment in an adjoining room where an intercom and video camera allow communication between the technician and the patient. The patient comes in at night and is hooked up to a number of machines which are used to monitor the activities of the brain, the eyes and the muscles. The recordings are done in a private room and there is no discomfort to the patient. The patient is not confined to a fixed position and can turn freely. Recordings are done during the night in a seven hour sleep period and the patient is discharged in the morning.

POLYSOMNOGRAM

The purpose of a polysomnogram is to evaluate the individual sleep architecture including the stages and cycles of sleep as well as to record the electrical activity of the brain, the eyes, muscles and heart.

1. Electroencephalogram (EEG)

Records the activity of the brain. This verifies and records the different stages of sleep.

2. Electro-occulogram (EOG)

Records the movement of the eyes and measures the periods of rapid eye movement (REM).

3. Electromyogram (EMG)

Records muscle activity throughout the body.

 4. Electrocardiogram (EKG)

 Measures cardiovascular abnormalities during sleep.

It also uses a finger or ear oximeter to measure the amount of oxyhemoglobin (oxygen saturation) in the blood. Patients suffering from OSA have a decreased amount of oxygen in the system.

COMMON METHODS OF OSA TREATMENT

1. Oral Appliance Therapy
2. Continuous Positive Air Pressure (CPAP)
3. Surgical Removal of Excess Palatal Tissue (UPPP) or the Laser Assisted Removal of the Uvula (LAUP)

Clearly, the largest number of patients suffering from obstructive sleep apnea are in the mild to moderate categories and should be treated with oral appliances. Despite the fact that treatment with the CPAP unit is extremely successful, there are a number of patients who cannot or choose not to wear the face mask with the attached air compressor. These patients are excellent candidates for oral appliances. Some patients either do not want surgery or have had surgery and the procedure has been unsuccessful in solving the problem of OSA. These patients prefer a non-surgical, non-invasive plastic intra-oral appliance that can be worn at night only to help solve their problem.

Today there are basically three types of appliances:

Soft Palatal Life Appliance
Tongue Retraining Device
Mandibular Repositioner


 It should be noted that since 1987 all medical devices, including oral appliances for the treatment of snoring and obstructive sleep apnea, are required to have marketing clearance from the FDA.

Types of Appliances

1. Snore Free

A prefabricated appliance constructed by the clinician at the chair. It is a relatively inexpensive, good diagnostic, temporary appliance and is used if the patient breaks or loses the permanent snoring appliance. .

2. Silent Nite

This two piece appliance consists of two plastic parts which cover the upper and lower teeth and are joined together with a plastic plunger. The advantage of this appliance is that it is extremely comfortable.

3. Modified  Herbst


This removable appliance is highly effective. The upper and lower acrylic components are held together by a plunger mechanism which holds the mandible forward in both the open and closed positions. The Modified Herbst has the advantage of allowing the patient to open and close as well as providing some limited side to side jaw movement.

4. Nocturnal Airway Patency Appliance ( NAPA )

This is a rigid appliance which stabilizes the jaw in the horizontal and vertical dimension.

5. Klearway Appliance

This is a one-piece appliance attached to the upper and lower teeth with a screw capable of advancing the jaw.

6.  Silencer Appliance

This is a two piece appliance held together with a special titanium hinge. This is one of the most comfortable appliances since it allows for jaw movements.

After the oral appliance has been used for a few months and the treatment appears to be working, then a second polysomnogram must be taken to confirm that the snoring and obstructive sleep apnea have been corrected. If the polysomnogram reveals that there is still a problem, then it is advantageous to have an adjustable appliance.

CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)

 The current gold standard utilized by the medical profession for the treatment of OSA is continuous positive airway pressure (CPAP). The patient wears a tightly fitting nose mask which is strapped to the head and connected by a hose to an air compressor pump. The air is forced into the airway through the nasal passages in order to open up the airway.

Complaints about the use of this air blower include pump noise, voice changes, skin irritations from the mask, nose and throat dryness, headaches from the strap around the head, tinnitus, difficulty getting to sleep, sinus infections, and difficulty breathing out against the air being forced through the nose.

The patients who should use CPAP are the severe cases of obstructive sleep apnea as the device may indeed be a life saver. In cases of mild to moderate OSA, or in cases where patients refuse to wear the CPAP, perhaps oral appliances may be the treatment of choice.

MOST COMMON SURGICAL TECHNIQUES

Laser Assisted Uvulaplasty (LAUP)

This is a very popular form of surgery now being performed. The purpose is to surgically remove the uvula when it is excessive and deemed to be causing the problem.

Uvulopalatopharyngoplasty (UPPP)
This is the surgical removal of excess palatal tissue which is thought to be causing the problem.
The disadvantage is that these surgeries can be quite painful during the healing period. Following the surgery, patients report voice changes and difficulty in swallowing their food.

Patients should be informed of all their options prior to any treatment whether surgical or non-surgical.

SLEEP ARCHITECTURE

This describes the stages and cycles of sleep. There are two main categories of sleep:

1. Non-Rapid Eye Movement (NREM)
2. Rapid Eye Movement (REM)

Non Rapid Eye Movement (NREM)

Transitional Phase - Between wakefulness and sleep. This lasts for one to seven minutes and is 5% of the total sleep time.
Light Sleep Phase - This is 50% of the total sleep time.
Slow Wave Phase (Delta Phase) - A deeper and more relaxed sleep associated with 20% of the total sleep time.

Rapid Eye Movement (REM)


This is a period of deep, refreshing sleep. Eyes move side to side and the skeletal muscles are nearly paralysed which results in a loss of muscle tone in the upper airway. This represents 25% of the total sleep time and is the stage where dreaming occurs.

Excessive Daytime Sleepiness (EDS)

People who suffer from obstructive sleep apnea have a fragmented sleep architecture which causes them to spend an excessive amount of time in the lighter stages of sleep at the expense of the Delta Phase and REM stage. This causes them to have excessive daytime sleepiness due to their lack of sleep at night.

Apnea and Hypoapnea


Apnea is defined as a period of cessation of breathing during sleep for ten seconds or longer. If the patient has more than five episodes of apnea per hour of sleep, this is considered clinically significant and helps confirm the diagnosis of obstructive sleep apnea. Hypoapnea occurs when the decrease in airflow results in a 4% decrease in oxyhemoglobin concentration in the blood.

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