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Sleep disorders 41 Insomnia

Cortese et al. (2006) found and AHI 1 hour greater than controls in children with ADHD. Race plays also an important role in the association between ADHD and OSAS. Hispanic children show a greater co-morbidity than Caucasian probands as far as learning problems, snoring and witnessed apneas (Goodwin et al., 2003). A positive significant association of DOA with SDB in the form of snoring and with increased sleep instability was also described by the same authors (Silvestri et al., 2009), akin to previous reports emphasizing the same associations (Lopes & Guilleminault, 2006 Guilleminault et al., 2005).

Diagnosis of parasomnias

All parasomnias more commonly affect persons who have breathing disorders during sleep. Polysomnography is appropriate for any patient with symptoms or signs of obstructive sleep apnea, such as daytime hypersomnolence, nocturnal hypoxia, loud snoring and increased neck circumference. REM behavior disorder often occurs concomitantly with degenerative neurologic illnesses that may require further evaluation. In adults, the onset of arousal disorders such as somnambulism and night terrors may reflect underlying neurologic disease. Thus, neurologic evaluation, including imaging of the central nervous system, may be indicated (Bornemann et al., 2006).

Inflammation Of Mucous Membranes

Sage has been found to have less antitussive effects than codeine, but a significantly higher or similar effect to dropropizine (Nosalova et al 2005). A small, double-blind study has suggested that use of an essential oil spray or gargle formulation that includes sage may help relieve snoring (Prichard 2004).

Steep situation 4 How long is too long

HtVNG If you don't feel rested after six to eight hours of sleep, you may have a serious sleep problem known as sleep apnea. Sleep apnea involves a series of episodes in which your breathing stops while you sleep. You awaken momentarily to gasp for air, and then you fall back asleep, only to have your breathing cease yet again. Sleep apnea results in very poor quality sleep and frequently leads to nodding off in the daytime. Snoring can be a sign of sleep apnea, but that's not always the case. If you think you may have sleep apnea, your physician can refer you to a sleep clinic where the condition can be accurately diagnosed.

Obesity and Sleep Apnea

There are several correlates of sleep apnea. It is well recognized that it is more prevalent in males, although the difference is less pronounced in population-based studies than in laboratory-based studies. 20 Some studies have suggested that the prevalence of sleep apnea in women increases after menopause. Snoring also correlates with sleep apnea, increasing up to late middle age and decreasing thereafter. 20, 282, 654, 655 The other major correlate of sleep apnea is obesity 20, 653, 654, 656 in both men and women. In general, women have to be significantly more obese than men for the clinical syndrome to be apparent. 657 At present, no published epidemiologic studies

Clinical Manifestations

Symptoms of pharyngitis depend on the etiology. Sore throat is the most common symptom associated with pharyngitis and represents the third most common complaint encountered in office-based medicine (2,3). Dysphagia, odynophagia, ear pain, fever, and malaise are other associated symptoms. Airway obstruction presents less commonly. Noninfectious inflammatory conditions may cause a similar constellation of symptoms without fever and malaise. Less frequently encountered symptoms include globus sensation, voice changes, snoring, nasal congestion, and frequent throat clearing (4). Neoplasms occurring within the

Nonergotderived dopamine agonists

Ropinirole acts as a dopamine agonist primarily on the D3 as well as D2 & D4 receptors. It was originally studied in the early 1990s for Parkinson's Disease and later found to be beneficial for RLS. Ondo studied 16 RLS patients in an open-label trial of ropinirole. Three patients discontinued ropinirole use. Of the remaining 13 patients, the average duration of use was 3.9 months and there was a 58.7 improvement in symptoms (Ondo W, 1999). Further studies reinforced the safety and efficacy of ropinirole in RLS. The TREAT RLS 1 study (Therapy with ropinirole efficacy and tolerability in RLS 1) was a randomized, double-blinded, placebo-controlled trial of 12 weeks duration. 146 subjects were randomized to the ropinirole group and 138 to the placebo group. The key endpoint was the IRLS severity score which showed significant improvement in the ropinirole group over the placebo group at week 12 (p 0.0036). The researchers concluded that ropinirole improves RLS compared with placebo and...

Differential diagnosis of REM sleep behavior disorder

When a diagnostic clarification is necessary, particularly when the risk for injury is high, the behaviors occur at any time of the night, other features suggesting an evolving neurodegenerative are present, or loud snoring and observed apnea suggestive of OSA are present, PSG with simultaneous video monitoring is warranted (Boeve, 2010a).

Sleepdisordered breathing disorders in neurological diseases

Sleep-disordered breathing in patients with Duchenne muscular dystrophy has a characteristic clinical course (Barbe, 1994). In children under 10 years mostly obstructive apneas occur, while in older children, with the development of disease, the apneas of central origin predominate (Smith, 1989 Suresh, 2005). The occurrence of obstructive sleep apnea and snoring at a younger age is associated with frequent enlargement of the tongue (Barbe, 1994 Suresh, 2005)

Sleepdisordered breathing SDB in patients with ischemic stroke

The first controlled study of sleep related breathing disorders in cerebrovascular diseases were carried out in the 80s. They concerned the snoring as a risk factor for ischemic stroke. The first studies were published by a group of Palomaki (Partinen et al, 1985). They compared the incidence of snoring in 50 men with ischemic stroke with a control group. The study was retrospective with use of a standardized questionnaire. Patients were divided into groups of regularly snoring (every night), often and seldom. Polysomnographic studies were not performed. It was shown that the relative risk of ischemic stroke is 10.8 times higher in regular snorers as compared with not snoring patients. Further results of these investigators have shown that snoring is independent of other risk factor for ischemic stroke (Palomaki 1989, 1991). Results of other studies on snoring as a risk factor of ischemic stroke, show an increased relative risk of stroke in snoring people (Koskenvuo, 1987). The...

The Sleep Medicine Physician

Physicians who have studied in this subspecialty can administer and interpret a sleep study. Sleep studies are critical for patients with signs or symptoms suggestive of sleep apnea (a disorder characterized by pauses and gasps while breathing during sleep) or narcolepsy (a neurological condition characterized by extreme tiredness and or falling asleep during the day at inappropriate times). Symptoms of sleep deprivation may include extreme daytime sleepiness, going to sleep while driving, loud snoring with pauses between breaths, and waking with an occipital headache (pain in the back of the skull and radiating down the neck). Sleep medicine physicians may or may not be interested in treating chronic insomnia. Some are comfortable with providing a long-term prescription of controlled substance sleep agents others will rely instead on sleep hygiene, tricyclic or SSRI medications, and referral for cognitive behavioral therapy.

Sleep and pregnancy

Weight gain, low annual family income, and single motherhood (P < 0.01). A weak but not significant effect of season on sleep scores was recorded The mean PSQI scores were 6.06 (+ -3.96) in winter, 5.21 (+ -3.21) in spring) 5.33 (+ -3.04) in summer and 5.53 (+ -2.41) in autumn) (P 0.076). In a similar study of 189 nulliparous women Facco et al demonstrated that compared with the baseline assessment (mean gestational age (13.8 (+ -3.8)) the mean sleep duration was significantly shorter at 30.0 (+ -2.2) weeks gestation (p< 0.01). They also observed that in the third trimester the proportion of patients who reported frequent snoring (at least three nights per week) was significantly increased, and that there was an increase in those who met the diagnostic criteria for the recognised sleep disorder 'restless leg syndrome'. Furthermore, poor sleep quality, as defined by a Pittsburgh Sleep Quality Index score greater than 5, became significantly more common as pregnancy progressed...

Obstructive Apnea

Symptoms Snoring is the most common symptom other signs include color changes, labored breathing or gasping for air during sleep or sleeping in unusual positions. Because obstructive sleep apnea may disturb sleep patterns, these children may wake up sleepy and continue to complain of fatigue and attention problems throughout the day that may affect school performance. one recent study suggests that some children diagnosed with attention deficit hyperactivity disorder (ADHD) actually have attention problems in school because of disrupted sleep patterns caused by obstructive sleep apnea.

Clinical examination

Probably the most useful equipment in assessing the upper airway is the flexible fibreoptic nasopharyngoscope which is widely available and allows brilliant visualisation of all aspects of the naso, oro and hypopharynx. Local anaesthesia in the form of a nasal spray can be used in allowing an easier and tolerable insertion of the scope and the different segments of the pharynx are carefully assessed. The patient could be asked to simulate a snoring sound to try and ascertain the level responsible for causing the turbulent airflow resulting in the snoring sound. Herzog3 has reported a study based on simulating snoring sound in order to establish a model of grading upper airway obstruction. However, not all patients can simulate snoring and some may do this with mouth open or closed and these patients are usually sitting up whilst during sleep patients may be supine, prone or in lateral

Acoustic analysis

This form of evaluation is safe in that there is no radiation involved and it is relatively cheap. It can be performed easily during sleep and at patient's home and simultaneously with polysomnography. Multiple night recordings can be carried out and based on sound frequency spectrum, acoustic analysis can potentially discern simple snoring from OS A.8 Attempts have been made to correlate snoring sound frequency with different levels of obstruction and comparisons of this technique have been made to others such as drug induced sedation endoscopy.9

Summary

In order to attain a successful outcome in treating patients with obstructive upper airway in snorers and OSA it is crucial to evaluate the upper airway dynamics very carefully. Apart from its usefulness in research, imaging has a relatively minor role to play in evaluation except in maxillo-mandibular advancement surgery.

Follow up

Te long time evolution of UARS patients, within the overall spectrum of sleep disordered breathing disorders, is an area of interest. RERA may be intermediate event between snoring and hypopnea. RERA predominate in younger and thinner people than apnea and hypopnea episodes. Hypopneas becoming true apneas with increasing age and weight. Few existing studies on the matter. In a five years follow-up study of untreated UARS patients, Guilleminault report that only 10 developed a OSAS and always in the context of weight gain (Guilleminault 2006b). Jonzak, in a retrospective study,also report that obesity as an aggravating factor of severity in follow up six years (Jonzak 2009).

Intech

Evaluation of the Upper Airway in Patients with Snoring and OSA 65 Sleep-related breathing disorders dominate sleep medicine so it is not surprising that there are several chapters in this area. The historical division in medicine of physicians and surgeons can be seen in this area or sleep disorders. It is dominated by respiratory physicians. However, surgeons also have a place, depending on the physical structures. Another curiosity in this area is that, whilst sleep apnoea demands treatment because of the adverse physical and social consequences if it is not treated, snoring is not regarded as such an urgent problem. However, there is evidence in terms of personal and social consequences as well as its symptomatic value, that highlight the need for more research in this area. Dr Kotecha's chapter is entirely pragmatic and practical, focussing on the evaluation of the upper airway so that the appropriate therapies can be applied.

Other parasomnias

Ten disorders are classified under this category (Table 1). The most common are sleep bruxism, sleep enuresis, and primary snoring. Primary snoring is reported in 40 to 50 of people over the age of 65 and approximately 25 of the middle-age group. Snoring is usually a symptom of sleep disordered breathing. Oral appliances and otolaryngologic procedures, including velopharyngeal surgery, can effectively resolve snoring. Most of the studies on oral appliances are conducted for treatment of obstructive sleep apnea syndrome, with no clear data on primary snoring. They have decreased the frequency of snoring by 50 .

The Parasomnias

Although clinical history may suggest a diagnosis, in some situations such as when there is a high risk of physical injury or loud snoring suggestive of obstructive sleep apnea, confirmation of diagnosis should be obtained by a single night of polysomnography (PSG) with video telemetry. PSG would show an increased electromyographic (EMG) activity during REM sleep. Symptoms of RBD may predate the diagnosis of PD. Schenck et al. (37) reported that in 1l of 29 men (38 ), 50 years or older in whom idiopathic RBD was diagnosed, a parkinsonian disorder was identified after a mean interval of 3.7 years following the diagnosis of RBD and 12.7 years after the onset of RBD. One study (41) suggested an increased risk of developing PD in individuals who have RBD and olfactory disturbance. This concept is consistent with the recent hypothesis of Braak et al. (21) who suggest that the preclinical stages 1 and 2 of PD start at the olfactory and medullary area of the brainstem. Although the...

Symptoms

Although OSAS and UARS share common symptoms, in most cases the clinical manifestations are different (Stoohs 2008). The most common symptoms of SAHS patients include chronic loud snoring, excessive daytime sleepiness, personality changes, depression and deterioration of quality of life (Pichel 2004). Hypersomnolence is the principal daytime manifestation of sleep disordered breathing. Excessive sleepiness resulting from increased breathing effort and sleep disruption is the guide symptom of UARS patients (Guilleminault 1993, 2001a). Drowsiness related to general exhaustion has a negative impact on quality of life. As in OSAS, snoring is a common symptom, predominantly in males, although the absence of snoring has also been described in this syndrome, the so-called silent UARS (Kristo 2005). In recent years, several studies have demonstrated strong associations between UARS and functional somatic syndromes, such as chronic fatigue syndrome, chronic insomnia, chronic pain, irritable...

Sleep nasendoscopy

An audit of 2,485 procedures performed over a period of 10 years at our institute has demonstrated that SNE correlates well with apnoea-hypopnoea index and mean oxygen desaturation.14 We have also demonstrated the usefulness of SNE in predicting treatment success in snorers using MAS.15,16 Similarly, SNE has allowed site specific target selection in surgical patients and improved surgical outcomes in our group of patients undergoing laser assisted palatoplasty with or without tonsillectomy has been reported.17-19 Sleep nasendoscopy assessment of snoring is useful as it provides evaluation of the upper airway in the dynamic mode during sleep. However, numerous controversies and debates have arisen and attempts have been made to address some of these by various authors. For instance, criticisms made by Marais20, whilst comparing snorers and non-snorers, it was claimed that snoring was produced during SNE in a large number of the non-snorers and was not produced in many of the snorers....

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