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Robert A. Gadlage MD FACS and Associates, PC

 
    Patient Information   

          Featured Topic: Sleep Disorders, Sleep Apnea, and Snoring

     SLEEP DISORDERS, SLEEP APNEA AND SNORING
There exists a great deal of interest in sleep disorders in today's world because it seems that we are more aware of the associated problems associated with sleep deprivation.  For many years everyone knew of a family member who was always falling asleep and snoring, napping during family gatherings, or was usually overweight and was the subject of ridicule.  We are much more aware that this entity of sleepiness and snoring has much deeper implications.

 There is data to support that over the past century in the USA, sleep time has declined approximately 20% according to a 1910 survey which found that Americans slept an average of 9 hours per night, now down to nearly 7 hours per night (2002 Sleep in America Poll).  This may vary among individuals, it was always thought that most adults needed 8 hours of sleep per night, teens need a bit more, but Bill Clinton during his Presidency admitted to sleeping only 5-6 hours per night.

Much of this can be attributable to our society changes, 24 hour TV, altered work shifts, and access to the Internet at any time.  But there are noted problems associated with certain individuals who are sleep deprived:

  • The most highly publicized being the cause of the Exxon Valdez disaster which was based upon the falling asleep of the captain (also thought to have some alcohol contribution), but which ended up with a total price tag of $2.5+ Billion cost to Exxon in settlement for damages.
  • The D.O.T. estimates that 100,000 auto accidents are the direct result of driver sleepiness resulting in 1,500 fatalities and 71,000 injuries per year. One sixth of all crashes (approximately 1,000,000 per year) related to driver inattention, fatigue being the most common cause of inattention.
  • They estimate that 20% of all drivers have fallen asleep at least once, 17% admit to having fallen asleep in the past year. Teens are at very high risk for sleep related auto accidents (in 55% of accidents, the teen driver admitted to having fallen asleep).
  • American and Canadian long haul truck drivers get fewer than 5 hours sleep per night.
  • $12.5 billion in diminished productivity and property loss.

Driving sleepy is now considered a crime in New Jersey (Maggie's Law) since a 20 year old woman, Maggie McDonnell, was killed in a head on collision in 1997 by a man who caused the accident telling the police that he had not slept in 30 hours. Unfortunately he was acquitted of vehicular homicide and he was only fined $200 for reckless driving.  Outraged, a NJ Assemblyman introduced a bill that was introduced and signed into law in 2003 that it is now possible to charge a motorist with vehicular homicide with up to 10 years in prison and $100,000 fine if his falling asleep kills another driver.  A similar sentiment exists in Great Britain as well where a man who fell asleep while driving caused a passenger train to derail and resulted in the death of 10 passengers.  He was sentenced to 5 years in jail.
     SLEEP DISORDERS, SLEEP APNEA, AND SNORING
There seems to be a great deal of interest in sleep disorders in today's world because it seems that we are more aware of the associated problems associated with sleep deprivation. For many years, everyone knew of some family member who was always falling asleep and snoring, napping during family gatherings, was usually overweight and was the subject of ridicule. We are much more aware that this entity of sleepiness and snoring has much deeper implications.

There is data to support that over the past century in the USA, sleep time has declined approximately 20% according to a 1910 survey which found that Americans slept an average of 9 hours per night, now down to nearly 7 hours per night (2002 Sleep in America Poll). This may vary among individuals, it was always thought that most adults needed 8 hours of sleep per night, teens need a bit more, but Bill Clinton during his Presidency admitted to sleeping only 5-6 hours per night.

Much of this can be attributable to our society changes, 24 hour TV, altered work shifts, access to internet at any time. But there are noted problems associated with certain individuals who are sleep deprived:

The most highly publicized being the cause of the Exxon Valdez disaster which was based upon the falling asleep of the captain (also thought to have some alcohol contribution) but which ended up with a total price tag of $2.5+ Billion cost to Exxon in settlement for damages.

The D.O.T. estimates that 100,000 auto accidents are the direct result of driver sleepiness resulting in 1,500 fatalities and 71,000 injuries per year. One sixth of all crashes (approximately 1,000,000 per year) related to driver inattention, fatigue being the most common cause of inattention.

They estimate that 20% of all drivers have fallen asleep at least once, 17% admit to having fallen asleep in the past year. Teens are at very high risk for sleep related auto accidents (In 55% of accidents, the teen driver admitted to having fallen
asleep).

American and Canadian long haul truck drivers get fewer than 5 hours sleep per night.

$12.5 billion in diminished productivity and property loss.

Driving sleepy is now considered a crime in New Jersey (Maggie's Law) since a 20 year old woman, Maggie McDonnell, was killed in a head on collision in 1997 by a man who caused the accident telling the police that he had not slept in 30 hours. Unfortunately he was acquitted of vehicular homicide and he was only fined $200 for reckless driving. Outraged, a NJ Assemblyman introduced a bill that was introduced and signed into law in 2003 that it is now possible to charge a motorist with vehicular homicide with up to 10 years in prison and $100,000 fine if his falling asleep kills another driver. A similar sentiment exists in Great Britain as well where a man who fell asleep while driving causing a passenger train to derail and resulted in the death of 10 passengers, was sentenced to 5 years in jail.

     TYPES OF SLEEP DISORDERS:
The top 5 most common sleep disorders include:
 
  1. Insomnia (trouble falling and staying asleep), effects 49% of adults, associated with GERD, Pulmonary disease, chronic pain, major depression, menopause, hyperthyroidism, anxiety, substance abuse, medications. However, 15-20%, have no underlying cause (primary insomnia) but is associated with impaired quality of life.  These patients are actually LESS sleepy during the day.  Treatment with medications, often helps in depression control.
     
  2. Narcolepsy (excessive daytime somnolence and sleep attacks) peak incidence ages 15-20, seen in 5 per 10,000 people in USA, cataplexy or sudden loss of tone in voluntary muscles, sleep paralysis and fearful visual (hypnogogic) hallucinations during sleep.
     
  3. Restless leg syndrome (RLS) which may be movement or vague disagreeable feelings like creeping, crawling, tingling, burning or itching sensations which cause an intense urge to move the limbs to relieve these feelings. 
     
  4. Periodic limb movement syndrome (PLMS) periodically recurrent repetitive limb movements as flexion of the ankles or knees or hips every 20-40 seconds during Non REM sleep.
     
  5. Sleep Apnea (Obstructive Sleep Apnea Syndrome or OSA) literally, "temporary cessation (at least 10 seconds) or absence of breathing during sleep," the most common sleep disorder in the USA (20 Million Americans) effecting 4% of men and 2% of women between the ages of 30-60.  It causes significant medical disorders, even death and remains underdiagnosed because of inadequate awareness.  The most common form of this is Obstructive Sleep Apnea caused by blockage to the passage of air anywhere between the nose and vocal cords, from nasal obstruction, allergies, nasal and sinus polyps and diseases, enlarged adenoids and tonsils, collapse of uvula and soft palate, enlargement or backward position of the tongue and tissues below and to the side of the tongue, recessive mandible and chin.

OSA is often associated with obesity, seen in 70% of patients with OSA.
A SIMPLE RULE OF THUMB IS THAT 90% OF THE POPULATION WITH A SIZE 16 INCH NECK OR LARGER HAVE OBSTRUCTIVE SLEEP APNEA.   It is commonly seen in the male gender 40 years of age or older. Race may be a factor, higher prevalence in Pacific Islanders, Mexican Americans, and African Americans.  Higher incidence associated with alcohol, smoking, and drug use.  It is also seen with endocrine abnormalities or thyroid problems, post menopausal females, and recently associated with Alzheimer's disease.

The long term consequences of OSA include high blood pressure(40%), myocardial infarction and stroke, headache, anxiety, depression and mood disorders, and diminished attention span.

Sleep Apnea is not a new disease, it has been referred to in literature by Charles Dickens in The Pickwick Papers in 1836, describing quite accurately a character named "Joe" (a fat boy with some difficulty to rouse from his lethargy...leaden eyes...mountainous cheeks...leered horribly on the food.  The fat and red faced boy in a state of somnolency rolled slowly off the box).  The Giant from Jack and the Beanstalk also fits this description.

     THE SYMPTOMS:
Patients usually complain of loud, habitual snoring, apnea episodes witnessed by spouse, and excessive daytime sleepiness.  I have found that the patient is usually accompanied by their spouse many times since the patient is not aware most of the time of the severity of the snoring or the interruption of the breathing that can be not only disturbing to the spouse, but also frightening and more often than not, is the cause of the couple not being able to sleep in the same bedroom.

     THE OFFICE EXAMINATION:
The Physician Sleep Specialist will present the patient with a brief test called the EPWORTH SLEEPINESS SCALE to determine how the patient feels about their likelihood of falling asleep in certain situations.  These findings will often be discussed with the patient to clarify the effect that it is having on the patient, not only physically but also emotionally and socially, since this can have a significant effect on the patient's job. 

A complete history and physical examination is performed and concentrates on the possible physical causes of the obstruction.

A thorough examination of the facial structure, dental and jaw alignment, and neck will be performed. 

A very thorough evaluation of the nose, it's shape and function (which may be effected by previous trauma or lack of support of the nostrils), the inside of the nose looking for obstruction of the septum or turbinates (swollen tissue just inside the nostrils that swell with allergies and infections), as well as polyps, cysts, or enlarged adenoids may be found on nasal examination or fiberoptic scope examination.

Examination of the mouth structures including the tonsils, soft palate, uvula, and base of the tongue is also performed directly and also by the usage of the flexible fiberoptic scope.

     THE DIAGNOSIS:
If the Sleep Apnea Symptoms have occurred only recently, a trial of medications may be attempted for a period and follow up examination may be helpful then in trying longterm medical treatment of sinus or allergy problems.  Usually however, in the chronic and longterm cases of OSA, further testing is usually scheduled which will include a SLEEP STUDY (Polysomnogram or PSG) and often a CT Scan of the sinuses to better identify areas of obstruction which may be contributing factors. 

Sleep Studies are usually performed in Sleep Labs and measure heart rate and rhythm, brain waves, muscle tone to the chin, eye movement, nasal pressure, snoring, respiratory effort at the chest and abdomen levels, oxygen saturation of the blood stream, body position, and leg movements.  This test will then be reviewed with the Physician Sleep Specialist to then determine the presence and if so, the severity and treatment options.

     THE TREATMENT:
The usual first order treatment option would be a CPAP sleep study then trial.  This would require a second sleep study where a mask would be applied to the nose and mouth, and a compressor provides a stream of air through the mask that will expand the airway during inspiration to support the structures and keep the tissues from collapsing and obstructing the airway.  Sometimes, pressure is even kept up during expiration so that there won't be collapse of the tissues (this is a BIPAP therapy) and the necessary pressures are titrated then maintained during sleep to a level to eliminate snoring and all respiratory events.  The CPAP or BIPAP mask and unit are then prescribed and a trial from 1 to 6 months is usually suggested to see how the patient will be able to comply with the usage for life.  After an appropriate trial, the patient revisits the Physician Sleep Specialist and discusses whether long term treatment with CPAP mask is likely to be successful (less than 47% long term compliance is longer than one year nationwide).  If the long term CPAP is not an option, then the Physician will discuss other medical or site directed surgical options.

Non-Surgical treatment options include the use of Oral Appliances which offer significant improvement when fashioned by experienced providers (www.dentalsleepmed.org) for selective patients.  The best candidates are younger in age, lower weight, smaller neck size, positional OSA, and are in good dental health. 

Surgical Treatment options are usually evaluated in three areas:

  • The Nose, internal nasal structures, and nasopharynx (adenoid area)
  • The Oropharynx which includes the Tonsils, Soft palate, and Uvula
  • The Base of the Tongue and Hypopharynx (area between the back of tongue and the vocal cords). 

As many as 75% of Americans say they had at least one symptom of a sleep problem a few nights a week over the past year.  Most people seek advice and treatment for their sleep problems because they are not getting the quality OR quantity of sleep. When talking to your Physician or Sleep Specialist, the patient will be asked questions to help determine how to best define and treat the specific disorder, which may range from anywhere between prescribing medications for the sleep disorder (insomnia), referral to a psychologist, or pursuing further testing.

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