Sleep Apnea :: Adults :: Alliance ENT

Sleep Apnea
Sleep apnea is more than just feeling tired during the day. You may be able to judge how well you are resting by answering the following questions: 0= would never doze 1= slight chance of dozing 2= moderate chance of dozing 3= high chance of dozing
Situation sitting and reading watching television sitting inactive in a public place (movie theater) as a passenger for an hour without a break lying down to rest in the afternoon sitting and talking to someone sitting quietly after lunch without alcohol in a car while stopped for a few minutes in traffic	Score ______ ______ ______ ______ ______ ______ ______ ______
Total Score	______
If you scored a 6 or greater, you may be suffering from sleep apnea. Please show these results to your physician. For a print version, click here ( pdf format)
Sleep apnea affects about one third of all snorers. It is a condition when the soft palate, tongue and walls of the throat block the airway so significantly that air cannot get to the lungs. It takes *one second* for the oxygen that reaches your lungs to permeate the entire body. Several important body organs have a high need for oxygen to be replenished quickly. Because of its high level of activity, the brain has the highest need of any of the body’s organs for oxygen. It takes only a few seconds of diminished oxygen supply before the brain begins to panic. It has to arouse itself from its deepest state of rest (REM sleep) to activate a stronger breath. Although someone does not consciously wake up during an apneic episode, it does disturb the brain’s rest. The body’s oxygen starvation also causes inflammation to blood vessels. Cause While awake your muscles maintain an open airway from your nose to your lungs. However, for obstructive sleep apnea (OSA) sufferers, when you lie down to sleep, your muscles relax and your tongue falls to the back of your mouth. With the throat blocked, normal breathing is impaired. An apnea is a cessation of breathing for 10 seconds or more. Any less severe interruption of breathing is a hypopnea. These can occur as frequently as 100 times an hour, resulting in fragmented sleep and life-threatening complications. There are several points of the airway that typically obstruct, but the back of the tongue is one of the most critical points of obstruction. Certain conditions, such as aging, depression, alcohol and some medications, will further relax the upper airway muscles and the apneas will worsen. Symptoms Adults: Tired and irritable High risk for motor vehicle accidents. Those with severe sleep apnea tend to fall asleep, even in the driver’s seat. Patients with sleep apnea are 7 times more likely to be involved in a car accident. These people are placing themselves, family, friends and other drivers at risk. They should not drive until this problem is improved. Affects the cardiovascular system by accelerating the narrowing of blood vessels. Sleep apnea raises the risk of high blood pressure, heart attack, stroke, irregular heartbeats and chest pain. Sleep apnea may be responsible for 30,000 cardiovascular deaths per year.The weakened blood supply also leads to impotence and dementia. Reduces work productivity and increases occupational injuries by reducing alertness and concentration…related to the “tired” brain. Children: May affect as many 5% of children, mostly boys from infancy to puberty, A child’s brain has even lower tolerance to the repeated interruptions to sleep. They tend to be cranky, ill-behaved and impulsive with mild learning disorders. They may be slow to develop, complain of headaches, be overweight and have poor social connections. They may be hyperactive and inattentive, often diagnosed with attention deficit/hyperactivity disorder (ADHD). How do I know if someone has sleep apnea? Loud snoring is the first hint, but that alone is not sleep apnea. Some people are overweight, but many have this problem because they have a large tongue, small chin or nasal blockage. A bedmate or parent should listen and look for: Snoring that contains snorting, choking and gasping sounds Listen for breathing that is not rhythmic – interrupted by brief pauses (hypopneas) Breathing that stops for 10 seconds– that is, long pauses and periods of silence (apneas) Restless body movements, particularly leg movements It is during this quiet period that the chest muscles are working to draw air into the lungs but the soft tissues of the upper airway are collapsed. These quiet periods are then followed by a noisy snorting or choking sound as the airway clears. Often the information that you can provide about sleep and daytime activity level provide strong evidence of a sleep disturbance. This is often adequate for the diagnosis of sleep apnea in children. Examination Patients with sleep apnea will be questioned about nasal breathing and examined to determine the areas where there is likely obstructions in the airway: the size and position of the jaw, the relative size of the tongue, palate, uvula and tonsils. A fiberoptic endoscope will be used to examine the nasal cavities (septum and turbinates), the back of the nose (adenoids), the collapsing of the walls of the throat, the size of the lingual tonsils and position of the tongue. Sleep Study In adults the next step is a sleep study. This test is painless and risk free, but does require that you spend an entire night in a private room in the sleep lab. Wires are taped to your head, face and chest. Your heart, lungs, brain, muscle movements, breathing, snoring and oxygen levels will be measured. On the day of the sleep study, stick to your normal routine. If you usually drink alcohol, take medication, eat or exercise before bed, ask someone at the Sleep Lab whether or not you should do so the night of the study. Bring your toothbrush, sleepwear, pillow, book or anything else that helps you sleep comfortably. For more information, see preparing for a sleep study. A sleep study performed at home may be more appealing to some, but gathers less information. There is a range in the severity of sleep apnea. While there is no perfect system for quantifying sleep disturbances, there are now years of experience in testing and treatment. Sleep lab technicians can help to judge whether or not you fell asleep long enough to evaluate your condition. There will be variations in your sleep from night to night and sometimes sleep studies need to be repeated. Nonetheless, this is a time-tested measure of airway obstruction. After your sleep study, the multiple sources of information (heart rate, blood pressure, oxygen level, EEG, snoring level and body movements) will be analyzed by a doctor board-certified in sleep disturbances. The final analysis will estimate the severity of your sleep apnea as mild, moderate or severe. Home Recordings For adults who cannot tolerate the process of a sleep lab and for select patients after treatment, there is the option of a sleep study that can performed at home. A home sleep study can be arranged through our office, but will not provide as much information as the traditional test performed in a sleep lab. It will also be necessary to confirm the degree to which your health insurance will pay towards a home sleep study. In children, an alternative to a sleep study is to record you child’s breathing on a tape recorder or video camera. You can share a minute or two of these recordings with your doctor to demonstrate the typical breathing pattern that you observe. Treatment All patients should be aware of steps that you can take to improve your condition. These steps include weight loss and reduced alcohol intake. *click here for our Handout titled "Good Habits to improve Sleeping"* Continuous Airway Pressure (CPAP)

	A CPAP machine has a mask, tube and pump. It uses air pressure to push the tongue forward. This opens the throat to air, and reduces snoring and apnea. You should put your CPAP mask on whenever you sleep or take a nap. • Drawing shows a full face mask.
	After you have been diagnosed with sleep apnea by a sleep study, you need to be fitted for a mask. There are several styles and many fitting options of masks. Some cover the mouth and nose; others cover only the nose (nasal “pillow”). With a mask in place, the sleep lab technician will measure how high an air pressure is needed to overcome your airway obstruction. The worse the sleep apnea, the higher the pressure. • A demonstration of CPAP using a nasal mask only.
	There continue to be improvements in the design of CPAP. Machines are becoming more portable, easier to clean, quieter, with better humidification so that water does not collect as much in the tubing and more gradual when raising and lowering the air pressures each night. Many people have small problems with CPAP, especially at first. Don't give up, even if you have some problems. Look for a support group in your area, so that you can talk with other people who also have sleep apnea. • This illustrates the delivery of pressured air through the nose only – “nasal pillows”
Here are some common problems you may have with CPAP, along with some possible solutions: The mask feels uncomfortable. Because everyone's face has a different shape, you may need to try different masks to find one that fits you well. Your nose feels dry and stuffy. You can try moisturizing your nose with a nasal saline Gel. (link) Some people prefer moist heated air. Your nose feels blocked up. Some people with sleep apnea also have nose problems. Some people who breathe through their mouths don't do as well with CPAP nose masks. A full-face mask that covers both the nose and the mouth may help these people. Ask your doctor if you have a nose problem that can be treated with a spray or surgery. The mask bothers your skin and nose. Because the mask must fit firmly over your nose and cheeks, it may irritate your skin. A different size or kind of mask may help. Some people benefit from using nasal pillows that fit into the nostrils and relieve pressure on the bridge of the nose. Using a regular CPAP mask one night and nasal pillows on the next night may help you feel more comfortable. The mask leaks air. Some people can't keep their jaw closed while wearing the mask. A chin strap can help hold up your jaw and keep the air in. You don't like the pressure. You may find that breathing out against the air pressure keeps you from sleeping deeply. Your doctor may ask you to use a bi-level machine that lowers the air pressure when you breathe out. The same mask may be used with CPAP and bi-level machines. You take the mask off during your sleep or don't wear it every night. Most people can't wear the mask all night long, every night, right from the start. Keep trying, even if you can only use the mask for an hour a night at first. Once you solve your comfort problems, you will be able to increase the time you wear the mask. Always try to wear the mask in the early morning hours, when sleep apnea is usually the worst. You just can't get used to the mask. Some people find that wearing a dental device that pushes their tongue forward helps. Or talk with your doctor about having throat or jaw surgery. How CPAP Changed My Life Easy; no more 1 to 4 hour naps after work, I get up in the morning easier, my family does not make me sleep in the basement any more (because of the snoring), no more "bad" dreams, my blood pressure is down, my energy is up and I have not fallen asleep while driving since getting the CPAP Oral appliance therapy A mandibular advancement device, or dental appliance, is similar to an orthodontic retainer or athletic mouth guard. It is worn in the mouth during sleep to prevent the tongue from falling back and obstructing the airway. Dentists with training in dental appliance therapy can make these specialized devices. A well-fitted dental appliance will effectively reduce or eliminate snoring and significantly relieve the symptoms of mild and moderate OSA. A dental appliance works in three ways: by bringing the lower jaw forward, by holding the tongue forward and by lifting a drooping soft palate. Dental appliances are relatively small and easy to wear and does not involve surgery. Shortcomings: not an option for people without teeth may not be a covered medical expense must be worn every night may cause pain in the area of the temporomandibular joint effective in controlling only mild to moderate sleep apnea effective in approximately 50% of people Local RI contact information: Stuart Ross, DMD, Martin Nager, DMD, Brenda Pierce, DDS 67 Jefferson Boulevard, Warwick, RI 02888 401-783-8464 Surgery As high as half of all people who try CPAP cannot tolerate the equipment for a variety of reasons. There are several surgical procedures that can be used alone or in combination to enlarge the opening at the back of the mouth and throat. Your doctor can use the results of a sleep study and examination to recommend the best combination of treatments. These surgeries represent an important alternative to CPAP.
	Palatoplasty as known as Uvulopalatopharyngoplasty (UPPP): This is a one-stage removal of the edge of the soft palate, uvula and tonsils (if present). It requires a general anesthetic and takes two weeks to heal completely. It reduces snoring in 90-95% of patients, but, as a single procedure, controls only a few select patients with sleep apnea. There is a small risk of a more nasal-sounding voice or fluids squirting into the back of the nose when drinking quickly.
click images to enlarge	Tongue Retention suture: Genioglossal procedure (www.Repose.com) This is a technique designed to address the problem of the tongue obstructing the airway. A permanent suture is placed through the back of the tongue and anchored to the jaw through a small incision below the chin. The permanent suture should not interfere with the movement of the tongue when eating or speaking, but it helps to prevent the tongue from falling back into the airway when lying on one’s back. This procedure will cause some bruising under the tongue and chin, about 3 weeks of pain, some temporary odd sensations when swallowing including a foreign body sensation, numbness or tingling and a change in taste and voice quality.The other surgical risks include bleeding, infection and inadequate teathering of the tongue. Unlike the alternative surgeries that involve osteotomies, the suture can be removed. The procedure has been approved by the FDA since 1997 and the doctors at Alliance ENT have been performing this procedure since 2005. One study of 30 patients with severe sleep apnea found a 73% cure rate when treated with a palatoplasty and tongue retention suture.
	Tongue reduction (Partial Glossectomy): The very back of the tongue can be partially removed to reduce its size. In some patients, this technique can be combined with others to be a highly effective solution.
	Lingual tonsillectomy: A supplemental procedure where redundant tissue at the back of the tongue can be cauterized and reduced in size. You cannot see your lingual tonsils.
	Mandibular (and maxillary) osteotomies: Another way to pull the tongue forward permanently is to cut the jaw bone and fix it in a more forward position. This often requires wiring of the teeth together while healing. This procedure is usually performed by an oral surgeon.
	Hyoid Suspension suture: Several sutures are placed in the throat through a small incision under the chin. This procedure should help to diminish the collapse of the soft tissues in the back of the throat when sleeping.
Tracheotomy: For some patients with severe obesity and life-threatening sleep apnea, a permanent opening through the neck into the airway is needed. click here for Palate Surgery Home Care info (patient area only)
"Let me tell you about my palatoplasty and tongue retention suture surgery. I have sleep apnea that has made me extremely tired. While sleeping, I would stop breathing, then gasp for air. I tried the “CPAP” unit, but I could not get used to it & still had interrupted sleep. The surgery was more involved than I realized, but the result for me was much improved sleep & a more rested feeling. Healing after surgery was slow but gradual and worth it. I now sleep better & am more rested." -Richard J. Cotta
“UPPP (palatoplasty) testimonial: The treatment I received from Dr. Godley was better than I expected. I had heard only horror stories from many people about the pain after this procedure. I felt okay within 4 to 6 days. I used very little pain medicine. I returned to work without any problems at all.” - Marguerita Cote
“I had my tonsils, uvula, adenoids, parts of my soft palate and my turbinates fixed. The surgery was quick and relatively painless. I woke up from the surgery and had a minor sore throat. Never used any pain medication. I breathe better during the day and sleep better at night. No more snoring or gagging. It was 1-2 weeks to fully recover. The biggest problem was swallowing food. It was a successful surgery and I fully trust this office for any future experiences.” - Michael Aceto
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Sleep Apnea

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