Many patients who snore also have obstructive sleep apnea (OSA). OSA is the most common sleep-related breathing disorder, and has a significant, negative impact on a patient’s quality of life, work efficiency, and driving safety. In 2016 and 2017, the National Transportation Safety Board reported that undiagnosed sleep apnea was involved in 2 train crashes. It has been reported that 26 percent of adults aged 30 to 70 years old have sleep apnea. Others have estimated that up to 80 percent of patients with moderate to severe sleep apnea are undiagnosed. This is particularly worrisome, as OSA appears to be related to the development of heart and vascular disease. Some studies have shown that up to 40% of patients with OSA have elevated blood pressure, and patients with OSA have up to a 2 to 3 times increased risk of heart attack and stroke. One meta-analysis which evaluated the results of 18 other studies found untreated sleep apnea to be “a significant contributor to motor vehicle crashes.” The authors concluded that “…individuals with OSA are clearly at increased risk for crash.” 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, and failure to thrive. Heart and lung problems (cor pulmonale, pulmonary hypertension) may also co-exist in children with sleep apnea.
It is for this reason that patients who snore should consider having a sleep study for diagnosis. Patients with OSA may have some of the following symptoms:
- Fatigue – Tired during the day, even after a night’s sleep
- Irregular snoring with gasps, snorting, and pauses in breathing
- Trouble concentrating; difficulty with memory
- Difficulty with sexual performance
- Bed-wetting (enuresis)
- Moodiness, irritability, depression
- Unexplained weight gain
Patients with snoring or sleep-disordered breathing should be carefully evaluated for the anatomical site most likely to contribute to their snoring. In many cases, snoring and obstruction is due to several features – deviated septum, enlarged turbinates, hypetrophied tonsils, long uvula and soft palate, small jaw (mandible). 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 shown below:
Use the following scale to choose the most appropriate number for each situation:
0 = would never doze or sleep.
1 = slight chance of dozing or sleeping
2 = moderate chance of dozing or sleeping
3 = high chance of dozing or sleeping
|Situation||Chance of Dozing or Sleeping|
|Sitting and reading||____|
|Sitting inactive in a public place||____|
|Being a passenger in a motor vehicle for an hour or more||____|
|Lying down in the afternoon||____|
|Sitting and talking to someone||____|
|Sitting quietly after lunch (no alcohol)||____|
|Stopped for a few minutes in traffic
|Total score (add the scores up)
(This is your Epworth score)
Some physician groups favor the STOP-BANG self-evaluation for patients to assess their own likelihood of having OSA. In this questionnaire, you are considered at high risk for sleep apnea if you answer “Yes” to 3 of these 8 questions below:
S: Do you snore loudly (loud enough to be heard through closed doors)?
T: Do you often feel tired, fatigued, or sleepy during the day?
O: Has anyone observed you not breathing during sleep?
P: Do you have or have you been treated for high blood pressure?
B: Is your Body Mass Index more than 35 kg/m2?
A: Is your age more than 50 years old?
N: Is your neck circumference greater than 40 cm?
G: Is your gender male?
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. While blood tests are not typically ordered for the evaluation of OSA, they may be suggested to investigate some of these related co-morbidities. A full list of medications should be reviewed, as some medications may exacerbate sleep disorders. It is often useful to speak to a patient’s bed-partner as patients can have a tendency to minimize their own symptoms and an observer can provide useful information which can contribute to the diagnostic evaluation.
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. In many cases a flexible fiberoptic trans-nasal pharyngo-laryngoscopy will be performed to further evaluate the oral airway. In cases where a patient already has a diagnosis of OSA, a drug-induced sleep endoscopy (DISE) may be performed to help pinpoint the anatomical source of obstruction. In a DISE procedure, progressive amounts of anesthesia are given to induce sleep so that obstruction may be observed. Once the site of obstruction is pinpointed, treatment is tailored to address this site. 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.
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 study. 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.
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.
Recent years have seen the introduction of home sleep studies [FIGURE 1] in which patients wear a monitor while they sleep in the comfort, and natural environment of own bed, instead of sterile sleep labs which are now less commonly utilized. There continues to be an increasing abundance of data in support of the efficacy, accuracy, and ease of use of these home sleep studies. In many doctor’s offices, patients can now schedule a “pickup” and “return” date to borrow a home-sleep study device for testing in their own bed.
There are cases when further data is required to accurately diagnose OSA and testing in a sleep lab may be recommended. In these situations patients will sleep in a monitored room where multiple measures are recorded including brain waves, eye movements, chin muscle activity, nasal and oral airflow, heart rate and rhythm, and leg movements. While these tests can be quite cumbersome, and are not necessary for many patients, they do provide valuable information that can assist in the diagnosis of a sleep disorder.
In summary, patients who snore or do not get “a good night’s sleep” on a regular basis, should consider the possibility that they have sleep apnea. Left undiagnosed and untreated, sleep apnea affects many organ systems and has significant negative impact on a patient’s health. Fortunately, treatments for OSA can be quite successful once a diagnosis has been made. Patients with a concern for OSA should seek medical evaluation.
Obstructive Sleep Apnea FAQs
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.
OSA is often due to obstruction along the airflow pathway. Common oral sites include the tongue base, soft palate, uvula, mandible (jaw), and tonsils. Nasal and nasopharyngeal sources such as the adenoids, septum, and inferior turbinates may also play a role. More inferiorly, the soft tissues of the neck may be predisposed to collapse and obstruction.
OSA is the most common sleep-related breathing disorder, and it is well-documented to have a serious impact on a patient’s quality of life, work efficiency, and driving safety. One meta-analysis which evaluated the results of 18 other studies found untreated sleep apnea to be “a significant contributor to motor vehicle crashes.” The authors concluded that “…individuals with OSA are clearly at increased risk for crash.”
What are some of the health issues related to sleep apnea?
Untreated OSA may lead to hypertension, coronary artery disease, memory impairment, stroke, adult onset diabetes, erectile dysfunction (men), as well as bed-wetting, behavior problems in children, obesity and deficits in attention.
What is a “sleep study” and what does it measure?
A sleep study should also be considered for patients who complain of snoring and who endorse signs of symptoms of OSA. While sleep studies measure many factors, some important measures include a patient’s oxygen saturation level, and the number of times per hour that a patient slows or stops breathing.
I have been told that I may not get enough oxygen when I sleep. What does this mean?
Sleep studies 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.
Treatment of Obstructive Sleep Apnea
Effective treatment of 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, dental/oral appliances, and positive pressure mask devices. 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, jaw surgery (mandibular advancement) and in recent years – Inspire therapy. Recent years have seen the rise of a variety of effective, minimally-invasive treatments for snoring and sleep apnea.
Weight gain and obesity are well-documented as contributing factors to OSA in many patients. One study found two-thirds of 1,000 OSA patients to be clinically obese (weight greater than 120% of ideal). 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 snoring. There exist a large number of studies which support the notion that signs and symptoms of OSA and snoring can be improved with weight loss. In some patients with significant obesity, surgical intervention (ie-bariatric surgery) may be utilized to help patients with OSA lose weight. 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. It is imperative that patients with OSA examine the status of their nutrition and fitness with an eye towards healthy, balanced interventions.
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 documented. Changing drinking habits and patterns, including decreased nocturnal alcohol consumption may have a positive impact on patients’ sleep disturbances.
Continuous Positive Airway Pressure (CPAP) and Oral appliances
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 opens the airway with forced air, and resists the collapse associated with OSA. Advancements in Positive Airway Pressure (PAP) technology have led to auto-titrating machines which 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.
Oral appliances – discussed elsewhere on this site – may be used to treat snoring as well as OSA. Oral appliances are carefully molded to an individual patient’s anatomy, and designed to keep the lower jaw in the forward position to help mitigate the backward compression of the tongue base on the oral airway. Patients should discuss their suitability for an oral appliance for OSA treatment with their dentist, oral surgeon, or otolaryngologist.
SELECT SURGERIES AND PROCEDURAL TREATMENTS FOR SLEEP APNEA
The Pillar Procedure (also discussed in the Snoring section of this site) is a minimally invasive, FDA-approved treatment for mild to moderate OSA. The Pillar Procedure – typically performed in the office setting – involves the placement of small implants into the soft palate to create stiffening and to minimize the soft tissue collapse associated with obstruction. The procedure is typically performed under local anesthesia and is well-tolerated by most patients with minimal post-procedure discomfort or down-time. Multiple studies support the Pillar Procedure as an effective treatment option for properly selected patients with OSA.
The tonsils are collections of lymphoid tissue located in the “tonsillar fossa” in the back of your oropharynx. This tissue can “hypertrophy” and lead to obstruction of the oral airway, thereby contributing to obstructive 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 and should be discussed with your surgeon.
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 or elongated 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 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 (ie-Pillar Procedure, tonsillectomy, etc).
Traditional surgery for sleep apnea revolved around the UPPP. In the UPPP, the uvula and tonsils are resected, along with part of the soft palate. The tonsillar walls (or “fossae”) are sewn together to help open the oral airway and to remove obstruction. The procedure has evolved with multiple modifications and offers varying success rates. Unfortunately, the procedure is often associated with significant post-operative pain and lengthy patient recovery times. Despite this; however, the procedure is quite effective for many patients and may be a good treatment choice for appropriately selected patients.
Before treatment I never realized how often I used to breathe through my mouth. Now my mouth is shut more often. I can sleep with my mouth shut. It looks better too. You rock, Dr. Becker.
Tongue Base Treatment
In some patients, an enlarged tongue base which relaxes during sleep may fall back in the oral airway (“hypopharynx”) and contribute to obstruction, 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. RFA of the tongue base can have mixed results and often requires multiple treatments over a period of weeks to months before noticeable improvement is appreciated.
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 rates. Typically, Genoglossus Advancement is performed in conjunction with other procedures, and not as a stand-alone surgery.
The hyoid bone is a 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. When this is the case, the hyoid bone 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 airway.
Inspire therapy involves placement of an FDA-cleared, implantable, neuro-stimulation device for patients with moderate to severe OSA who cannot tolerate CPAP. The device is implanted via 3 small incisions typically as an outpatient procedure, and delivers mild stimulation to key upper airway muscles to keep the airway open when patients sleep. The STAR trial – to evaluate the efficacy of Inspire therapy in 126 patients with OSA – has demonstrated over 75 percent reduction in apneic events per hour. Patients who undergo Inspire therapy typically undergo rigorous pre-procedure evaluation to make sure that they are good candidates for the procedure.
Patients with Obstructive Sleep Apnea have a variety of treatment options to help manage their OSA. Treatments range from weight loss and CPAP utilization, to office or outpatient procedures, and more involved surgeries with a hospital stay. Patients with a diagnosis of OSA are encouraged to consult with their Otolaryngologist or sleep physician so that they can become aware of the full range of options, and which might be most suitable for management of their sleep apnea.