Snoring and obstructive sleep apnea occur when the muscles in the back of the throat relax during sleep, causing vibration that produces snoring sounds or complete or partial airway obstruction. Obstructive sleep apnea is defined by cessation of breathing lasting 10 seconds or more during sleep and is classified based on the respiratory disturbance index. Polysomnography is the gold standard test used to diagnose sleep apnea and involves monitoring various physiological parameters during sleep. Treatment options include lifestyle changes, oral appliances, continuous positive airway pressure therapy, and various surgical procedures to reduce tissue volumes or advance structures in the throat.

1. Snoring and Obstructive
sleep Apnea

2. Snoring
 It is an undesirable disturbing sound that occurs during sleep.

3. Terminology
 Sleep apnoea. It is cessation of breathing that lasts for 10 s or more during sleep.
Less than five such episodes is normal.
 Apnoea index. It is number of episodes of apnoea in 1 h.
 Hypopnoea. It is reduction of airflow. Some define it as drop of 50% of airflow
from the base line associated with an EEG defined arousal or 4% drop in oxygen
saturation.

4.  Respiratory disturbance index (RDI). Also called apnoea– hypopnoea index. It is
the number of apnoea and hypopnoea events per hour. Normally RDI is less than
five.
 Based on RDI, severity of apnoea has been classified
 Mild- 5–14;
 Moderate -15–29
 Severe ≥ 30

5.  Arousal. Transient awakening from sleep as a result of apnoea or respiratory
efforts.
 Arousal index. It is number of arousal events in 1 h. Less than four is normal.
 Sleep efficiency. Minutes of sleep divided by minutes in bed after lights are
turned off.

6. MECHANISM OF SNORING
 Muscles of pharynx are relaxed during sleep and cause partial obstruction.
Breathing against obstruction causes vibrations of soft palate, tonsillar pillars and
base of tongue producing sound

7. Etiology
 In children- Adenotonsilitis
 Adult- Nasal pathology/ Nasopharyngeal pathology/ Oral cavity/Orophageal
pathology or larygopharyngeal pathology.

8. Site of snoring
 Soft palate
 Tonsilar pillars
 Hypopharynx

9. Symptomatology
 Snoring spouse syndrome
 Excessive day time sleepiness
 Morning head ache
 General Fatigue
 Memory loss
 Irritability and depression
 Decreased libido
 Increase risk of road accidents

10. Assessment of Day time sleepiness

11. Treatment of Snoring
 1. Avoidance of alcohol, sedatives and hypnotics.
 2. Reduction of weight.
 3. Sleeping on the side rather than on the back.
 4. Removal of obstructing lesion in nose, nasopharynx, oral
cavity, hypopharynx and larynx. Radiofrequency has been
used for volumetric reduction of tissues of turbinates, soft
palate and base of tongue.
 5. Performing uvulopalatoplasty (UPP) surgically with cold
knife or assisted

12. Obstructive sleep Apnea

13.  Apnoea means no breathing at all. There is no movement of air at the level of nose
and mouth. It is of three types.
 Obstructive. There is collapse of the upper airway resulting in cessation of airflow.
Other factors may be obstructive conditions of nose, nasopharynx, oral cavity and
oropharynx, base of tongue or larynx.
 2. Central. Airways are patent but brain fails to signal the muscles to breathe.
 3. Mixed. It is combination of both types.

15. Work up for a case of OSA
Detailed clnical history – with Epworths sleepiness scale scoring.
Physical examination
 BMI
 Collar size- not more than 42cm in males and 37.5 in females
 complete Head and neck examination
 Mullers manoeuvre- using flexible nasal endoscope patient is asked to breath
forcibly in- collapse of soft palate is checked for during the inspiration

16.  Systemic examination
 Cephalometric examination
 Polysomnography.-GOLD STANDARD FOR OSA.

17. Polysomnography
 It is the “gold standard” for diagnosis of sleep apnoea and records
various parameters which include.
 EEG.
 ECG
 EOM
 EMG
 Pulse oximetry
 Nasal and oral airflow—for episodes of apnoea and hypopnoea.
 Sleep position—helps to know whether apnoea/hypopnoea episodes
occur in supine or lateral recumbent position.
 Blood pressure.
 Oesophageal pressure.

18. Treatment for OSA
 Change in lifestyle-
 Reduce the use of alcohol
 Smoking should be avoided
 Reduction of weight
 Positional Therapy
 Intraoral device
 CPAP- Continuous Positive airway pressure

19. Surgery for OSA
 Tonsillectomy and adenoidectomy
 Nasal surgery
 Palate surgery
Uvulopalatoplasty (UPP)
Uvulopalatopharyngoplasty (UPPP)
 Advancement pharyngoplasty
 Tongue base surgery: lingual tonsillectomy, laser midline glossectomy
 Tongue base radiofrequency reduction
 Mandibular osteotomy with genioglossus advancement