Notes

The only successful way to roll a snorer off their back is to affix a hard object to the back of their night shirt so when they roll on their back it is uncomfortable and they roll to their side. We recommend the Ben Snore Ball. The easiest is a folded sock attached with a clothes pin. More sophisticated is a sewn pocket filled with a golf whiffle ball or other similar hard sphere.

The diagnosis of Sleep Disordered Breathing (SDB), typically Obstructive Sleep Apnea (OSA), is frequently missed. Many have SDB and are unaware that this is not the way everyone sleeps and feels. Classic symptoms are daytime sleepiness, falling asleep during the day, sitting, driving or watching T.V. Other symptoms include snoring and morning headache. Poor job performance and failing personal relationships are common sequelae, but in and of themselves not indicators of OSA. If in doubt, rule it out. Today's home overnight sleep tests are increastingly accurate.

The multichannel home sleep study measures airflow, oxygen in the blood, body position, and respiratory effort. This is ideal for diagnosing obstructive sleep apnea.

UP3 is a uvulopalatopharyngoplasty. This resects the tonsils and uvula and trims the soft palate.

UP1 is a uvulopalatoplasty. This is an office procedure and is not covered by most medical insurance. This surgery can be performed with laser or cautery. The laser procedure received the greatest publicity and is termed a LAUP (laser assisted uvulopalatoplasty).

CPAP is continuous positive airway pressure administered by a Nasal Mask delivered by a miniture respirator. Properly administered CPAP manages the majority of sleep apnea patients. In all patients with OSA, it is the first line treatment.

CPAP is not for everyone. Some cannot tolerate the mask, others cannot tolerate the air blowing in their nose and others find it unesthetic. Surgery is indicated when CPAP is not tolerated. UP3 has a 50% success rate. In some cases base of tongue advancement or reduction is required. Those who fail will require maxillomandibular advancement, expensive, but effective.

Overview of Sleep Disordered Breathing

Snoring is the premier symptom of obstructive sleep apnea and is a major social nuisance. The first thing to do with any snorer is to roll them off their back, for the obstruction and snoring of an individual sleeping supine may come from a retro-displaced tongue. This is easily corrected by sleeping on the side or in a prone position. Having a mate kick you is not a healthy way to learn to sleep on your side. The only technique I know is the Davidson bio-feedback system. You place a small hard object in your night shirt propitiously placed between the scapulae such that whenever one rolls on one's back, one is sufficiently uncomfortable, that one immediately turns to one's side or stomach. While most will grumble for a night or two, the majority learn to sleep on their side or stomach.

If the snoring persists, the next line of questioning focuses on sleep apnea.

Is the patient sleepy during the day? Does the patient wakeup with frontal headaches? Does the patient fall asleep during the day? Does the patient fall asleep driving? Does the patient fall asleep watching TV when he/she would prefer not to, sitting and reading, as a passenger in a car, sitting and talking to someone, or even sitting quietly after lunch? If so, these are signs of sleep deprivation and require explanation.

One can also administer the Epworth Sleepiness Test as follows:

If the answers point to sleep apnea, a workup is required.

A multichannel home study is today's best sleep evaluation. Sp02 and respiration are monitored. This reliably diagnoses normals and patients with OSA. Inconclusive results point to other diagnoses and generally require a sleep medicine evaluation and often a more complex sleep evaluation.

For those with sleep apnea the correct treatment is a CPAP. For those who fail CPAP surgery is recommended.

If the patient does not have symptoms of sleep apnea, or if the symptoms are equivocal and the studies are negative, then the patient has a snoring disorder. For those who cannot travel with companions and cannot cohabitate a bedroom with their spouse -- this is a major complaint.

The standard recommended surgery is a uvulopalatoplasty, an operation in which the uvula is resected and the central soft palate shortened. The success rate in selected patients is 90%.

If the patient has large tonsils and particularly if they are young and likely to accumulate weight with age, this is an individual who is going to develop sleep apnea and the correct operation for this individual is a uvulopalatopharyngoplasty. This is an operation that resects the tonsils, resects the uvula, shortens the soft palate and tightens the lateral pharyngeal walls. It requires a general anesthetic. It incurs the risks of tonsillectomy and it is sufficiently uncomfortable that most adults will miss a week of work, Nonetheless, it is a better operation and the patient should be encouraged to pursue this. The financial implications will have to be addressed locally.