During sleep, a series of respiratory events may occur, including:
Snoring: This is the sound of deep breathing produced in the airway while sleeping, without episodes of apneas, hypopneas, or oxygen desaturation. It should not be associated with excessive daytime sleepiness.
Apnea: This is the absence or a reduction of airflow greater than 90% for at least 10 seconds. If accompanied by respiratory effort, it is called obstructive apnea. If there is no respiratory effort, it is referred to as central apnea.
Hypopnea: This is a reduction in airflow between 30% and 90% for at least 10 seconds, causing oxygen desaturation greater than 2–4%.
These and other events are identified through polysomnography (PSG), which is considered the gold standard for sleep studies. This test involves recording a range of neurophysiological and cardiorespiratory parameters during sleep. It helps distinguish physiological from pathological apneas, central from obstructive apneas, and determine their severity.
The Spanish Consensus Document on Sleep Apnea-Hypopnea Syndrome, published in 2005, defines OSAHS as a group of signs and symptoms resulting from repeated episodes of partial or complete obstruction of the airway due to pharyngeal soft tissue collapse during sleep. The main consequence of this airway collapse is oxygen deprivation during sleep, which over time leads to serious consequences for the patient.
Clinical Consequences of OSAHS
Sleep-related: excessive daytime sleepiness, morning headaches, increased risk of traffic accidents, depression, and irritability.
Cardiovascular: hypertension, arrhythmias, stroke, coronary artery disease, heart failure.
Pulmonary: pulmonary hypertension, cor pulmonale.
Other: sudden death.
Risk Factors for OSAHS
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- Overweight and obesity
- Anatomical factors: hypertrophic soft tissue in the airway (e.g., enlarged tonsils, adenoid hypertrophy), maxillary hypoplasia, retrognathia
- Advanced age
- Male sex: men are twice as likely to suffer from OSAHS as women
- Menopause
- Family history of OSAHS
- Use of sedatives
- Alcohol consumption
- Tobacco use
Treatment of Snoring and OSAHS
In our experience, when a patient consults us for snoring, it is essential to determine whether it is a case of simple snoring or if the patient suffers from OSAHS. To this end, before prescribing treatment, we perform a full medical history with anamnesis and physical examination. If necessary, a polysomnography will be requested and an individualized treatment plan will be proposed.
We usually begin by recommending lifestyle changes and both pharmacological and non-pharmacological measures. Only if symptoms persist despite these measures will we consider CPAP therapy, surgery, and/or alternative treatments such as mandibular advancement devices (MADs) — always depending on each individual case.
Simple Snorer
Medical Treatment:
- Weight loss
- Elimination of alcohol, tobacco, caffeine, and sedatives
- Changing sleep position
- Treatment of gastroesophageal reflux, sinusitis, nasal polyposis
- Nasal strips
- Mandibular advancement devices (MADs)
Surgical Treatment:
- Septoplasty
- Turbinoplasty (surgery of the nasal turbinates)
- Palatal implants
- Radiofrequency treatment of the soft palate
- Somnoplasty (ablation of soft tissue in the upper airway)
OSAHS
- Medical Treatment:
- Lifestyle changes: weight loss, reduce intake of alcohol, tobacco, caffeine, and sedatives
- Pharmacological treatment: nasal corticosteroids or decongestants, treatment of gastroesophageal reflux
CPAP (Continuous Positive Airway Pressure):
A mechanical device that delivers continuous positive pressure to the airways to keep them open and prevent collapse and apnea episodes. It is considered the first-line or gold-standard treatment for patients with mild to severe OSAHS, and multiple studies support its efficacy. Unfortunately, a high rate of treatment abandonment is also documented. The main drawback, despite its high effectiveness, is poor patient adaptation and tolerance, often due to sensations of claustrophobia, choking, dryness of mucous membranes, etc.Mandibular Advancement Devices (MADs):
These are first-line treatments equivalent to CPAP in patients with mild to moderate OSAHS and second-line in severe cases.Over the past decades, MADs have become an increasingly common alternative for treating snoring and OSAHS. They gently move the lower jaw forward, along with the tongue, tightening the pharyngeal muscles. The device is worn like a dental splint and helps keep the airway open during sleep, reducing or eliminating snoring and obstructive apnea episodes.
Before recommending a MAD, patients must be thoroughly evaluated during wakefulness and sometimes with drug-induced sleep endoscopy (DISE), performed by both ENT specialists and dentists. A temporary device may be used to simulate its effect and evaluate its potential efficacy.
Compared to CPAP, MADs are better tolerated by both patients and partners, used more nights and for longer periods. Therefore, they are a very good and well-accepted alternative that improves sleep quality, reduces daytime sleepiness, and enhances the quality of life for patients and their partners.
Although many MADs are available, they should be custom-made, adjustable, high-quality, and durable. Evaluation by a dentist specialized in dental sleep medicine is essential. A thorough dental, periodontal, muscular, and joint assessment is required to ensure the device will protect the patient’s teeth, gums, and joints in the long term.
They are generally well tolerated, though some short-term side effects may occur during the adaptation phase. Several visits are usually necessary to fine-tune the device for each patient until the optimal therapeutic position is achieved.
Surgical Treatment
Surgery is indicated in patients with poor quality of life, excessive daytime sleepiness, and those who cannot adapt to CPAP, if an anatomical point of airway collapse that is surgically correctable has been identified.
Types of surgery depend on the anatomical location of the collapse:
Nasal Surgery: Improves CPAP tolerance in OSAHS patients. Includes septoplasty (nasal septum surgery), turbinoplasty, polypectomy, reconstruction of nasal valve collapse, and functional rhinoplasty.
Pharyngeal Surgery: Includes adenoidectomy (removal of adenoids), tonsillectomy (removal of tonsils), pharyngoplasties, base of tongue reduction, genioglossus advancement, and hyoid suspension.
Laryngeal Surgery: Epiglottoplasty, tracheostomy.
Other Surgeries: Hypoglossal nerve stimulation, which increases pharyngeal muscle tone and improves inspiratory airflow.