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

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 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