Snoring during sleep is a common thing, many literary subjects often snore to depict a person sleeping sweetly, is this really the case? Modern medical knowledge tells us that snoring during sleep is a sign of narrow upper respiratory tract and poor breathing, often accompanied by sleep apnea in serious cases, which can cause serious health effects and even endanger life. Is this alarming? No, snoring during sleep is indeed a medical condition.
In the past 30 years, sleep apnea syndrome has gradually received great attention from the medical community at home and abroad, the so-called sleep apnea syndrome refers to the occurrence of apnea during sleep more than 5 times per hour on average. The common manifestations of this disease are severe snoring during sleep, apnea, morning headache and daytime drowsiness, and in severe cases, dozing off while driving, reading newspaper or going to the toilet. Patients may experience personality changes, decreased judgmental behavior and impotence. According to domestic and foreign medical studies, the prevalence of sleep apnea syndrome is about 2-10%, with a high prevalence in obese males and those with craniofacial anomalies, and the incidence increases with age.
Sleep apnea syndrome is a common and potentially fatal disease; hypoxia and hypercapnia caused by repeated apnea during sleep are the basis of pathophysiological changes in patients, which can lead to imbalance of body fluids and neural regulation, increased secretion of catecholamines, renin-angiotensin, microvascular constriction, endocrine dysfunction and hemodynamic changes, resulting in multi-system organ function damage. Long-term consequences are not good. It can cause or aggravate respiratory failure, and is a risk factor for cerebrovascular accidents, myocardial infarction, hypertension, etc. Sleep apnea can cause secondary lesions in the heart, brain, lungs, kidneys and other important organs, and the sudden death rate is significantly higher than other people, so timely prevention and early treatment are needed. Another study reported 246 untreated OSAS patients with a mortality rate of 10.8% for apnea index >20 and 2.1% for AI<20 at 8 years of follow-up. Timely and reasonable diagnosis and treatment are powerful measures to improve the quality of survival and prevent various complications.
The cause of sleep apnea is atrophy and obstruction of the upper airway during sleep, and the mechanism of its occurrence is complex, with the function of the central respiratory regulation, the tension of the upper airway muscles during sleep, and the morphology and position of the surrounding tongue, soft palate and jaws all playing a role. Sleep apnea can be divided into three types: obstructive, central and mixed, of which obstructive is the most common.
Obstructive sleep apnea is common in obese people. Obesity causes fat deposition around the upper airway, narrowing the upper airway and reducing the muscle tone of the upper airway during sleep, thus making it easy for breathing obstruction to occur; patients with obstructive sleep apnea mostly have craniofacial soft and hard tissue morphology abnormalities, such as nasal septal deviation, nasal polyps, soft palate hypertrophy, giant tongue, enlarged tonsils, tumors in the oropharynx, trauma or tumor surgery, jaw bone Defects, etc. The upper and lower jaws are the main support skeleton of the face and upper airway, and their morphology and position determine the shape of the bony upper airway space.
The purpose of diagnosis is to clarify the type and degree of sleep disorder, sleep quality and the location, degree and cause of upper airway stenosis in order to provide a reliable basis for treatment design. Before treatment, physicians must clarify the type and severity of the patient’s sleep breathing disorder and the site, cause and degree of upper airway stenosis or obstruction. Different types and degrees of sleep disordered breathing require different treatments; different causes, sites and degrees of upper airway stenosis or obstruction require different approaches to address them. Polysomnography (PSG), cephalometric lateral radiographs and nasopharyngeal fiberoptic endoscopy are the main tools to analyze and diagnose sleep apnea syndrome.
Polysomnography comes from the continuous monitoring of the patient’s nighttime sleep, which responds to the presence or absence of sleep apnea, the nature and degree of sleep apnea, sleep quality, and whether the patient sleeps with hypoxia, changes in heart rhythm and blood pressure. Polysomnography is currently the internationally accepted method for diagnosing sleep disordered breathing disorders.
Morphological analysis of the upper airway is mainly based on cephalometric lateral radiographs, nasopharyngeal fiberoptic endoscopy and CT, etc. The morphological examination and analysis can clarify the narrowing and obstruction of the upper airway, as well as whether it is accompanied by craniofacial soft and hard tissue deformities, and provide a basis for treatment.
Cephalometric analysis is a simple, reliable and economical diagnostic method, which can not only provide the actual situation of the upper airway and surrounding tissues, but also clarify the location and degree of craniofacial deformity of the patient. Cephalometric analysis is generally performed through computer-aided diagnostic systems with high efficiency and reliability. As long as the patient takes a lateral cephalometric film, the data required by the clinic can be obtained through computerized system analysis. And with the help of computer-assisted surgical simulation and prediction system, the surgery can be done on the computer before the surgery in order to obtain the best surgical plan, data and realistic pictures of the head and facial appearance after the surgery.
The purpose of nasopharyngeal fiberoptic endoscopy is to clarify the patient’s nasal cavity up to the patient’s hypopharyngeal cavity in the upper airway and is an intuitive, easy, economical and less painful method of examination. A test called Muller allows predicting the site of narrowing or even obstruction of the upper airway while the patient is sleeping.
Treatment for snoring and sleep apnea syndrome can be divided into two categories: surgical and non-surgical; the treatment varies according to the staging of the disease, the site of narrowing or obstruction of the upper airway, the degree and the cause.
The main non-surgical treatments that are internationally recognized as effective are upper airway positive pressure ventilation therapy (CPAP, Bi-CPAP, Auto-CPAP), functional oral appliances (dental braces) and bariatric therapy.
Upper airway positive pressure ventilation therapy is to bring a ventilation device to support the upper airway with positive pressure while the patient sleeps, to prevent the upper airway from collapsing, to keep breathing, to correct sleep hypoxia, and to improve sleep quality. It can not only eliminate the annoying snoring sound of patients, but also ensure that patients do not lack oxygen during sleep, thus ensuring good sleep quality and interrupting the development of systemic diseases such as hypertension, heart and kidney and brain hypoxia damage due to sleep hypoxia, so that patients can maintain a high quality of life; each type of home ventilator is portable, small in size and light in weight. The small size and light weight of the ventilator bring convenience to patients who travel frequently.
It is suitable for the treatment of most patients of all types, and is generally used for patients who cannot or do not want to receive surgical treatment and elderly patients who are not suitable for surgical treatment. Its advantages are: good effect, less pain, safety, disadvantages: must adhere to the night with the use, and need to be used for life, patients often feel trouble. And the current positive pressure ventilation machine (commonly known as ventilator) is expensive, generally the unit price of more than 4,000 to 30,000 yuan.
There are three types of positive pressure ventilators: single level, dual level and fully automatic. The so-called single level (CPAP) that is, the type of treatment can only provide a pressure set by the doctor, whether the patient in the exhalation or inspiration phase it provides the same level of pressure, if the patient needs to open the upper airway pressure is high, then the patient often feel more effort when exhaling, there will be a “stuffy” feeling. Therefore, it is generally used for patients with lower pressure requirements.
Bi-level positive pressure ventilation (Bi-CPAP) provides two different levels of pressure during the expiratory and inspiratory phases, so that patients who need higher pressure are more comfortable during exhalation. It is also more responsive than a fully automated positive pressure ventilator and is more in sync with the patient’s breathing. It is more expensive than CPAP, costing about 8,000 to 20,000 RMB per hour.
The advantage of Auto-CPAP is that it can automatically provide the pressure required by the patient, but its synchronization needs to be further improved. Some patients have the feeling that the breathing rate is not coordinated with the machine, and they always feel that the ventilation machine is half or one beat slower than the patient’s breathing. At the same time, the size of automatic positive pressure ventilators is generally large and not very convenient to carry. Its price is around 20-30 thousand RMB.
Positive pressure ventilation therapy is a safe, effective and less painful treatment. The most common side effects are: nasal congestion, upper airway dryness, nasal pain and sore throat, nosebleeds, etc. The patient’s compliance with this treatment plays a key role in the effectiveness of the treatment, and surveys show that more than half of the patients are not able to adhere to the band for a long time. The warming and humidification of the gas pumped into the patient’s upper airway during positive pressure ventilation therapy can greatly reduce the side effects of treatment. The treatment is used with caution in patients with pulmonary alveolar disease, which can cause pneumothorax in patients.
Weight loss treatment is an important part of obesity with sleep apnea and an important means of preventing postoperative recurrence. According to the report, China has become an obese country, and according to the data, the prevalence of obesity in Shanghai adults is more than 30%, and obesity is the most common cause of sleep apnea. It is difficult to lose weight and even more difficult to control the rebound. Obesity and related disorders are a serious challenge for human beings in the new century. Weight loss is mainly achieved by controlling intake, absorption and increasing consumption for therapeutic purposes. Diet control, exercise and medication are the common means, and even surgery can be performed for severe obesity.
Functional oral appliances prevent upper airway obstruction and collapse by preventing the tongue from dropping back or moving the mandible forward, and are more effective in patients with mild to moderate upper airway stenosis. Its advantages are: it is effective, small and convenient, and economical (cost of $600-800); disadvantages: it has some discomfort and cannot be used for patients with open mouth breathing, temporomandibular disorders, nasal congestion and missing or unstable teeth; discomfort with orthodontic appliances is the main reason why patients abandon treatment.
Surgery is an aggressive treatment for mixed patients with obstructive and significant peripheral soft and hard tissue deformities. The main goal is to enlarge the oropharyngeal cavity and reduce upper airway obstruction. Methods include soft palate and linguoplasty, hyoid suspension, jaw advancement, distraction osteogenesis and radiofrequency temperature-controlled volume reduction therapy.
Surgical treatment is indicated for patients with redundant soft tissue deformities (e.g., tonsillar hypertrophy, soft palate and tongue hypertrophy in obese patients) and hard tissue deformities (e.g., small mandibular deformities) resulting in narrowing, or obstruction of the upper airway. For patients with central or mixed sleep apnea with mainly central causes and obstructive sleep apnea due to neuromuscular dysfunction of the upper airway, surgical treatment is less effective.
The advantages of surgical treatment are: good and crisp results and simultaneous relief of both sleep disordered breathing and craniofacial deformities. The disadvantages are: there are certain risks, a certain degree of pain in the short term and possible complications. In obese patients it must be combined with bariatric treatment, and weight gain after surgery is one of the main causes of recurrence.
The morphology of the upper airway and surrounding tissues, the site and degree of upper airway obstruction during sleep are the main basis for the choice of surgical approach. Correct morphological analysis of the upper airway and surgical selection are the key to successful treatment, and the ideal treatment effect can be achieved with proper surgical selection.
Uvulopalatopharyngoplasty (UPPP, commonly known as uvulopalatopharyngoplasty) removes the patient’s overgrown, hypertrophied soft palate and enlarged tonsils to improve the narrowing of the oropharyngeal area. It should only be used for snoring patients and patients with sleep breathing disorders due to excessive soft tissue at the level of the soft palate. The success rate of indiscriminately performing UPPP on patients is only about 40%, and the long-term results are even worse. Improper indication of the procedure is the main reason for its failure. The main complications are bleeding, infection, and postoperative palatopharyngeal closure dysfunction (e.g., choking on food during feeding, excessive nasal sounds), and there have been deaths due to improper postoperative airway management both in China and abroad. Quantitative resection and strict control of surgical indications are key measures to improve the success rate of treatment and reduce complications. Currently, there is a misuse of this procedure in China.
Tonguloplasty is used in patients with upper airway narrowing or obstruction due to patient’s tongue hypertrophy. It is not accepted by patients because the procedure must be performed in conjunction with tracheotomy, which may cause postoperative tongue movement, sensory impairment and pulmonary infection as well as cause neck scarring. It is currently used sparingly, mostly in cases of tongue hypertrophy due to tumors, such as tongue hemangioma. Treatment of tongue hypertrophy due to obesity is now being replaced by radiofrequency temperature-controlled volume reduction therapy.
Hyoid suspension is performed by severing the subglottis muscle group and anterosuperiorly suspending the hyoid bone to achieve anterior displacement of the tongue root and enlargement of the hypopharyngeal cavity to relieve posterior tongue and hypopharyngeal stenosis or obstruction. Postoperative wound infection, bleeding, suspension fascial rejection, recurrence of fascial relaxation and mandibular midline fracture are its main complications.
Anterior maxillary transposition is mainly used in cases of recessional jaw deformity and micromaxillary deformity with sleep disordered breathing, to increase the volume of the intrinsic oropharyngeal cavity to relieve upper airway stenosis or obstruction and to correct craniofacial deformity. It is also the ultimate treatment for obesity with severe obstructive sleep apnea. The efficiency of bimaxillary advancement is more than 98%, but the operation is very traumatic and technically demanding, so it is only carried out in a few large hospitals.
Traction osteogenesis was applied to the treatment of craniofacial deformities in the mid-1990s. Its principle is to lengthen the jaws to correct the small caliber deformity of the upper airway and craniofacial deformities by cutting open the stunted or undersized jaws and pulling the cut bones daily to make new bones form in the osteotomy area. The advantages of the procedure are: it is less invasive and can achieve a significant osteogenic advancement of the jaw that cannot be achieved by traditional surgery, while avoiding the morphological and functional abnormalities of the donor area caused by bone grafting and the developmental disorders of the jaws of adolescent patients due to excessive surgical trauma. The procedure is particularly suitable for adolescent patients with craniomandibular deformity and sleep apnea. This treatment is currently performed in only a few units in China.
Radiofrequency/low-temperature plasma ablation treatment has been used to treat obstructive sleep apnea since the late 1990s. It uses radiofrequency needles to emit radiofrequency energy into the hypertrophic soft tissues, causing the soft tissues in contact with them to degenerate, necrotize, resorb and scarify to achieve the purpose of decongestion and atrophy of the soft tissues around the upper airway to enlarge the caliber of the upper airway. The treatment is less traumatic (less painful), less complications, good treatment effect for mild patients, and patients generally do not need to be hospitalized. It can relieve the narrowing and obstruction of the upper respiratory tract caused by enlarged turbinates, nasal polyps, enlarged tonsils, soft palate and tongue, and can be repeatedly treated. The disadvantages are: the effect appears only after 4-6 weeks after each treatment, multiple treatments are needed, and the RF head is disposable and expensive (2-3,000 per hand).