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Ear, Nose and Throat (ENT), Head and Neck Surgery
OSA Part 1 - What ? How? Who ? Am I the One ?
What is OSA and how does OSA happen?
Breathing problems can occur during sleep giving rise to disorder called 'Sleep -disordered breathing
(SDB)'
"Apnea" = Derived from the Greek word for "lack of breath," means a condition whereby a person stops
breathing for at least 10 seconds, or even longer.
Therefore, "Sleep apnea" = apnea occurring during a person's sleep
There are 3 types of sleep apnea: (as in the Venn diagram)
1.
Obstructive-OSA is the commonest type of sleep apnea
2.
Central
3.
Mixed
Central sleep apnea (CSA) occurs when breathing effort stops resulting in reduction and cessation of
airflow during sleep. It is usually caused by various neurologic disorders and failure of the breathing
centre in the brain.
Normally
during
sleep,
the
muscles
that
control
the
tongue
and
soft
palate
hold
the
airway
open.
Snoring
occurs
as
a
result
of
sound
produced
by
vibrations
of
the
soft
tissue
structures
which
can
be
due
to
turbulent
flow
through a narrowed airway.
In
OSA
,
these
upper
airway
muscles
relax,
resulting
in
snoring
and
breathing
difficulties.
The
degree
of
narrowing
depends
on
the
severity
of
these
soft
tissue
collapse,
therefore
the
name
"Obstructive"
.
However,
in
OSA,
one
continues
with
his
breathing
effort,
though
with
much
difficulty
(as
compared
to
CSA
where
the
persons
stops
his
breathing
effort-involuntarily).
Therefore,
in
OSA,
one
stops
breathing
repeatedly
and
intermittently
for
at
least
10
seconds,
may
last
for
30
seconds
or
even
longer.
The
more
severe
the
OSA,
the
more
frequent
the
cessation
of
breathing.
The
patient
also
tends
to
breathe through the mouth in order to overcome the obstruction.
With no/reduced air flowing into the lungs, oxygen levels drop and carbon
dioxide levels rise in the blood. The level of carbon dioxide would rise so
much as to remind the brain to resume breathing, hence causing the arousal.
Eventually, the patient awakens abruptly and resumes breathing. He quickly
falls back to sleep again -and resumes the loud snoring.
During
the
brief
arousal
from
deep
sleep,
the
blood
pressure
spikes
up,
sometimes
by
as
much
as
30
mm
Hg
systolic
(the
top
number
in
your
hypertension
reading).
As
the
person
goes
back
to
sleep,
typically
unaware
of
having
awakened,
the
throat
muscles
relax
once
again,
the
airway
closes,
and
the
sleep
apnea
pattern
is
repeated
again
and
many
times
throughout
the entire night.
These subsequent and frequent arousals, although necessary for breathing
to restart, prevent the patient from getting enough restorative, deep sleep -
hence waking up feeling unrefreshed and excessively sleepy the next day,
affecting the quality of your life, work and relationships in the long run.
...... Is this you ?
What is the difference between snoring and OSA ?
While everyone with SDB tends to snore, but not everyone who snores has SDB.
Snoring in the absence of SDB is termed primary or simple snoring
i.e. snoring without obstructive apnea, frequent arousals or gas exchange
abnormalities that brings about health complications.
Snoring is very common in OSA, but its absence does not exclude
OSA. Therefore a proper consultation with clinical examination is
necessary.
(Are you confused yet ? Hopefully things are clearer as you read on)
What is the current problem with OSA ?
Lack of awareness (thank you for reading this, at least there is one less person less aware of OSA now)
In a US study, it is estimated that up to 93% of females and 82% of males with moderate to severe OSA
remain undiagnosed. There is also much room of improvement in terms of awareness of this condition among the doctors
(i.e general practitioners, physicians, surgeons alike.
So, why should I worry if I have OSA ?
OSA can cause serious health problems. In addition to affecting the quality of your life due to disrupted sleep patterns,
untreated OSA (through chronic complex body physiological and biochemical changes) can lead to:
1.
Stroke (Almost 70% of people who had suffered from a stroke have sleep apnea)
2.
Hypertension (>35% of people with sleep apnea suffer from hypertension)
o
People with mild to moderate sleep apnea were twice as likely to become hypertensive.
o
People with moderate to severe sleep apnea were almost 3 times as likely to become hypertensive.
o
Usually, normal adults who do not have OSA will typically experience nighttime blood pressure drops of
about 10%.
o
In OSA, during sleep, the heart tries to counter the build-up of carbon dioxide by pumping harder.
Increases in arterial pressures of 30 mm Hg or more do occur.
3.
Increased risk for heart attack (myocardial infarction) (in >35% of sleep apnea patients)
o
Among 6 major disease groups reviewed, cardiovascular diseases which occupied third place as a cause of death in 1950 emerged as the
number one killer during the 1970s and has remained so since
o
Mortality due to coronary heart disease has increased by more than three fold over the last 40 years and is still rising -Cardiovascular/heart
disease is in fact the number 1 killer in Malaysia !
4.
Increased risk of motor vehicle accidents (7 times more likely to occur in OSA patients) -even without OSA, some of us are already sleepy when
driving especially after a stressful tiring day. What more with OSA.
5.
Increased risk of work-related accidents
6.
Reflux disorder i.e repeated overflow of stomach/gastric contents into the esophagus
(Gastroesophageal Reflux Disease, GERD ) or throat (Laryngopharyngeal Reflux, LPR)
7.
Diabetes -increasing evidence linking OSA and exacerbation of diabetes
8.
Appetite increase - OSA causes increased appetite stimulant hormone (ghreline) and
decresed appetite suppresant hormone (leptin). Increased appetite leads to worsening of
the vicious cycle of OSA and obesity.
9.
Depression - People with sleep apnea often complain of fatigue, lack of energy and
poor sleep, all of which are hallmarks of depression.
10.
Memory loss
11.
Increased incidence of marital disharmony - even 'spousal arousal syndrome' has
been coined as a result the bed partner’s snoring
12.
Decreased quality of life
There are thousands of clinical research papers backing these data. Still, the list is being
expanded at a worrisome rate (no joke really!) as new research data pours in.
How do know if I probably have OSA?
The dominant symptoms of OSA are excessive sleepiness, impaired concentration and
snoring.
OSA symptoms include:
•
Restless sleep, moving around or unusual sleep position
•
Choking episodes-waking up at night to 'catch a breath'
•
Nocturia/enuresis - awaken as a result of SDB, and then they notice the urge to urinate
•
Morning headache
•
Excessive daytime sleepiness (EDS) -a very common symptom, may cause
o
Personality changes -eg. irritability
o
impaired cognitive skills
o
Job performance to be affected
•
weight gain
•
sexual dysfunction- decreased libido
•
sedative use-in an attempt to improve
sleep at night, some may develop
dependance
Bed partner's input are good indicators: -look for
choking episodes, witnessed episodes of
breathing cessation (apnea), tossing and turning
in bed.
For screening purposes, Epworth Sleepiness Score can be
used as as a validated guide as a method of assessing the
likelihood of falling asleep or EDS in 8 different situations.
Download link here.
Who is at risk of OSA?
Having all these physical attributes put you at a higher risk for
OSA:
•
increased neck circumference [ > 17 inches (43cm) in men, > 16 inches (38cm) in
women].
•
short neck
•
body mass index (BMI) > 30 kg/m2
o
The excess adipose tissue of obese individuals acts to narrow the airway and
alter airway shape, increasing the susceptibility of the upper airway to collapse.
•
a high Modified Mallampati score (a uniform clinical method af assessing the palate
space in the mouth)
•
the presence of retrognathia (lower jaw displaced backwards)
•
lateral peritonsillar narrowing,
•
large tongue (macroglossia),
•
tonsillar hypertrophy,
•
elongated/enlarged uvula,
•
high arched/narrow hard palate,
•
nasal abnormalities (polyps, septal deviation, valve abnormalities, turbinate hypertrophy) and/or
•
overjet (protrusion of upper jaw over the lower jaw)
(Clinical examination and flexible endoscopy of the upper airway can identify the above findings)
Smoking and alcohol consumption also contribute to snoring and OSA, not to mention it is already a known high
risk factor for
heart/cardiovascular disease
OSA is common among those with heart/cardiovascular disease.
-It affects as many as 30% of coronary artery disease patients, 50%
of congestive heart failure patients, 60% of stroke patients and
80% of drug resistant hypertensive patients
High-risk factors:
•
obesity
•
congestive heart failure
•
atrial fibrillation
•
treatment refractory hypertension
•
type 2 diabetes
•
stroke, nocturnal dysrhythmias
•
pulmonary hypertension
•
high-risk driving populations (such as bus drivers, pilots,
commercial truck drivers),
•
patients being evaluated for bariatric surgery (surgery to
correct morbid obesity).
OSA General info
Prevalence rate is about- 2% in women, 4% in men
85% of OSA patients are of the male gender
2/3 of OSA patients are obese ...read here for the new pandemic -THE OBESITY PANDEMIC
incidence increases with aging -its prevalence increases 2-3 times in
older persons (>65 y) compared with individuals aged 30-64 years.
About 1% to 10% of children have sleep apnea; In young children, sleep
apnea is usually caused by enlarged tonsils and adenoids
Prevalence of OSA in women appears to increase after menopause
More interesting facts here about sleep and snoring.
I'm not even fat or obese, can I still have OSA?
Yes, you can still have OSA even if your thin.
The "Box vs Contents concept" holds true -theory of relativity..
That is, you have a risk of airway narrowing if
...you have a small bony frame ‘box’ eg small jaw bones, although the
soft tissue contents are of normal size
...or you have larger-than-normal ‘contents’ eg. large tonsils, large tongue, thick walls in the throat, although you have jaw bones of normal size
What about OSA in children ?
All snoring and apnea is abnormal in children
About 2% of children are affected, with a peak incidence at age 2-5 years old
Unlike adults (who tend to be obese), apneic children tend to be underweight & short
True daytime sleepiness as in adults is unusual in children- hyperactivity and irritability on waking more common.
Many are mouth breathers
Usually due to adenotonsillar hypertrophy unless craniofacial abnormalities in certain congenital syndromes (eg. small lower jaw bone structures).
Copyright Vincent Specialist Solutions Sdn Bhd 2016. All rights reserved
OSA
is
a
stress
on
the
heart,
and
if
left
untreated,
leads
to
many
complications
that
YOUR
body
will
later
have
to
take
a
beatIng for !
(PDF files will open in a new window)
In a normal subject, air flows into the nose and throat before entering the
windpipe into the lungs.
In
an
OSA
patient,
upper
airway
obstruction
reduces/prevents
airflow
through
the
nose
and/or
throat,
subsequently
into
the
lungs.
This
can
be
caused
by
narrowing
or
backward
collapse
of
the
soft
palate
(yellow
line),
tongue (green line), and/or epiglottis (black line) in the animation.
(source of unlabelled diagram: Netter Atlas of Anatomy)
© Vincent Tan ENT
BASE OF
TONGUE
20 interesting facts about sleep and snoring.
(source : The British Snoring & Sleep Association)
No..it’s no longer a laughing matter
Continue to OSA Part 2 -Diagnosis & Treatment
LEVEL OF OBSTRUCTION
Physical attributes and findings
determine the level of
obstruction in OSA.
Understanding the level of
obstruction is crucial in treating
OSA. Other than a thorough
clinical examination,
flexible
endoscopy
of
the
upper
airway
(FNPLS)
in
the
comfort
of
the
ENT
clinic
can
yield
much
information.
Epworth Sleepiness Scale questionaire
© Vincent Tan ENT
This patient education is provided in good faith to help patients and their families learn more about their medical conditions, the options available to them and the possible consequences of
their decisions. This information is not intended to be used for diagnosis, or treatment of any specific individual. Please consult with your ENT doctor regarding your particular circumstances.
Keen to know more about
OSA
Disorder
Services
provided here ?
OSA
leaves
you
unrefreshed
in
the
next
morning,
feeling
like a ’zombie’ !
NEW evidence linking
obstructive sleep apnea
(OSA) to cardiovascular/heart
disease (eg. hypertension,
stroke, heart attack)- the No.1
killer in Malaysia ..
Are you at risk ?
The obesity pandemic (as appeared in Malaysian
daily The Star on 23/9/11
Why is “SLEEPING
SOUNDLY” not as beautiful
and healthy as it sounds
anymore ?
RELATED LINKS
华文版
.
Best viewed with Google Chrome browser
Recommended BMI classification for Asians
Last update: 12/12/15
Talks about SNORING & O.S.A on 12/1/16
(for educational purposes)