ENT aspects of sleep apnea syndrome


 * Snoring = rhonchopathy;
 * OSAS = obstructive sleep apnea syndrome;
 * SAS = sleep apnea syndrome.

Etiology and pathogenesis

 * Pharyngeal obstruction – partial (ronchopathy) x complete (OSAS).
 * The muscle tone is not enough to overcome the negative air pressure during inspiration and thus to maintain the lumen – the pharynx collapses; muscle tone decreases with age.

Other factors:


 * the size of the velopharyngeal space (soft palate, uvula, tonsils, adenoid vegetation, tumors);
 * the size of the retroglossal space (retroposition of the tongue, hypertrophy of the lingual tonsil);
 * obstruction of the nasal cavity and nasopharynx.

The most common site of obstruction – soft palate, retroglossal space. Turbulent airflow through a partially collapsed larynx → vibration → snoring. Complete collapse of pharyngeal musculature → apnoeic pause (tens of seconds to minutes !!) → awakening reaction → restoration of muscle tone → restoration of breathing (often explosive snoring).

Consequences
Ronchopathy – mainly bothers the surroundings; OSAS – effect especially on KVS:


 * CVD – hypertension, higher incidence of IM , CAD , arrhythmias, stroke.
 * Disruption of sleep architecture - impact on quality of life - deterioration of cognitive functions, depression, sexual dysfunction, daytime sleepiness.

Diagnostics

 * 1) Benign rhonchopathy – without apnoeic pauses, without hypoventilation and hypoxia, the quality of sleep is not impaired.
 * 2) Syndrome of increased HCD resistance - increased respiratory effort → increased intrathoracic pressure → awakening, without hypoventilation and hypoxia.
 * 3) OSAS – apnoeic pauses (duration min. 10 s; more than 10 per hour); it is necessary to differentiate the central SAS (without HCD obstruction).

Targeted anamnesis (if possible also from the partner); subjectively – insufficiently refreshing sleep, increased daytime sleepiness; habitus - often obesity; ENT examination – nasal patency, spaciousness of the velopharyngeal area and the area behind the root of the tongue, size of the mandible, position and size of the root of the tongue; possibly imaging methods – lateral X-ray cephalometry, CT, MR; examination in the sleep laboratory - all-night polysomnographic monitoring (distinguishing simple rhonchopathy from SAS and obstructive apnoeic pauses from central ones).



Therapy

 * 1) Conservative
 * 2) * Lifestyle – sleep hygiene (regularity, adequate length), do not consume alcohol in the evening, avoid hypnotics, do not sleep on your back, do not smoke, weight reduction for obese people.
 * 3) * CPAP (continuous positive airway pressure) – nasal positive pressure ventilation; the nasal mask - excess pressure in the HCD - prevents the collapse of the pharyngeal muscles.
 * 4) Surgery
 * 5) * Nose and nasopharynx – septoplasty, adenotomy.
 * 6) * Velopharyngeal space
 * 7) ** UPPP (uvulopalatopharynphoplasty) – resection of part of the soft palate, part of the palatal arches and the entire uvula, bilateral tonsillectomy.
 * 8) ** LAUP (laser assisted uvuloplasty) – laser uvuloplasty, outpatient procedure.
 * 9) * Radiofrequency ablation – insertion of needles into tissue → delivery of radiofrequency energy → thermal damage → coagulation necrosis → a scar that is smaller in volume than the original tissue.
 * 10) * Tongue retroposition, maxillomandibular shift, tracheostomy.


 * Simple rhonchopathy – LAUP, radiofrequency ablation.
 * Light to medium SAS – UPPP.
 * Severe SAS – CPAP, UPPP (if CPAP is not possible).

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