Snoring and obstructive sleep apnea syndrome are common issues.
Snoring occurs when the flow of air through a narrowed upper airway causes the surrounding tissues to vibrate, creating noises of varying pitch and volume. In the case of simple snoring, which is noisy breathing during sleep without airway obstruction, multiple factors can potentially be at work in creating the noise. These include overall body mass/obesity, enlargement of the tonsils and adenoid, the presence of nasal congestion from rhinitis and/or septal deviation, and the prominence or bulkiness of the back of the tongue relative to the amount of space available for this structure. Treatment is usually medical, and may include medications for nasal issues or an appliance that is worn at night to pull the jaw and tongue forward during sleep. Surgery in the form of tonsillectomy and/or adenoidectomy or nasal surgery may also be helpful in well-selected patients.
Obstructive sleep apnea syndrome (OSAS) exists when the upper airway becomes narrowed to the point of obstruction (apnea) during sleep. While adult patients with OSAS are generally obese, this is not always the case. Other anatomic variables and/or neuromuscular issues can also be involved. Symptoms and signs of OSAS include loud snoring, daytime sleepiness, frequent headaches (generally in the AM), and witnessed nocturnal gasping and transient obstructions. Evaluation for OSAS includes a detailed history and physical examination, including a trans-nasal endoscopic examination to assess the anatomic features and functional tendencies of the individual patient’s upper airway.When OSAS is suspected, patients are referred for an overnight sleep study. Aside from weight loss to an appropriate body mass, the “Gold Standard” treatment for OSAS of moderate severity or worse is continuous positive airway pressure (CPAP) therapy, in which a machine is used nightly to apply air under pressure to the upper airway, effectively holding it open and thereby preventing obstruction. The air pressure is generally applied via a mask that is worn over the nose or nose and mouth. Other treatments include oral appliance therapy, which works by pulling the jaw and tongue forward to allow improved airflow. Surgery by itself is generally most successful as a curative measure for patients with relatively mild OSAS, and may include removal of the tonsils with or without the adenoid, and surgery to shorten the soft palate and widen the oral pharynx. Nasal surgery may also be recommended to serve as an adjunct to these procedures or to lower the upper airway’s resistance to airflow, allowing CPAP to be applied at a lower and more tolerable pressure. This can sometimes be the difference between success and failure in the treatment of a patient with severe OSAS. In pediatric patients with OSAS, symptoms can include loud snoring with or without witnessed gasping or obstructions, but patients may first present with the new onset of parasomnias such as bedwetting, night terrors or sleepwalking. In contrast to adults with OSAS, pediatric OSAS is generally due to obstruction by severely enlarged tonsils and adenoid tissue. In the absence of obesity and neuromuscular issues, removal of the tonsils and adenoid is generally curative.
