Snoring and Sleep Disorders

Far from being solely an annoyance to the non-snoring partner, snoring may be indicative of a far more serious problem: sleep apnea or sleep hypopnea. That is, either a complete cessation of breathing or inadequate breathing during sleep, frequently due to obstruction of the airway by the back of the tongue or the soft palate, resulting in an inadequate Oxygen supply to the body. Since they must expend greater effort to force air past this obstructed airway, patients with such conditions are prone to several serious and potentially life-threatening conditions such as hypertension, or congestive heart failure. Therefore, it is vitally important to determine the nature and extent of a patient's sleeping problem; and whether it is merely snoring or a more serious underlying condition.

These diagrams above, illustrate a normal airway with patient upright, the airway in a patient in a supine position with a normal airway, and a patient with an obstructed airway.

The gold standard for accurately and comprehensively determining the full extent of a sleep disorder is a PSG or POLYSOMNOGRAM in which the patient is monitored on as many as 14 different channels, recording heart and respiratory rate, blood pressure, respiratory muscle activity, blood Oxygen level, and several other parameters in an overnight study at a sleep laboratory. Such a study can determine whether the sleep disorder is obstructive (that is, due to the tongue or other structures blocking the airway) or central (caused by factors within the central nervous system)

A frequently employed screening technique in our office, used to determine whether indeed a patient is receiving sufficient oxygen is a PULSE OXIMETER, which measures tissue oxygenation by means of a sensor fastened to one of the patient's fingers. The instrument is taken home by the patient, turned on overnight, and returned to the office for analysis. Should the overnight study indicate inadequate Oxygen levels during sleep, a polysomnogram is usually indicated.

Another diagnostic tool almost routinely used in our office is the PHARYNGOMETER, an instrument which, using a form of "sonar" can determine both the location and degree of obstruction of the patient's airway and, by giving airway readings at various jaw positions, can help to predict whether or not a mandibular advancement sleep appliance will be effective.

   
This photograph shows a patient being tested with the pharyngometer, while the computer screen shows the increase in airway (blue tracing) with the bite opened and the mandible protruded compared to the original airway volume (green tracing).

   
The MRI films above indicate a closed airway on the left (see arrow) and the same airway with the patient wearing a mandibular advancement appliance. Note the increase in airway.

Also used is the RHINOMETER, employing a principal similar to the pharyngometer, to determine any obstruction in the nasal airway. Should any obstruction exist; patients are usually referred to an ENT physician.

   
The above photograph shows the rhinometer in use, while the computer screen indicates airway volume at different areas in the nasal cavity.

If the above studies indicate that a mandibular advancement appliance would be of benefit, a permanent appliance, is then fabricated. This consists of upper and lower " splints", connected together, which can be adjusted both front-to-back as well as expanded vertically, to provide the maximum airway. Once in use, this appliance can be further modified, to accommodate changes in the patient's musculature, sleep posture, etc.

   
The photograph above shows the appliance most frequently used in our office. It is called an EMA - or Elastomeric Mandibular Advancement appliance. This particular appliance is most frequently used for patients exhibiting nocturnal bruxism, since the elastic connectors allow considerable side to side movement during sleep. Also, since connectors of variable length and elasticity can be used, the degree of mandibular protrusion can be adjusted and controlled. Since it is frequently necessary to adjust the vertical dimension of the appliance as well as the anteroposterior position, this appliance can also be easily adjusted to the proper vertical position.

In addition to the EMA appliance, there are several other designs employed in our office, depending on the unique requirements of each patient.