---

Snoring

Description: The effects of loud snoring are numerous. Both the intensity and inherent irregularity of the snoring sound produce its annoying effects. A bedpartner's sleep disruption can be substantial, leading to sleep deprivation and serious tension at home. Often a major source of embarrassment for the sleeper, it can disrupt business and vacation travel. Its presence must also be recognized as an important clue to a potentially even more serious medical disorder, the interrupted breathing in sleep known as sleep apnea syndrome.

Reasonably consistent and disruptive snoring is extraordinarily common, with estimates that 1/3 of the male and 20% or more of the female population is affected. By age 60, around 60% of men and 40% of women do so. The intensity can be truly extraordinary: the world's record is nearly 90 decibels, louder than a pneumatic drill.Snoring is best seen as the sound produced by vibration of the soft tissues of the throat. These tissues relax far more than is normally seen in those who don't snore. The loudest is typically a deep guttural quality, not the usually softer nasal variety arising from nasal obstruction or congestion.

• Evaluation: Specific testing to characterize and quantify the snoring sound itself is usually unnecessary. However, a careful review of a person's sleep and medical histories is important to try and ensure this doesn't signal a more serious underlying condition. A third or more of those who consistently snore have obstructive sleep apnea. It is impossible for any physician to be able to really tell that a person's breathing is truly normal while they sleep. The measurement of breathing during sleep before anyone undergoes surgery of the throat or uses a dental device for what may seem to be simple snoring is absolutely essential, as these treatments may help or eliminate snoring but there ability to stop apnea in sleep is very unpredictable. You must know ahead of time what you really have, so that you don't become someone with undetected sleep apnea, a "silent apneic".
  
  
• Treatment: A wide range of treatments are available for snoring once it has been properly evaluated. These include weight reduction, sleep position therapy, decongestants, modification of alcohol intake, modification of medications being taken for other conditions, nasal patency devices, allergy therapy, dietary modification to eliminate foods affecting nose and throat function, nasal surgeries, palatal surgeries, special dental devices, specially designed pillows, and prescription medications. Surgical techniques include radiofrequency devices (Somnoplasty), laser (LAUP), and traditional palatoplasty (UPPP). Remember that snoring is not necessarily simple but there are rational and effective solutions when its properly evaluated.
  
  

Sleep Apnea: the dissruptive and threatening side of sleep.

• Description: Sleep Apnea Syndrome is a very serious medical disorder usually developing in long-term loud (though it doesn't have to be loud) snorers. It consists of repeated stopping breathing spells during sleep called apneas, the result of the excessive relaxation and then collapse of the muscles in the back of the mouth. Most are overweight but not necessarily obese, middle-aged and male, though women beginning during menopause are often affected. It is very common, estimates ranging up to 10 to 15% of men and up to half of that many women. It often produces progressive abnormal daytime sleepiness with irresistible sleep episodes, trouble staying awake to drive. High blood pressure, a major increased risk of heart and stroke, memory problems, mood changes, even sexual dysfunction may all develop. It is the one sleep disorder where there is a substantial risk of dying if it goes undetected.
  
  
• Evaluation: Accuracy of diagnosis is essential for such a serious disorder. This should begin with a discussion with your primary care provider where available and then with the sleep medicine specialist. This sleep disorder can only be properly evaluated by sleep testing, polysomnography. This is the only accurate way to confirm the suspicion someone has sleep apnea, measure how often apneas occur, their length, what happens to oxygen levels, how stressed the heart is, how disrupted sleep is, the effects of sleep position, etc. The results form the core basis for the selection of the best treatment. Polysomnography is also essential to initiation of one of the main treatments for sleep apnea, nasal continuous positive airway pressure. Polysomnography is also essential in order confirm that surgical or dental orthotic therapy has been satisfactorily effective; these treatments often eliminate snoring and may even make people sleep and feel much better yet leave the person with still serious but undetected apnea.
  
  
• Treatment: A wide selection of treatment options are available. They are often successful - if properly tailored to a particular person's sleep apnea as well as their special circumstances. Therapies to consider include weight reduction, sleep position therapy, decongestants, adjustment of alcohol intake, modification of medications being taken for other conditions, nasal patency devices, allergy therapy, dietary modification to eliminate foods affecting nose and throat function, nasal surgeries, palatal surgeries, special dental devices, specially designed pillows, and prescription medications. Surgical techniques include the radiofrequency device Somnoplasty, laser (LAUP), and traditional palatoplasty (UPPP). Even more complex surgical treatments may be appropriate in selected instances, including extensive jaw and facial bone modifications on the one hand, to the first treatment for the disorders, tracheotomy, on the other.

Fortunately, the latter is very rarely needed. The dominant treatment, however, is nasal continuous positive airway pressure (CPAP), or the closely related device nasal bilevel positive airway pressure. It consists of a small nasal mask and flow generator using room air at varying flow rates, the air used creating a cushion or kind of air splint which prevents the throat from collapsing as well as stopping snoring. This is almost always effective, non-invasive, and adjustable so that treatment can be modified should the disorder worsen. It is a well tolerated and accepted treatment used by tens of thousands nightly and is the treatment of choice for those with moderate or severe sleep apnea. One form of treatment or another is almost always effective. Remember that the first step in treating this disorder is a sleep medicine consultation followed by polysomnography.

Upper Airway Resistance Syndrome

• Description: This disorder is a relatively recently discovered category of sleep apnea syndrome. The main symptom is abnormal daytime sleepiness in people with chronic snoring who don't actually stop breathing in their sleep. Individuals with this were once mistakenly thought to have narcolepsy. This turns out to be a very common disorder that is often a precursor to fully developed sleep anea.
  
  
• Evaluation: 'UARS' develops because of a relaxation in the throat beyond that associated with simple snoring, making it harder to inhale, increasing the work of breathing and resulting in fragmented sleep with lots of arousals (of which the person is not aware). Polysomnography is essential in order to be certain actual apnea isn't present. The confirmation of the diagnosis used to depend on some invasive and unpleasant measures that have largely been replaced by assessing the response to a trial use of the non-invasive device nasal CPAP.
  
  
• Treatment: The full spectrum of treatments for sleep apnea may also be used for this disorder, though the more complex or invasive surgical procedures such as tracheotomy or extensive facial remodeling aren't recommended. Therapies to consider include weight reduction, sleep position therapy, decongestants, modification of alcohol intake, modification of medications being taken for other conditions, nasal patency devices, allergy therapy, dietary modification to eliminate foods affecting nose and throat function, nasal surgeries, palatal surgeries, special dental devices, specially designed pillows, and prescription medications. Surgical techniques include radiofrequency devices (somnoplasty), laser (LAUP), and traditional palatoplasty (UPPP).

Restless Legs Syndrome (RLS)

This disorder causes a very unpleasant, irresistible urge to move the legs. Restless legs syndrome causes tingling, pulling or other painful sensations in the legs at night, making it extremely difficult to fall asleep and stay asleep. Up to 10% of the U.S. population may have RLS. Many people have a mild form of the disorder, but RLS severely affects the lives of millions of individuals. In order for you to be officially diagnosed with RLS, you must meet the criteria described in the four bullets below.

• You have a strong urge to move your legs which you may not be able to resist. The need to move is often accompanied by uncomfortable sensations. Some words used to describe these sensations include: creeping, itching, pulling, creepy-crawly, tugging or gnawing.
  
  
• Your RLS symptoms start or become worse when you are resting. The longer you are resting, the greater the chance the symptoms will occur and the more severe they are likely to be.
  
  
• Your RLS symptoms get better when you move your legs. The relief can be complete or only partial but generally starts very soon after starting an activity. Relief persists as long as the motor activity continues.
  
  
• Your RLS symptoms are worse in the evening especially when you are lying down. Activities that bother you at night do not bother you during the day.

Behavioral Sleep Disorders

People with behavioral sleep disorders have little (if any) knowledge of these behaviors that occur while they are asleep. REM sleep behavior disorder, confusional arousals, nocturnal eating, sleepwalking, sleep terrors, nightmares and rhythmic movement disorder are just a few examples of behavioral sleep disorders that can be quite serious or even dangerous. Behavioral sleep disorders are often found in children as well as adults.

Narcolepsy

This neurological disorder affects the control of sleep and wakefulness, causing excessive daytime sleepiness and uncontrollable episodes of falling asleep during normal waking hours.

The word narcolepsy comes from two Greek words that can be roughly translated as seized by numbness. The two primary symptoms in narcolepsy reflect this phrase:

• Excessive daytime sleepiness, with frequent daily sleep attacks or a need to take several naps during the day.
  
  
• Temporary and sudden muscle weakness (called cataplexy), usually brought on by strong emotions.

Some, but not all patients experience other symptoms:

• "Microsleep" episodes, in which the patient behaves automatically but without conscious awareness.
  
• A sense of paralysis that occurs between wakefulness and sleep (called atonia).
  
• Dream-like states between waking and sleeping (called hypnagogic hallucinations).
  
• Periodic leg movements during sleep (periodic limb movement disorder). REM (rapid eye movement) sleep is abnormal in narcolepsy. In fact, narcolepsy is sometimes defined as the loss of boundaries between wakefulness, non-REM sleep, and REM sleep.

Primary symptoms of narcolepsy include:

Excessive Sleepiness. All people with narcolepsy experience excessive sleepiness during the day with episodes of falling asleep rapidly and inappropriately, even when fully involved in an activity. These events may be characterized by the following behaviors:

• Periods of drowsiness may occur every three or four hours and usually end in short naps.
  
  
• Individual may sleep for a few minutes, particularly if they are in an awkward position, or for a few hours if they are lying down.

Individuals often underestimate the duration of their drowsy periods and may not recall clearly their behavior during that time.

Cataplexy. This is a sudden loss of voluntary muscle control, usually triggered by emotions such as laughter, surprise, fear or anger. Cataplexy occurs more frequently during times of stress or fatigue.

The cataplectic attack may involve only a slight feeling of weakness and limp muscles (such as sagging facial muscles, a nodding head, buckling knees, loss of arm strength, garbled speech); but it also may result in immediate total body collapse, during which the person may appear unconscious, but remains awake and alert. These attacks may last from a few seconds up to thirty minutes.

Hypnagogic hallucinations. These are vivid, realistic, often frightening dreams.

Sleep paralysis or temporary inability to move. Either of these symptoms can occur during the process of going to sleep or waking up, while the brain is partially asleep and partially awake.