Causes of Snoring and Sleep Apnea
Why do I snore?
When we breathe (inhale and exhale) air flows in a smooth, laminar manner. Obstructions that occur along the path of airflow lead to irregular, turbulent air movement. Air turbulence is often accompanied by irregular vibration of the structures of the upper airway. The resultant sound – snoring – may range from mild to severe.
What is obstructive sleep apnea?
When the flow of air slows during sleep (reduced by at least 30%) this is known as a hypopnea. When the flow of air stops completely during sleep (for at least 10 seconds), this is known as an apnea. When these abnormal events (apnea and hypopnea) are due to obstructive, anatomic causes – often related to the collapse or blockage of the upper airway, a patient is considered to have Obstructive Sleep Apnea, or OSA.
What are some of the anatomic causes of snoring?
Snoring is commonly associated with abnormalities of the soft palate or uvula. An overly long or floppy soft palate may vibrate irregularly with airflow. This abnormal vibration makes a sound – snoring. Other sources may also contribute to snoring and, for this reason, careful and complete evaluation is imperative in order to direct effective treatment. Nasal sources (deviated septum, inferior turbinate hypertrophy, polyps, chronic and allergic nasal congestion), nasopharyngeal sources (enlarged adenoids and nasopharyngeal growths) oral sources (enlarged tongue base, small jaw, enlarged uvula or tonsils), and throat and neck sources (floppy neck soft tissues) may all contribute to snoring and to sleep apnea in Phildelphia. In some cases, snoring may be increased by alcohol consumption late at night (which causes your throat to relax and become more floppy).
What are some of the anatomic causes of sleep apnea?
Obstructive sleep apnea (OSA) may similarly be related to obstruction along the airflow pathway. Common oral sites include the tongue base, soft palate, uvula, mandible (jaw), and tonsils. Nasal and nasopharyngeal sources may also play a role. Specifically, the adenoids, septum, and inferior turbinates should all be carefully evaluated. More inferiorly, the soft tissues of the neck may be predisposed to collapse and obstruction.
Impact of Snoring
How common is snoring?
Snoring is widespread, and is believed to affect as many as 50% of adults including both men and women; over 45 million Americans. In one 2006 survey of over 2,000 British couples, 56% of respondents admitted that they snored (70% of men admitted to snoring; 40% of women admitted to snoring). 30% of the respondents stated that their bed partner snores1. 48% of the respondents stated that snoring affected their personal relationships, with 46% of respondents admitting that they sleep in separate bedrooms as a result of snoring. Respondents noted that they felt snoring had caused them to be irritable (47%), had led to arguments (36%), and had impacted their sexual relationships (17%). Some respondents stated that snoring had led to their divorce. Others noted that snoring had led to poor sleep (72%), and had impacted their ability to work effectively (38%).
I am told that I snore at night. Is this why I am tired in the morning?
Drowsiness, irritability, and decreased libido may all be associated with snoring. It appears that snoring is independently associated with daytime somnolence, and not merely a proxy for sleep apnea.2 One study provided evidence of an association between snoring severity and reduced sexual satisfaction.3 Does snoring affect my heart?
People who snore have been shown to have increased rates of hypertension (elevated blood pressure) when compared to those who do not snore.4 Studies have also documented a positive correlation between loud snoring and the risk of heart attack and stroke.
One 2008 study found that “objectively measured heavy snoring is an independent risk factor for early carotid atherosclerosis..and stroke.”5 Another study evaluated over 1500 patients who suffered acute myocardial infarcts (heart attaches), and found that “heavy snoring is associated with case fatality…in patients with a first acute myocardial infarction.”6
What about snoring and diabetes?
In women aged 25-79 years old, one recent study found snoring with or without sleep apnea to be related to the presence of diabetes mellitus7 . This is of particular concern, as diabetes is strongly related to cardiovascular disease and early death. An earlier study supports these results, having found a two-fold higher risk of developing diabetes in women who snore compared to women who do not snore8 . Fortunately, there is some evidence that in diabetic patients with sleep apnea, diabetic parameters improve when patients’ sleep apnea is brought under control. 9 , 10 , 11
Are there any risks of snoring specific to women?
For women of child-bearing age, snoring and witnessed sleep apnea appear to be related to such complications during pregnancy as pre-eclampsia.12 One study found that women who snore during pregnancy have an increased incidence of pregnancy-induced hypertension, and that snoring may indicate a risk for growth retardation of the fetus.13 On another note, the presence of OSA seems to significantly increase in women who have gone through menopause, although this risk may decrease with hormone replacement therapy.14
My partner tells me I snore through the night. I am a little tired. Am I safe to drive?
Raising a public safety issue, a 2009 study of 7905 subjects discovered that men suffering from excessive daytime sleepiness who habitually snore drive significantly more than others15 . Other studies have noted that snoring men have a greater than 3-fold higher risk of traffic accidents than those who do not snore!16
My son/daughter snores. Is this OK?
Even in children, snoring may be pathological. One study found a direct relationship between primary snoring and elevated blood pressure in children.17 This raises concerns, as elevated blood pressure is a known risk factor for adverse cardiovascular events. Other studies have found links between childhood snoring and diminished academic performance in primary school children.18 Suggestions have been made that children with routine, habitual snoring should be screened routinely for hypertension, and academic performance.19
I think snoring is affecting my personal relationships. Can this be the case?
Snoring may have a severe impact on inter-personal relationships. According to one study of 4900 couples, as many as 80% of snoring couples end up in separate bedrooms. Another study of women who sleep with men who snore found that these women were almost twice as likely as women who sleep with non-snorers to report problems with insomnia, daytime fatigue, daytime sleepiness, awakening unrefreshed from sleep, and morning headache. A study from the Mayo clinic showed that snoring also seems to be associated with reduced sexual satisfaction in men.20 It is clear that snoring impacts both the patient who snores as well as his or her bed-partner.
Fortunately, several studies have documented statistically significant improvements in marital relations after a patient’s snoring was corrected.21 , 22 , 23 One study of 10 married couples performed at the Mayo Clinic found that the bed-partner of the snoring patient gained an additional 74% to 87% of sleep per night after their partner’s snoring was corrected.
Impact of Sleep Apnea
I have sleep apnea in South Jersey. Is it safe for me to drive?
OSA is the most common sleep-related breathing disorder,24 and it is well-documented to have a serious impact on a patient’s quality of life, work efficiency, and driving safety.25 One meta-analysis which evaluated the results of 18 other studies found untreated sleep apnea to be “a significant contributor to motor vehicle crashes.”26 The authors concluded that “…individuals with OSA are clearly at increased risk for crash.”
Does my sleep apnea affect my heart?
OSA appears to be related to the development of heart and vascular disease, as noted by a 2008 publication of the American Heart Association and the American College of Cardiology.27 Almost 40% of patients with OSA have elevated blood pressure. Moreover, it appears that patients with OSA may have a 2 to 3 times increased risk of heart attack and stroke.28 , 29 , 30 Americans who have OSA are more likely to die suddenly of cardiac causes between 10 p.m. and 6 a.m. than during the other 16 hours of the day combined, according to findings of a Mayo Clinic study.
What are some of the other health issues related to sleep apnea?
In terms of lifestyle issues, some studies have found an association between the presence of OSA and erectile dysfunction in men.31 , 32 Untreated OSA may also lead to hypertension, coronary artery disease, memory impairment, stroke, and adult onset diabetes. In one study, snoring was found to be associated with elevation in blood glucose markers, potential signs of impending diabetes.33
Can sleep apnea have a big impact on the health of children?
OSA may also have a significant impact on the health of children. Children with OSA have been shown to suffer from bed-wetting (enuresis), behavior problems, deficient attention span, obesity,34 and failure to thrive. Heart and lung problems (cor pulmonale, pulmonary hypertension) may also co-exist in children with sleep apnea.35
Diagnosis of Snoring and Sleep Apnea
Would you give an overview of how doctors evaluate patients with snoring and possible sleep apnea?
Patients with snoring should be carefully evaluated for the anatomical site most likely to contribute to their snoring. Questionnaires should be used to help qualify the degree to which snoring impacts the patient and the patient’s bed partner. Patients should also be carefully questioned to see if they have any signs of symptoms of obstructive sleep apnea – often associated with snoring. Several questionnaires exist to assist with this evaluation. One such questionnaire is the Epworth Sleepiness scale
Will you please tell me a little bit about what is involved in a septoplasty?
The nasal septum is a bony and cartilaginous structure located in the rough midline of the nose, which separates the right from the left side. While the septum may be slightly deviated to one side or the other in many patients, in some patients this deviation will cause a functional obstruction and consequent turbulent airflow and snoring.
What else will my doctor look for?
Any evaluation for snoring or sleep apnea should include a thorough history and physical examination. Patients should be screened for pertinent co-morbidities such as high blood pressure, obesity, daytime sleepiness, diabetes, reflux, and stroke. The nose, nasal passage, mouth, oral cavity, tongue, soft palate, uvula, mandible (jaw), tonsils, adenoids, and neck soft tissues should all be carefully examined as possible sources for snoring and OSA. Simple, quick, and painless procedures are available for otolaryngologists (ear, nose, and throat doctors) to help pinpoint the source of the problem. Spending the time on the front end to locate the correct site of the problem will save a lot of time and frustration later if treatments are directed at the incorrect site.
What is a “sleep study” and what does it measure?
A sleep study (to qualify and quantify the degree of OSA) should also be considered for patients who complain of snoring and who endorse signs of symptoms consistent with OSA. The American Academy of Sleep Medicine has stated that an accurate diagnosis of OSA requires objective testing such as a sleep study38 . While sleep studies measure many factors, the Apnea-Hypopnea Index (AHI) (sometimes referred to as the Respiratory Disturbance Index – RDI) is often considered the primary measurement of a sleep study. The AHI is defined as the number of times an hour that the airflow is reduced. AHI of 5-15 is consistent with mild OSA, AHI of 15-30 is consistent with moderate OSA, and AHI greater than 30 is consistent with severe OSA. For instance, a patient whose sleep study shows an interruption/cessation of airflow for greater than 10 seconds that occurs 7 times per hour (7 apneas), along with a decrease/reduction in airflow that last at least 10 seconds and that occurs 5 times per hour (5 hypopneas) would have an AHI of 12 (7 apneas + 5 hypopneas). This is consistent with mild OSA. There is a similar but distinct measurement system used for children.
I have been told that I may not get enough oxygen when I sleep. Is this possible? How can this be evaluated?
Sleep studies typically will also measure a patient’s oxygen levels (saturation). While levels normally should hover in the mid to upper 90’s (ie-97% oxygen saturation), they can dip quite low in patients with OSA. This makes sense, since when patient’s stop breathing they stop filling their lungs with air thereby slowing the delivery of oxygen. As our bodies demand high levels of oxygen to work effectively, this desaturation – if high enough- can have a significant impact on bodily functions.
I really don’t want to go to a “sleep center” to get a sleep study. I have been told that these centers are uncomfortable and sterile. Is there any other way for me to get a sleep study?
Recent years have seen the introduction of home sleep studies in which patients wear a monitor while they sleep in the comfort, and natural environment of own bed, instead of sterile sleep labs [FIGURE 1 BELOW]. There continues to be an increasing abundance of data in support of the efficacy, accuracy, and ease of use of these home sleep studies.39 , 40 41 42 43
FIGURE 1 – Image of patient having a sleep study while sleeping in his/her own bed. A variety of sensors transmit information to the wrist-worn device shown here.
Talking to Your Bed Partner about Snoring and Sleep Apnea
I feel guilty about snoring and sleep apnea. Do other people have similar emotions about this?
Patients who snore or disrupt their bed partner’s sleeping because of devices such as CPAP machines may experience feelings of guilt. Patients have expressed the following sentiments to me:
“My loud sleeping keeps my wife from getting a good night’s sleep. When she wakes up the next day- tired and frustrated – despite her efforts to be generous to me, her frustration and anger finally boil over. My sleep habits are damaging our relationship!”
“Whenever I go on a business trip with my company, my co-workers do everything they can to not share a room with me. My snoring has become a joke at work. It is demoralizing.”
“I have been with my boyfriend for 6 years. I know that I snore and keep him up. He tries everything – ear plugs, nudging me onto my stomach – but I can sense the frustration. I feel that my snoring is driving us apart.”
I have also heard from the partners of snorers and CPAP-users comments such as:
“I know it is not his fault, but I just can’t sleep with all of that noise. I haven’t said anything because it is pointless. After all, he doesn’t mean to snore. It just happens.”
In some cases, I have heard:
“I am going to leave him. I am exhausted from sleeping next to a fire truck every night. I just can’t take it anymore. I don’t want to say anything; I don’t want to hurt his feelings.” “It is very difficult for me to bring up this topic with my bed-partner. How should I start a conversation and begin to talk about snoring/sleep apnea?”
The first step in addressing snoring and sleep apnea issues is moving beyond guilt. People who sleep loudly may have guilt about the noise they make at night. This should be addressed in an open and positive way. There are tactful and sensitive ways to discuss sleep and snoring issues. Often these involve focusing on the positive. You may let your partner know that this relationship means enough to you that you are willing to go through the hard work of helping him or her to address the loud sleeping.
One way to start this conversation might be as follows:
“Because I want our relationship to work, I want to talk to you about how snoring/CPAP is affecting our relationship.” or
It may also be useful to focus on the health aspects related to snoring and sleep apnea. One might say: “I read that people who snore are more likely to have heart attacks and strokes. I think we need to see someone to help us address this. It is important!”
If your partner’s CPAP machine is driving you crazy you might similarly say: “I am so glad that your CPAP is helping you. I know that sleep apnea can have some real health-related complications. I have read that there are new, minimally-intrusive treatments that work. How would you feel about the two of us looking into some of these solutions that might be a little less disruptive?”
Similarly, one might say:
I have found that these statements of caring will help the snorer/CPAP-user see that loud sleeping is impacting his or her relationship. A positive focus tends to disarm the snorer and let them move beyond a defensive posture. Instead, the loud sleeper is often touched that his or her partner cares enough to talk about this problem.
By focusing on the positive – the fact that you care enough about your relationship to have the courage to bring this up – these conversations can even bring a couple closer together. Going through this process of addressing a difficult and complicated issue can make a relationship stronger and more lasting. But this really is a difficult topic!
Difficult topics are often difficult to speak about. Remembering why you are having the conversation is important. Smoking cessation, weight loss, marriage counseling are all issues that require prolonged effort and discussion in order to have successful outcomes. Often, when difficulties and disagreements arise, it is useful to re-focus on why you are having the discussion – because you both care enough to work for a successful outcome. Similarly, discussions about the management and treatment of loud sleeping may benefit from this acknowledgement. You are having the conversation because you and your bed-partner care enough about each other to try to work through this issue so that you can return to happily sharing a bed in a pleasant way that strengthens your relationship. It is important to remember and to acknowledge this fact during your discussions. What should I say if my bed-partner doesn’t respond well to me bringing up the topic of snoring/sleep apnea? In some cases, your partner may react poorly to your bringing up the issue of their loud sleeping. They may respond with denial and adopt a defensive posture: “I do not snore. You are just too sensitive.”
Sometimes people feel helpless, as if the condition is simply beyond their control. They may respond: “I can’t help it. Why are you giving me a hard time about this? It is beyond my control!”
Patients using CPAP may first be offended that you would bring up this topic. They might say: “CPAP keeps me healthy. My doctor says I need to use it. So what do you want me to do? Why are you bringing this up anyway?”
As noted above, discussing loud sleeping with a bed partner can be difficult. Issues of pride, guilt, anger, frustration may be lingering just beneath the surface of this topic. This is why it is important to discuss the issue rather than bury it and refuse to talk. While it can be embarrassing to talk about loud sleeping, it can also help to raise a relationship to a new level of satisfaction once this is addressed. This should always remain the focus of conversations. Namely, the reason you are bringing this up is because you care enough to go beyond the awkwardness of the topic, and have a difficult discussion for the sake of your relationship, and for your and your partner’s health. It is often useful to use this fact as a refrain. For instance, at difficult points in this discussion, you can say:
“I know this is a difficult topic for you. But honestly it is uncomfortable for me too. I am bringing this up because it impacts our relationship whether we want to acknowledge it or not. It is real, and I care about us, so please help me talk about this.”
Remember to stick to the facts – they are on your side. You can remind your bed-partner: “Your snoring is unhealthy. It can affect your health. I care about you. So please help me with this. Let’s look for ways to get this under better control.”
On occasion you may have to make the facts evident. Let your partner know that you are going to make an audio recording of them at night while they are sleeping. The next day, these facts may serve as a catalyst for acknowledgement and discussion.
My bed-partner just doesn’t want to talk about snoring and sleep apnea. How do I overcome this obstacle? As pointed out in the beginning of this section, the topic of loud sleeping is often difficult for the sleeper and the bed-partner to discuss. Both individuals may be uncomfortable with the topic. The loud-sleeper may be defensive with emotions of guilt or denial. The bed-partner may also have a sense of guilt for being “too sensitive” as well as anger and frustration at their hours of lost sleep. Just as it was important for you to have speak about your frustration with lost sleep and difficult nights, it may also be important for your bed-partner – the loud sleeper – to air his/her feelings. A discussion requires 2 people; both partners in a relationship need to speak, and both need to be heard. If your partner does not speak, you should prompt him/her to do so:
“What do you think about what I have said?” or
“What are your feelings about this?” or
“I know that this is a difficult topic, but I would really like to hear how you feel about this?”
These are all ways in which you might prompt discussion if your partner is hesitant to speak.
What if none of these approaches work?
It needs to be acknowledged that discussing loud sleeping with a bed partner can be a difficult task. Patients with sleep apnea may be particularly difficult to speak to, as moodiness, irritability, and fatigue – all of which may result from OSA – contribute to making discussion of this topic a more challenging endeavor. In some cases, the issues have such strong emotions attached that moving past these feelings can be a challenging task. In these situations, patients should not be shy about seeking help of their physician, a psychologist, relationship counselor, or a psychiatric specialist. The fact that the issues are this difficult to discuss is just further evidence of their impact, and supports the suggestion of seeking professional assistance. In summary, do not be shy if you need help. Help is available, and it is usually worth the effort!
Overview of Treatments for Snoring and Sleep Apnea
Effective treatment of snoring and OSA depends on proper diagnosis and location of the anatomic source of the problem. Treatments can be medical or surgical and vary in efficacy. Medical treatments include lifestyle changes (weight loss and dietary changes), sleep positioning pillows, nasal sprays, dental/oral appliances, nasal strips, and positive pressure mask devices. Inhalant allergies may also contribute to snoring and OSA, and should be treated when present. Medical interventions are preferable to surgery; however, some of the interventions (ie-use of the continuous positive airway pressure device) are uncomfortable and have poor patient compliance.
Surgical treatments include nasal surgery, adenoid and tonsil surgery, palate surgery, and jaw surgery (mandibular advancement). Some of these surgeries may be performed with the laser (laser-assisted uvulopalatoplasty, or LAUP) Unfortunately most of the surgeries involving the oral cavity (tonsils, palate, jaw) and pharynx (uvulopalatopharyngoplasty, or UPPP) have significant pain and morbidity as well as lengthy patient recovery times with only modest success rates.
Fortunately, the past few years have seen the rise of a variety of effective, minimally-invasive treatments for snoring and sleep apnea. These treatments, along with others, will be discussed in detail in this and the following chapters.
Medical Treatments of Snoring and Sleep Apnea
What is CPAP? How does it work?
Continuous Positive Airway Pressure (CPAP) has long been considered a standard treatment option for patients with OSA for decades. With CPAP, patients sleep with a mask that forcibly opens the airway and resists the collapse associated with OSA. While the treatment can be very effective when utilized properly it is, unfortunately, often felt to be very cumbersome – both for the patient and his/her bed partner.
FIGURE 2 – Patient sleeping with a typical CPAP mask
Some patients find the device claustrophobic and disruptive. Others find that using CPAP leads to nasal stuffiness, post-nasal drainage, and congestion. As a consequence, many patients are unable to adhere to a treatment plan with CPAP and remain – in essence – untreated and exposed to all of the health and social risks of OSA44 . Studies have found that up to 83% of patients become non-adherent to CPAP use.45 , 46 These patients are of particular concern, since some studies have shown that patients intolerant of CPAP have a 10% increased mortality risk at 5 years when compared to patients with OSA who do adhere to treatment.47 , 48
Fortunately, the past several years have seen some advancements in Positive Airway Pressure (PAP) technology. Specifically, Auto-titrating machines are now available which continuously respond to airway resistance and auto-adjust the airway pressure delivered. By this continual re-calibration, these newer machines may be more effective and efficient than the traditional CPAP mask. Also available are smaller, more comfortable facial pillows which have been designed to make wearing positive airway pressure masks more tolerable.
What are oral appliances? How do they help with snoring and sleep apnea?
In some cases of snoring and OSA an oral appliance may be used for treatment. An oral appliance is an artificial (often plastic or acrylic) device similar in appearance to a mouth-guard [FIGURE 2]. The device is intended to be worn at night during sleep. By moving the lower jaw (mandible) forward, the appliance decreases the likelihood of the oral soft tissues collapsing and obstructing the airway. It is this obstruction that may contribute to snoring and OSA. A second type of oral appliance – a Tongue Retaining Device – applies suction to the tongue at night in order to keep it from falling back in the throat [FIGURE 3].
A 2006 review of 41 studies found mixed results with oral appliances. Only 52% of patients were able to control their OSA with an oral appliance, and oral appliances were found to be less effective than CPAP49 . As with CPAP, it appears that many patients find it difficult to tolerate oral appliances. Patient compliance rates seem to vary in studies, and have been reported to be as low as 25%.50
The use of oral appliances may have associated complications. Commonly reported minor (often temporary) side effects have been noted to occur in up to 86% of patients. More severe and persistent complications have been noted to occur in up to 75% of patients. Complications/ adverse events include TMJ (temporomandibular joint) pain, myofascial pain, dental/tooth pain, tongue pain, dry mouth, gum irritation, severe gagging, excessive salivation, occlusal/bite changes, and TM joint sounds.51
Figures 3-4 – A typical oral appliance (left) and A tongue Retaining Appliance
Lifestyle Treatments for Snoring and Sleep Apnea
I have gained some weight. Does this contribute to my snoring/sleep apnea?
It is well-documented that weight gain and obesity can contribute to snoring and OSA52 53 . One study found two-thirds of 1,000 OSA patients to be clinically obese (weight greater than 120% of ideal)54 . It has been demonstrated that increased weight and body mass will lead to alterations in upper airway structure and function which predispose to OSA and snoring55 56 .
Can weight loss improve my snoring and/or sleep apnea?
There exist a large number of studies which support the notion that signs and symptoms of OSA and snoring can be improved with weight loss57 58 59 . In some patients with significant obesity, surgical intervention (ie-bariatric surgery) may be utilized to help patients with OSA lose weight60 . Studies seem to support the efficacy of these interventions, although long-term follow-up data is incomplete61 62 . It is apparent that a patient’s overweight status can play a significant role in his/her snoring and OSA. In addition to the other health benefits of good nutrition and fitness, working towards a healthy weight may have significant benefits for patients with OSA and snoring. It is, therefore, imperative that patients with OSA and snoring examine the status of their nutrition and fitness with an eye towards healthy, balanced interventions.
Does drinking alcohol contribute to my snoring and/or sleep apnea?
Drinking alcohol may cause the soft tissues of the airway to relax and increase the likelihood of soft tissue collapse associated with snoring and sleep apnea. In fact, it the increased rate of sleep apnea in patients who drink has been well documented63 64 . Changing drinking habits and patterns, including decreased nocturnal alcohol consumption may have a positive impact on patients’ sleep and snoring signs and symptoms.
Allergy Treatments for Snoring and Sleep Apnea
Can allergies (i.e., “hay fever”) contribute to snoring and/or sleep apnea?
When inhalant allergies (i.e., – “hay fever”) affect the nasal passages, known as allergic rhinitis. The swelling of the nasal lining associated with allergic rhinitis can lead to turbulent airflow with snoring as a consequence. Additionally, several studies have suggested a link between allergic rhinitis and OSA with allergic rhinitis as a risk factor for OSA69 70 71 . This link is likely based on the fact that nasal airway resistance accounts for two-thirds of total airway resistance72 . When the nasal airway becomes blocked as a result of allergic-swelling, total airway resistance increases. Others have shown improvement in OSA parameters after medical treatment of allergic rhinitis73 74 75 .
How can I get tested for allergies? Do I need to have one of those painful looking skin tests?
For those who would like to acquire more in-depth scientific knowledge about allergy, please visit Chapter 4 of the free on-line textbook – “Diagnosis and Management of Disorders of the Nose and Sinuses.” This book is available at: http://www.noseandsinus.com. In short, however, it will suffice to say that allergy testing should be part of the evaluation of most patients with complaints of snoring and sleep apnea. Allergy testing is now simple, quick, and easy. While some patients are best tested with standard “prick” testing, many patients can easily be tested with a mere blood test (RAST test).
I found out that I do have allergies. How do I treat them?
For those patients who do have allergies, there are many management options available. Oral antihistamines, nasal anti-histamines and nasal steroid sprays – along with several other medicines – are effective options for many patients. These treatments will often improve or control patient symptoms; however, they must be taken on a regular basis as long as the triggering allergen (e.g., dust mites, cats, ragweed, etc.) is present. Unlike allergy pills and sprays, immunotherapy is designed to “cure” patients of their allergies. Immunotherapy comes in two forms: allergy shots (SubCutaneous ImmunoTherapy – SCIT) and allergy drops (SubLingual ImmunoTherapy – SLIT). Each of these options has “pros” and “cons.” Allergy shots are effective; however, there is a small but real safety risk. Every year 3-5 people in America will die from an allergy shot. There is also an associated level of inconvenience with allergy shots since most allergists require patients to come to their office on a weekly basis to have their shot administered. Allergy drops are placed under the tongue six days/week. SLIT has been practice with great efficacy in Europe for 40 years and there has never been a documented fatality from an allergy drop. On the other hand, it is often the case that patients will need to take their allergy drops for 6-12 months longer than allergy shots before their allergies have been fully treated.
Minimally-Invasive Treatments for Snoring and Sleep Apnea
I hear there are some newer, less invasive options for treating snoring and sleep apnea. Can you tell me a little more about these?
The past decade has seen the rise of effective, minimally-invasive treatments for patients with snoring and/or OSA who have failed to respond to medical interventions. Some of these treatments are discussed below.
What are the inferior turbinates, and how do they contribute to snoring/sleep apnea?
The inferior turbinates are highly vascular structures that extend from the front of the nose along the side of the nasal floor all the way back towards the opening into the throat (nasopharynx). These are the only structures within the nasal cavity that freely swell and shrink on a routine basis (the nasal cycle). When these structures are enlarged (hypertrophied), especially at the front of the nose, they can cause significant functional obstruction. In many instances patients with inferior turbinate hypertrophy can be managed with medical and allergy treatments. In other cases surgical reduction of the inferior turbinates may be indicated.
FIGURE 5 – Endoscopic view into the right nasal cavity shows obstruction of the nasal airway (arrow) by the enlarged right inferior turbinate (triangle). The nasal septum is also seen (star). How can the inferior turbinates be treated?
Treatment of the inferior turbinates is a matter of some controversy. Some authors advocate inferior turbinate sacrifice as an almost routine treatment of nasal obstruction; others categorically advise against surgical reduction because of the risk of atrophic rhinitis. In our view, there should be a balanced approach. A thorough search to determine the cause of nasal obstruction is essential, and that cause should be addressed. The proper treatment of nasal obstruction is not simply turbinectomy. By the same token, it is unlikely that the inferior turbinates are immune from pathologic conditions; turbinate hypertrophy must be recognized. A graduated stepwise approach to the inferior turbinates is prudent. It is possible that atrophic rhinitis does develop in some patients after inferior turbinectomy, so we undertake this procedure with great caution. Also, newer techniques have been designed specifically to limit the incidence of atrophic rhinitis.
The advent of radiofrequency devices (Somnus Medical Technologies Inc., Sunnyvale, CA; Coblation Corp., California) to reduce the size of the inferior turbinates has been a significant advance providing a conservative procedure that may be performed with the patient under local or general anesthesia as an alternative to more aggressive approaches. Radio-frequency (RF) volumetric tissue reduction uses radio-frequency heating to induce submucosal tissue destruction, leading to reduction of tissue volumes. The RF generator (Somnus Medical Technologies) is connected to a specialized single-use delivery tip and hand-piece. The tip is a 22-gauge electrode, 4 cm long; the active portion is 1 cm, and the remaining 3 cm is insulated. Two thermocouples allow constant temperature feedback at the location of treatment and in the surrounding tissue, thereby limiting mucosal injury. Topical and infiltrative anesthesia is used. To avoid tissue shrinkage, some surgeons prefer not to use vasoconstrictive agents, which could increase the risk of mucosal injury. Under direct vision, we place the RF electrode in the anterior-inferior portion of the turbinate, with several millimeters of the inactive portion in contact with the mucosa to avoid mucosal injury. We then deliver the RF energy at a specified energy setting. Measure the temperature at the delivery site constantly, and modulate the rate of energy delivery to ensure a maximal temperature of less than 75¡C. This allows the procedure to be performed with the patient under local anesthesia, without pain. Time and experience have shown that the recommended energy levels create a submucosal injury that causes favorable tissue shrinkage. Often a second lesion immediately posterior to the first is both safe and effective. Several authors have suggested that is reasonable to expect 70% to 80% subjective improvement in patients treated with this technique.
Is radio-frequency ablation of the inferior turbinates safe?
While RFA of the inferior turbinates appears to be effective for many patients, there is a risk of minor and major complication. One paper recently reported the case of a patient who suffered orbital apex syndrome and subsequent blindness after RFA treatment of the turbinates76 .
What is sub-mucosal resection of the inferior turbinates?
A submucosal resection of the turbinate may also be performed as a minimally invasive method to treat the inferior turbinates. With newer techniques using powered instrumentation, the submucosal tissues of the inferior turbinate which provide the bulk of the turbinate can be removed in a fairly atraumatic fashion with a resultant decrease in the overall size of the turbinate. Another technique involves resection of the lateral aspect of the turbinate along with the bony concha. We tend to reserve this latter technique for patients with severe turbinate hypertrophy. All of these newer techniques, however, are designed to preserve the inferior turbinate’s physiological functions of warming, lubricating, and air-conditioning are preserved. Submucosal resection may also be complemented by outfracture of the turbinate bone. This maneuver is a very effective means to open the nasal airway; however, it is best performed under general anesthesia.
What is the Pillar procedure for snoring and sleep apnea? Does it really work?
In the Pillar Procedure, small implants are inserted into the soft palate to help stiffen the soft palate and diminish the collapse that contributes to snoring and sleep apnea. The Pillar Procedure is performed under local anesthesia and takes around 20 minutes to perform in the clinic setting with most patients. Several studies have shown a significant decrease in patient snoring intensity with associated decreases in daytime sleepiness and significant improvements in lifestyle after patients underwent the Pillar Procedure. Other studies have demonstrated patient and bed partner satisfaction with the reduction in snoring after the Pillar Procedure at 80% or higher77 78 . Studies of patients with OSA demonstrate approximately 80% of patients with a reduction in their AHI (sleep index), and results were sustained at one year after palatal implants/Pillar Procedure79 80 81 82 83 84 . Another study has documented significant improvement in snoring and sleep apnea with insertion of palatal implants in patients who had failed surgical intervention with prior uvulapalatopharyngoplasty85 . The data in support of the Pillar Implant as an effective, minimally invasive treatment for patients with snoring and/or OSA continues to grow.
Can Radio-frequency Ablation be used on the palate for snoring and sleep apnea?
While the bulk of data seems to support the safety and efficacy of the Pillar Implants for snoring and sleep apnea, the past few decades have also seen the rise of radio-frequency treatments for OSA and snoring. Many surgeons around the world have suggested the use of radio-frequency ablation (RFA) on the palate as a minimally-invasive treatment option. A recent review of 30 articles published between 1998 and 2008 found that while RFA treatments for snoring appeared relatively safe, there was insufficient evidence to support the claim that this treatment method is effective over the long-term86 .
Surgical Treatments for Snoring and Sleep Apnea
Can you tell me a little about surgery for snoring and sleep apnea?
While medical, allergy, and minimally-invasive procedures are preferred by most patients for the treatment of snoring and OSA, surgical treatments are also available. Surgical options for snoring and OSA are constantly evolving. Effectiveness of these more invasive procedures varies tremendously, and are not universally applicable. Surgical options should be tailored to each patient’s individual anatomy and should be decided upon only after in-depth discussion between a physician and his/her patient. Some of these procedures, particularly those involving the pharynx, are associated with significant post-operative pain and, in some cases, severe risks of complication and morbidity. This should also be discussed and considered carefully.
Can the nose contribute to my snoring and sleep apnea? If so, what are my treatment options?
In cases where nasal obstruction is present, and felt to contribute to snoring or sleep apnea, interventions directed towards this area may be appropriate. In so far as snoring may be associated with nasal complaints, the nasal septum, inferior turbinates, and adenoids should be evaluated. Inferior turbinate treatments have been discussed previously, in the section on minimally-invasive treatments.
Will you please tell me a little bit about what is involved in a septoplasty?
The nasal septum is a bony and cartilaginous structure located in the rough midline of the nose, which separates the right from the left side. While the septum may be slightly deviated to one side or the other in many patients, in some patients this deviation will cause a functional obstruction and consequent turbulent airflow and snoring.
FIGURE 6 – Anatomy of the nasal septum (side view)
FIGURE 7 – Endoscopic view into the left nasal cavity shows obstruction of the nasal airway (triangle) by the deviated nasal septum (star). Obstruction leads to turbulent nasal airflow.
FIGURE 8 – Intraoperative view of the patient in the FIGURE above shows the wide open nasal airway (triangle) after straightening of the deviated septum.
When correction of a deviated septum is indicated, it is typically performed as a minimally invasive, outpatient procedure. Physicians at the Becker Nose and Sinus Center do not typically use any nasal packing. Post-operative pain is typically minimal (most patients will take a few pain pills for a few days), and there is some stuffiness that lasts for about 7-10 days while the nasal cavity swelling diminishes. While patients will commonly report improved sleeping, decreased mouth breathing, and diminished snoring, data to support septoplasty as a curative treatment for OSA is lacking.
Figure A show a pre-operative CT scan view of a patient with septal deviation and nasal airway obstruction. Note the white arrow pointing to the deviated septum. Figure B shows the same patient several months after the surgery by Dr. Samuel Becker. Note the straightened septum and wide open nasal airway.
What are the adenoids, and can they contribute to snoring/sleep apnea?
The adenoids are typically normal lymphoid tissue that rest in the nasopharynx (where the nasal cavity turns into the “throat” in the back). In children it is not uncommon for the adenoids to be large enough (“hypertrophied”) to obstruct nasal airflow and lead to snoring and, in some cases, OSA. While the adenoids typically shrink and regress with age, there are several adults in whom the adenoids are persistent and large. In these cases, the adenoids may lead to nasal airway blockage, turbulent airflow, snoring, and/or OSA.
How do you treat large adenoids which contribute to snoring and sleep apnea?
When hypertrophied adenoids cause nasal obstruction, patients will often be encouraged to try a nasal steroid spray to see if the airway can be opened. If this fails to lead to improvement, and the adenoids are sufficiently large, it may be worthwhile to consider an adenoidectomy to remove this tissue and open the nasal airway. Adenoidectomy is performed under general anesthesia. There are multiple techniques to remove the adenoids ranging from simple curetting to more recently introduced techniques such as with collation or powered-instrumentation technology. As with all surgical interventions, the risks, benefits, alternatives, and complications should be discussed with your physician and carefully considered.
My child has large tonsils. Can these contribute to snoring and sleep apnea? How can this be treated?
Like the adenoids, the tonsils are lymphoid tissue that normally rest in the “tonsillar fossa” in the back of your oropharynx. As with adenoids, this lymphoid tissue can “hypertrophy” and lead to blockage and obstruction of the oral airway. The consequent blockage and turbulent airflow may contribute to snoring and/or sleep apnea. More common in children, tonsillar hypertrophy may also be present in adults. If found to be a significant source of obstruction, removal of the tonsils via tonsillectomy may be indicated. Techniques to remove the tonsils vary widely. The past decade has seen the rise of “sub-capsular”, and partial tonsillectomies as less invasive treatments for patients with tonsillar hypertrophy. These newer procedures seem to be associated with decreased post-operative pain; however, there appears to be insufficient data at this time to support their efficacy.
Tonsillectomy procedures are typically associated with significant post-operative pain, particularly in adult patients. Some have described the “worse sore throat of my life.” Complications vary and include bleeding and hemorrhage (most common complication; occurs in 2-3% of patients87 88 ), change in voice, dehydration, mouth and lip burns, and – on rare occasion – death. In some cases, the problem (snoring, sleep apnea) may persist after tonsillectomy.
What is the uvula? Does it contribute to snoring/sleep apnea? If so, how is it treated?
The uvula, the “punching bag” in the back of your throat, is comprised of a series of intertwined muscles with a mucosal lining. On occasion, an enlarged uvula may contribute to snoring and /or OSA. In these instances the uvula may be surgically resected or removed. Usually, the uvula alone is not a significant enough source of snoring/obstruction that removal of just the uvula will solve the patients’ problem. It is for this reason that uvulectomy is usually performed as an adjunct to other procedures (i.e., Pillar Procedure, tonsillectomy, etc). Patients have noted significant pain after this procedure89 .
My doctor said I need a “throat operation” call a UPPP. What is this? Does it work?
Traditional surgery for sleep apnea revolved around the UPPP. Unfortunately, time has shown that this procedure has only modest success rates and is typically associated with significant post-operative pain and lengthy patient recovery times. More recently, physicians have introduced modified versions of the UPPP including “Radiofrequency-Assisted Uvulopalatoplasty” (RA-UPP), “Laser-Assisted Uvulopalatoplasty.” (LA-UP), and “Laser-Assisted Uvulopalatopharyngoplasty.” (LA-UPPP).
One “meta-analysis” which evaluated the results of 37 other studies representing 992 patients found only a 40% success rate in patients who underwent UPPP90 . Studies looking at the efficacy of RA-UPP and LA-UPPP for snoring and sleep apnea have also found less than encouraging results91 92 93 . Two trials found no significant change in the Apnea-Hypopnea Index (primary outcome measure) in patients who had LA-UPPP when compared to those who had no surgery94 95 . Others have shown that in a large subset of patients, UPPP and related procedures may not only fail to improve patient symptoms, but may, in fact, result in a worsened patient condition96 97 !
Are there complications associated with a UPPP?
UPPP may be associated with some significant complications. In a review of 3130 patients who underwent UPPP, there were 47 (1.5%) serious, non-fatal complications, and 7 (0.2%) deaths. An additional 91 (3%) complications ranging from respiratory complications, re-intubation, and pneumonia to cardiovascular complications and hemorrhage were also documented. For these reasons, many patients seek less invasive options with more appealing success rates.
Does the tongue contribute to snoring and sleep apnea? If so, how can this be treated?
In some patients, an enlarged tongue base which relaxes during sleep may fall back in the oral airway (“hypopharynx”) and contribute to obstruction, turbulence and – ultimately – snoring and OSA. Surgeries to treat this area include a Midline glossectomy and – more recently – Radiofrequency ablation (RFA) of the tongue base. Midline glossectomy is less commonly performed given the significant post-operative complications of bleeding, difficulty swallowing, and airway edema necessitating possible tracheostomy98 . RFA of the tongue base appears to be reasonably affective for snoring in appropriate patients. It does; however, often require multiple treatments over a period of weeks to months before noticeable improvement is appreciated. Data does not seem to support the same efficacy of RFA for treatment of OSA with success rates reported under 40%99 .
What is a genioglossus advancement?
The genioglossus muscles forms the bulk of the tongue, and connects the tongue to the chin anteriorly. Relaxation of this muscle may contribute to OSA in some patients. In these instances, the muscle may be surgically advanced forward to provide more space in the oral cavity and oropharynx. There are several variations on this surgical procedure, with varying success rates100 101 . Typically, Genoglossus Advancement is performed in conjunction with other procedures, and not as a stand-alone surgery. What is the hyoid bone? Can it contribute to snoring and sleep apnea?
The hyoid bone is horseshoe-shaped located in the front of the neck just above the “Adam’s apple” (thyroid cartilage). The hyoid is the only “floating” bone in the body, that is not connected to another bone. In some cases a posteriorly-located hyoid may contribute to sleep-disordered breathing, and OSA.
If the hyoid bone is causing some of my problems, how can it be treated?
When the hypoid bone is found to contribute to sleep-disordered breathing, and OSA, it may be surgically re-positioned. A variety of techniques have been developed to accomplish this task. Hyoid suspension is typically combined with other techniques designed to address this area of the airway102 103 . Reports vary, and success rates seem to hover around 50%104 105 .
One technique involving the hyoid which has gained popularity in recent years is the “Repose Bone Screw System” for OSA. In this technique, two procedures are concomitantly performed to address tongue and hyoid-based OSA (the procedures may also be performed individually). In the tongue suspension procedure, the tongue base is repositioned via sutures attached to a titanium screw. In the hyoid suspension procedure, the hyoid is resuspended via two titanium screws which are implanted into the mandible. For appropriate patients who are treated with the Repose System, studies seem to support a success rate of 50 – 80%106 107 108 .
What is cranio-facial distraction?
In some instances of severe OSA, the soft tissues of the mouth (tongue, etc) fall backwards at night and obstruct the airway as a result of a small oral space. When a wider space is needed a “Maxillomandibular expansion” (MME) may be performed. In this procedure, the upper and lower jaws are fractured and a mechanical expander is surgically inserted. Over the next several weeks, the bones are slowly expanded by enlarging the “distractor.” One sufficient distraction is achieved, patients require additional orthodontic work to close the newly created gaps between teeth.
In other cases, the upper and lower jaw are moved forward via “Maxillomandibular advancement” (MMA). In this surgery – typically lasting several hours in duration – the airway is enlarged by breaking the bones of the jaw and the maxilla and manually moving them forward and securing them in place with metal screws to create more space. Both MME and MMA surgeries last several hours, and often involve overnight hospitalization. Typically, patients will be out of work for 2 – 4 weeks after these procedures. Often these procedures are performed in conjunction with other surgeries designed to address a patient’s OSA.
What is a tracheostomy? When is it performed for the treatment of sleep apnea?
As noted earlier, OSA can have significant impact on patients’ health and – in some cases – life-expectancy. In severe cases of OSA, extreme interventions may be required. In a tracheotomy, a surgical opening is made through the skin of the lower neck and directly into the trachea. A hole is cut into the trachea thereby bypassing the sites of obstruction higher up. While a tracheotomy is typically considered “curative” of OSA, it is an extreme measure with potentially severe complications, and is performed only in special circumstances.
Persistent Problems After Treatment
My earlier procedure for snoring/sleep apnea did not work. How can this be?
Snoring and sleep apnea may have many distinct anatomic and physiologic causes. In some patients, just one factor contributes to their signs and symptoms; in others there may be multiple factors which contribute in varying degrees. Consequently there are many different treatments that may help to improve and to eliminate a patient’s snoring and/or sleep apnea. No one solution fits all patients. In some patients, more than one type of treatment may be indicated.
Some patients have persistent snoring and sleep apnea despite prior procedures. Unfortunately, some of the more invasive procedures classically performed for snoring and sleep apnea have uninspiring success rates.
My earlier procedure for snoring/sleep apnea did not work. What should I do now?
Patients who have failed to improve despite medical or surgical intervention may benefit from a re-evaluation. Sometimes it may be a simple fine-tuning of a previously prescribed medication or procedure. Sometimes a patient may simply require some more aggressive allergy management, or a more targeted nasal spray. On other occasions a separate procedure may be warranted. In short, patients should not be discouraged, as the armamentarium of effective treatment options for patients with snoring and sleep apnea is vast.
As an example, uvulapalatopharyngoplasty (UPPP) – for many years the standard surgery for snoring and sleep apnea – has been noted to have a success rate of less than 50% for both snoring109 and for sleep apnea110 . Fortunately, patients who have undergone previous ablative surgical procedures such as a UPPP and have persistent symptoms may receive dramatic improvement from the addition of minimally invasive treatments.
A study of 26 patients who failed management with UPPP found additional symptomatic improvement of snoring, daytime sleepiness, and overall quality of life perception in 70% of these patients after the minimally invasive placement of Pillar implants111 . A separate 2008 study of 16 patients with persistent symptoms after UPPP found significant improvement in snoring and daytime sleepiness after placement of palate implants (similar to Pillar implants)112 .
1 The Great British Snoring Survey. http://www.pflhealthcare.com/release.cfm?ID=70 Return
2 Svensson M, Franklin K, Theorell-Haglow J, Lindberg E. “Daytime Sleepiness Relates to Snoring Independent of the Apnea-hypopnea Index in Women From the General Population.” Chest. 2008;134(5):919-924. Return
3 Hanak V, Jacobsen M, McGree M, Sauver J, et al. “Snoring as a Risk Factor for Sexual Dysfunctin in Community Men.” J Sex Med. 2008; 5:898-908. Return
4 Kim J, Yi H, Shin KR, et al. “Snoring as an independent risk factor for hypertension in the nonobese population: the Korean Health and Genome Study.” American Journal of Hypertension. 2007;20(8):819-24. Return
5 Lee SA, Amis TC, Byth K, et al. “Heavy snoring as a cause of carotid artery atherosclerosis.” Sleep. 2008;31(9):1207-13. Return
6 Janszky I, Ljung R, Rohani M, Hallqvist J. “Heavy snoring is a risk factor for case fatality and poor short-term prognosis after a first acute myocardial infarction.” Sleep. 2008; 31(6):801-7. Return
7 Valham F, Stegmayr B, Eriksson M, Hagg E, et al. “Snoring and Witnessed Sleep Apnea is Related to Diametes Mellitus in Women.” Sleep Medicine. 2009;10:112-117. Return
8 Al-Delaimy W. “Snoring as a Risk Factor for Type II Diabetes Mellitus: a Prospective Study.” Am J Epedemiol. 2002;155:387-393. Return
9 Brooks B, Cistulli P, Borkman M, Ross G, et al. “Obstructive Sleep Apnea in Obese Noninsulin-Dependent Diabetic Patients: Effect of Continuous Positive Airway Pressure Treatment on Insulin Responsiveness.” J Clin Endocrinol Metab. 1994;79:1681-1685. Return
10 Harsch I, Schahin S, Bruckner K, Radepiel-Troger M, et al. “The Effect of Continuous Positive Airway Pressure Treatment on Insulin Sensitivity in Patients with Obstructive Sleep Apnoea Syndrome and Type 2 Diabetes.” Respiration. 2004;71:252-259. Return
11 Babu A, Herdegen J, Fogelfeld L, Shott S, Mazzone T. “Type 2 Diabetes, Glycemic Control, and Continuous Positive Airway Pressure in Obstructive Sleep Apnea.” Arch Intern Med. 2005;165:447-452. Return
12 Perez-Chada D, Videla A, O’Flaherty M, et al. “Snoring, Witnessed Sleep Apneas, and Pregnancy-Induced Hypertension.” Acta Obstet Gynecol Scand. 2007;86(7):788-792. Return
13 Franklin K, Holmgren P, Jonsson F, et al. “Snoring, Pregnancy-Induced Hypertension, and Growth Retardation of the Fetus.” Chest. 2000;117(1):137-141. Return
14 Bixler E, Vgontzas A, Lin H, et al. “Prevalence of Sleep-Disordered Breathing in Women: Effects of Gender.” Am J Resp Crit Care Med. 2001;162:608-613. Return
15 Valham F, Eriksson M, Stegmayr B, Franklin K. “Snoring Men with Daytime Sleepiness Drive More than Others: a Population-Based Study.” Sleep Medicine. 2009;10:1012-1015. Return
16 Young T, Blustein J, FinnL, Palta M. “Sleep-Disordered Breathing and Motor Vehicle Accidents in a Population-Based Sample of Employed Adults.” Sleep. 1997;20:608-613. Return
17 Li A, Au C, Ho C, Fok T, Wing Y. “Blood Pressure is Elevated in Children with Primary Snoring.” Journal of Pediatrics. 2009; 155(3):362-368. Return
18 Urschitz M, Guenther A, Eggebrecht E, Wolff J, et al. “Snoring, Intermittent Hypoxia, and Academic Performance in Primary School Children.” Am J Resp Crit Care Med. 2003; 168:464-468. Return
19 Loughlin G. “Primary Snoring in Children – No Longer Benign.” Journal of Pediatrics. 2009; 155(3):306-307. Return
20 Hanak V, Jacobsen D, Mcgree M. “Snoring as a risk factor for sexual dysfunction in community men.” Journal of Sexual Medicine. 2008;5(4):898-908. Return
21 Gall R, Isaac L, Kryger M. “Quality of life in mild obstructive sleep apnea”. Sleep 1993; 16, S59-S61. 1993]]. Return
22 Armstrong M, Wallace C, Marais J. “The effect of surgery upon the quality of life in snoring patients and their partners: a between-subjects case-controlled trial.” Clinical Otolaryngology & Allied Sciences. 1999; 24(6): 510. Return
23 Cartwright R, Knight S. “Silent partners: the wives of sleep apneic patients.” Sleep. 1987;10:244-248. 1987 Return
24 Young T, Palta M, Dempsey, et al. “The Occurrence of Sleep-Disordered Breathing Among Middle-Aged Adults.” N Engl J Med. 1993;328:1230-1235. Return
25 Powell N, Chau J. “Sleepy Driving.” Med Clin N Am. 2010;94:531-540. Return
26 Tregear S, Reston J, Schoelles K, Phillips B. “Obstructive Sleep Apnea and Risk of Motor Vehicle Crash: Systematic Review and Meta-Analysis.” Journal of Clinical Sleep Medicine. 2009;5(6):573-581. Return
27 Somers V, White D, Amin R, et al. “Sleep Apnea and Cardiovascular Disease: an American Heart Association/American College of Cardiology Foundation Scientific Statement from the American Heart Association Council for High Blood Pressure Research Professional Education Committee, Council on Clinical Cardiology, Stroke Council, and Council on Cardiovascular Nursing in Collaboration with the National Heart, Lung, and Blood Institute National Center on Sleep Disorders Research.” J Am Coll Cardio. 2008;52:686-717. Return
28 Valham F, Mooe T, Rabben T, et al. “Increased Risk of Stroke in Patients with Coronary Artery Disease and Sleep Apnea: a 10 year Follow-Up.” Circulation. 2008;118:955-960. Return
29 Marin J, Carrizo S, Vicente E, et al. “Long-Term Cardiovascular Outcomes in Men with Obstructive Sleep Apnoea-Hypopnoea With or Without Treatment with Continuous Positive Airway Pressure: an Observational Study.” Lancet. 2005;365:1046-1053. Return
30 Yaggi H, Concato J, Kernan W, et al. “Obstructive Sleep Apnea as a Risk Factor for Stroke and Death.” N Engl J Med. 2005;353:2034-2041. Return
31 Guilleminault C, Simmons FB, Motta J, Cummiskey J, et al. “Obstructive sleep apnea syndrome and tracheostomy. Long-term follow up experience.” Arch Intern Med. 1981; 141:985-988. Return
32 Teloken P, Smith E, Lodowsky C, Freedom T, Mulhall J. “Defining association between sleep apnea syndrome and erectile dysfunction.” Urology. 2006;67:1033-1037. Return
33 Joo S, Lee S, Choi H, et al. “Habitual snoring is associated with elevated hemoglobin A1c levels in non-obese middle-aged adults.” Journal of Sleep Research. 2006;15(4):437-44. Return
34 Arens R, Muzumdar H. “Childhood Obesity and Obstructive Sleep Apnea Syndrome.” J Appl Physiol. 2010. 108: 436-444. Return
35 Chan J, Edman J, Koltai P. “Obstructive Sleep Apnea in Children.” American Family Physician. 2004. 69(5):1147-1154. Return
36 Johns M. “A New Method for Measuring Daytime Sleepiness: the Epworth Sleepiness Scale.” Sleep. 1991;14:540-545. Return
37 Lee NR. “Evaluation of the Obstructive Sleep Apnea Patient and Management of Snoring.” Oral Maxillofacial Surg Clin N America. 2009;21:377-387. Return
38 Kushida C, Littner M, Morgenthaler T, et al. “Practice Parameters for the Indications for Polysomnography and Related Procedures: an Update for 2005.” Sleep. 2005;28(4):499-521. Return
39 Pittman S, Ayas N, Macdonald M, Malhotra A, et al. “Using a Wrist-Worn Device Based on Peripheral Arterial Tonometry to Diagnose Obstructive Sleep Apnea: In-Laboratory and Ambulatory Ventilation.” Sleep. 2004;27(5):923-932. Return
40 Madani M, Frank M, Lloyf R, Dimitrova D, Madani F. “Polysomnography Versus Home Sleep Study: Overview and Clinical Application.” Atlas Oral Maxillofacial Surg Clin N Amer. 2007;15(2):101-109. Return
41 Michaelson P, Allan P, Chaney J, Mair E. “Validations of a Portable Home Sleep Study with Twelve-Lead Polysomnography: Comparisons and Insights Into a Variable Gold Standard.” Annals of Otol Rhinol Laryngol. 2006;115(11):802-809. Return
42 Bar A, Pillar G, Dvir I, Sheffy J, et al. “Evaluation of a Portable Device Based on Peripheral Arterial Tone for Unattended Home Sleep Studies.” Chest. 2003;123(3):695-703. Return
43 Patel M, Davidson T. “Home Sleep Testing in the Diagnosis and Treatment of Sleep Disordered Breathing.” Otolaryngologic Clin N America. 2007;40(4):761-784. Return
44 Weaver T, Maislin G, Dinges D, et al. Relationship between Hours of CPAP Use and Achieving Normal Levels of Sleepiness and Daily Functioning.” Sleep. 2007;30(6):711-719. Return
45 Weaver T, Sawyer A. “Management of Obstructive Sleep Apnea by Continuous Positive Airway Pressure.” Oral Maxillofacial Surg Clin N America. 2009. 21:403-412. Return
46 Yetkin O, Kunter E, Gunen H. “CPAP Compliance in Patients with Obstructive Sleep Apnea Syndrome.” Sleep Breath. 2008;12:365-367. Return
47 Campos-Rodriguez F, Pena Grinan N, Reyes-Nunez N, et al. “Mortality in Obstructive Sleep Apnea-Hypopnea Patients Treated with Positive Airway Pressure.” Chest. 2005;128(2):624-633. Return
48 Yaggi H, Concato J, Kernan W, et al. “Obstructive Sleep Apnea as a Risk Factor for Atroke and Death.” N Engl J Med. 2005;353(19);2034-2041. Return
49 Ferguson K, Cartwright R, Rogers R, Schmidt-Nowara W. “Oral Appliances for Snoring and Obstructive Sleep Apnea: A Review.” Sleep. 2006;29(2):244-262. Return
50 Ferguson K, Cartwright R, Rogers R, Schmidt-Nowara W. “Oral Appliances for Snoring and Obstructive Sleep Apnea: A Review.” Sleep. 2006;29(2):244-262. Return
51 Ferguson K, Cartwright R, Rogers R, Schmidt-Nowara W. “Oral Appliances for Snoring and Obstructive Sleep Apnea: A Review.” Sleep. 2006;29(2):244-262. Return
52 Phillips B, Hisel T, Kato M, et al. “Recent Weight Gain in Patients with Newly Diagnosed Obsrtuctive Sleep Apnea.” Journal of Hypertension. 1999;17(1):1297-1300. Return
53 Young T, Palta M, Dempsey J, et al. “The Occurrence of Sleep-Disordered Breathing Among Middle-Aged Adults.” N Engl J Med. 1993;328:1230-1235. Return
54 Guilleminault C, Dement W. “Sleep Apnea Syndromes and Related Disorders.” In: Williams R, Karacan I, Moor C, eds. Sleep Disorders: Diagnosis and Treatment. New York: Wiley, 1988:47-71. Return
55 Schwab R, Gefter W, Hoffman E, et al. “Dynamic Upper Airway Imaging During Awake Respiration in Normal Subjects and Patients with Sleep Disordered Breathing.” Am Rev Respir Dis. 1993;148:1385-1400. Return
56 Haponick E, Smith P, Bohlman M, et al. Computerized Tomography in Obstructive Sleep Apnea: Correlation of Airway Size with Physiology During Sleep and Wakefulness.” Am Rev Respir Dis. 1983;127:221-226. Return
57 Schwartz A, Gold A, Schubert N, et al. “Effect of Weight Loss on Upper Airway Collapsibility in Obstructive Sleep Apnea.” Am Rev Respir Dis. 1991;144:494-498. Return
58 Suratt P, McTier R, Wilthoit S. “Changes in Breathing and the Pharynx after Weight Loss in Obstructive Sleep Apnea.” Chest. 1987;92:631-637. Return
59 Tuomilehto H, Seppa J, Partinen M, et al. “Lifestyle Intervention with Weight Reduction: First-line Treatment in Mild Obstructive Sleep Apnea.” Am J Respir Crit Care Med. 2009;179:320-327. Return
60 Grunstein R, Stenlof K, Hedner J, et al. “Two Year Reduction in Sleep Apnea Symptoms and Associated Diabetes Incidence After Weight Loss in Severe Obesity.” Sleep. 2007;30(6):703-710. Return
61 Lettieri C, Eliasson A, Greenburg D. “Persistence of Obstructive Sleep Apnea After Surgical Weight Loss.” Journal Clin Sleep Med. 2008;4(4):333-338. Return
62 Marien H, Rodenstein D. “Morbid Obesity and Sleep Apnea. Is Weight Loss the Answer?” Journal Clin Sleep Med. 2008;4(4):339-340. Return
63 Sahlin C, Franklin K, Stenlund H, Lindberg E. “Sleep in Women: Normal Values for Sleep Stages and Position and the Effect of Age, Obesity, Sleep Apnea, Smoking, Alcohol, and Hypertension.” Sleep Medicine. 10(9):1025-1030. Return
64 Peppard P, Austin D, Brown R. “Association of Alcohol Consumption and Sleep Disordered Breathing in Men and Women.” J Clin Sleep Med. 2007;3(3):265-270. Return
65 Htoo A, Talwar A, Feinsilver S, Greenberg H. “Smoking and Sleep Disorders.” Med Clin N America. 2004;88:1575-1591. Return
66 Lavie L, Lavie P. “Smoking Interacts with Sleep Apnea to Increase Cardiovascular Risk.” Sleep Medicine. 2008;9(3):247-253. Return
67 Phillips B, Danner F. “Cigarette Smoking and Sleep Disturbance.” Arch Intern Med. 1995;155:734-737. Return
68 Wetter D, Young T, Bidwell T. “Smoking as a Risk Factor for Sleep-Disordered Breathing.” Arch Intern Med. 1994;154:2219-2224. Return
69 Ersu R, Arman A, Save D, et al. “Prevalence of Snoring and Symptoms of Sleep-Disordered Breathing in Primary School Children in Istanbul.” Chest. 2004;126:19-24. Return
70 Ng D, Chan C, Hwang G, Chow P, Kwok K. “A Review of the Roles of Allergic Rhinitis in Childhood Obstructive Sleep Apnea Ayndrome.” Allergy and Asthma Proceedings. 2006;27(3):240-242. Return
71 Kalpaklioglu A, Kavut A, Ekici M. “Allergic and nonallergic rhinitis: the threat for obstructive sleep apnea.” Annals of Allergy, Asthma, & Immunology. 2009; 103(1):20-25. Return
72 Miljeteig H, Hoffstein V, Cole P. “The Effect of Unilateral and Bilateral Nasal Obstruction on Snoring and Sleep Apnoea.” Laryngoscope. 1992;102:1150-1152. Return
73 Chau K, Ng K, Kwok K, et al. “Survey of Children with Obstructive Sleep Apnea Syndrome in Hong Kong of China.” Chin Med J. 2004;117:657-660. Return
74 Brouillette R, Manouklan J, Ducharme F, et al. “Efficacy of Fluticasone Nasal Spray for Pediatric Obstructive Sleep Apnea.” J Pediatr. 2001;138:838-844. Return
75 Kiely J, Nolan P, McNicholas W. “Intranasal Corticosteroid Therapy for Obstructive Sleep APnoea in Patients with Co-existing Rhinitis.” Thorax. 2004;59:50-55. Return
76 Faure C, Seghir C, Hamon M, et al. “Orbital Apex Syndrome Following Inferior Turbinate Radiofrequency.” Rev Laryngol Otol Rhinol. 2009;130(2):121-123. Return
77 Nordgard S, Wormdal K, Vegand B, et al. “Palatal Implants: a New Method for the Treatment of Snoring.” Acta Otolaryngol. 2004;124:1-7. Return
78 Saylam G, Korkmaz H, Firat H, et al. “Do Palatal Implants Really Reduce Snoring in Long-Term Follow Up?” Laryngoscope. 2009;119:1000-1004. Return
79 Ho W, Wei W, Chung K. “Managing Disturbing Snoring with Palatal Implants: a Pilot Study.” Arch Otolaryngol Head Neck Surg. 2004;130:753-758. Return
80 Nordgard S, Stene B, Skjostad K, et al. “Palatal implants for the treatment of snoring: long-term results.” Otolaryngology – Head & Neck Surgery. 2006;134(4):558-64. Return
81 Goessler UR, Hein G, Verse T, et al. Soft palate implants as a minimally invasive treatment for mild to moderate obstructive sleep apnea. Acta Otolaryngol 2007;127:527-31. Return
82 Walker R, Levine H, Hopp M, et al. Extended follow-up of palatal implants for OSA treatment. Otolaryngol Head Neck Surg 2007;137: 822-7. Return
83 Nordgard S, Hein G, Stene BK, et al. One-year results: palatal implants for the treatment of obstructive sleep apnea. Otolaryngol Head Neck Surg 2007;136:818 -22. Return
84 Friedman M, Schalch, Lin H, et al. “Palatal implants for the treatment of snoring and obstructive sleep apnea/hypopnea syndrome.” Otolaryngol Head Neck Surg. 2008; 138(2):209-216. Return
85 O’Connor-Reina C, Garcia-Iriarte M, Casado-Morente J, et al. “Snoring surgery with palatal implants after failed uvulopalatopharyngoplasty.” Eur Archives Oto-Rhino-Laryngol. 2008; 265(6):687-693. Return
86 Back L, Hytonen M, Roine R, Malmivaara A. “Radiofrequency Ablation Treatment of Soft Palate for Patients with Snoring: A Systematic Review of Effectiveness and Adverse Effects.” Larygnscope. 2009;119:1241-1250. Return
87 Randall D, Hoffer M. “Complications of Tonsillectomy and Adenoidectomy.” Otolaryngol Head Neck Surg. 1998;118(1):61-8. Return
88 Rakover Y, Almog R, Rosen G. “The Risk of Postoperative Haemorrhage in Tonsillectomy as an Outpatient Procedure in Children.” Int J Pediatr Otorhinolaryngol. 1997;41(1):29-36. Return
89 Ariyasu L, Young G, Spinelli F. “Uvulectomy in the Office Setting.” Ear Nose Throat J. 1995;74:721-722. Return
90 Sher A, Schechtman K, Piccirillo J. “The Efficacy of Surgical Modifications of the Upper Airway in Adults with Obstructive Sleep Apnea Syndrome.” Sleep. 1996;19:156-177. Return
91 Stuck B. “Radiofrequency-Assisted Uvulopalatoplasty for Snoring: Long-Term Follow-up.” Laryngoscope. 2009;119:1617-1620. Return
92 Madani M. “Laser Assisted Uvulopalatopharyngoplasty (LA-UPPP) for the Treatment of Snoring and Mild to Moderate Obstructive Sleep Apnea.” Atlas Oral Maxillofacial Surg Clin N America. 2007;15:129-137. Return
93 Franklin K, Anttila H, Axelsson S, et al. “Effects and Side-Effects of Surgery for Snoring and Obstructive Sleep Apnea – A Systematic Review.” Sleep. 2009;32(1):27-36. Return
94 Ferguson K, Heighway K, Ruby R. “A Randomized Trial of Laser-Assisted Uvulopalatoplasty in the treatment of Mild Obstructive Sleep Apnea.” Am J Respir Crit Care Med. 2003;167(1):15-19. Return
95 Larossa F, Hernandez L, Morello A, et al. “Laser-Assisted Uvulopalatoplasty for Snoring: Does It Meet the Expectations?” Eur Respir J. 2004;2491):66-70. Return
96 Senior B, Rosenthal L, Lumley A, et al. “Efficacy of Uvulopalatopharyngoplasty in Unselected Patients with Mild Obstructive Sleep Apnea.” Otolaryngol Head Neck Surg. 2002;123:179-182. Return
97 Walker R, Grigg-Damberger M, Gopalsami C, et al. “Laser-Assisted Uvulopalatoplasty for Snoring and Obstructive Sleep Apnea: Results in 170 Patients.” Laryngoscope. 1995;105:938-943. Return
98 Fujita S, Woodson B, Clark J, et al. “Laser Midline Glossectomy as a Treatment for Obstructive Sleep Apnea.” Laryngoscope. 1991;101(8):805-809. Return
99 Kezirian E, Goldberg A. “Hypopharyngeal Surgery in Obstructive Sleep Apnea: An Evidence Based Medicine Review.” Arch Otolaryngol head Neck Surg. 2006;132(2):206-213. Return
100 Demian N, Alford J, Takashima M. “An Alternative Technique for Genioglossus Muscle Advancement in Phase I Surgery in the Treatment of Obstructive Sleep Apnea.” Oral Maxillofac Surg. 2009;67(10):2315-2318. Return
101 Silverstein K, Costello B, Giannakpoulos H, et al. “Genioglossus Muscle Attachments: An Anatomic Analysis and the Implications for Genioglossus Advancement.” Oral Surg Oral Med Oal Pathol Oral Radiol Endod. 2000;90(6):686-688. Return
102 Baisch A, Maurer J, Hormann K. “The Effect of Hyoid Suspension in a Multilevel Surgery Concept for Obstructive Sleep Apnea.” Otolaryngol Head Neck Surg. 2006;134(5):856-861. Return
103 Riley R, Powell N, Guilleminault C. “Obstructive Sleep Apnea and the Hyoid: A revised Surgical Procedure.” Otolaryngol Head Neck Surg. 194;111(6):717-721. Return
104 Kezirian E, Goldberg A. “Hypopharyngeal Surgery in Obstructive Sleep Apnea: An Evidence Based Medicine Review.” Arch Otolaryngol head Neck Surg. 2006;132(2):206-213. Return
105 Bowden M, Kezirian E, Utley D, et al. “Outcomes of Hyoid Suspension for the Treatment of Obstructive Sleep Apnea.” Arch Otolaryngol Head Neck Surg. 2005;131(5):440-445. Return
106 Omur M, et al. “Tongue Base Suspension Combined with UPPP in Severe OSA Patients.” Otolaryngol Head Neck Surg. 2005;133(2):218-23. Return
107 Terris, D, Kunda, L. “Minimally Invasive Tongue Base Surgery for OSA.” J Laryngol Otol. 2002; Return
108 Vicente, et al. “Tongue Base Suspension in Conjunction with UPPP for Treatment of Severe Obstructive Sleep Apnea: Long-Term Follow-up Results.” Laryngoscope. 2006; 116:1223-1227. Return
109 Levin B, Becker G. “Uvulopalatopharyngoplasty for Snoring: Long-term Results.” Laryngoscope. 1994;104:1150-1152. Return
110 Janson C, Gislason T, Bengtsson H, Eriksson G, et al. “Long-term Follow-Up of Patients with Obstructive Sleep Apnea Treated with Uvulopalatopharyngoplasty.” Arch Otolaryngol Head Neck Surg. 1997;123:257-262. Return
111 Friedman M, Schalch P, Joseph N. “Palatal Stiffening After Failed Uvulopalatopharyngoplasty With the Pillar Implant System.” Laryngoscope. 2006;116:1956-1961. Return
112 O’Connor-Reina C, Garcia-Iriarte M, Casado-Morente J, Gomez-Angel D, et al. “Snoring surgery with palatal implants after failed uvulopalatopharyngoplasty.” Eur Arch Otorhinolaryngol. 2008;265:687-693 Return