Sleep Disorders: Treatment and Factors of Snoring and Sleep Apnea
Guest: Dr. M. Boyd Gillespie – Otolaryngology/Head & Neck Surgery, MUSC
Host: Dr. Linda Austin – Psychiatrist, MUSC
Dr. Linda Austin: I’m Dr. Linda Austin. I’m talking with Dr. M. Boyd Gillespie, who is Director of the MUSC Snoring Clinic and an ear, nose, and throat surgeon. Dr. Gillespie, earlier, your outlined how you go about diagnosing sleep apnea; when someone comes in with a snoring problem. You’ve mentioned that there are, really, three levels: mild, moderate, and severe apnea, and the treatment depends upon that. So let’s talk about the mild case. In that kind of situation, how do you go about helping that person?
Dr. M. Boyd Gillespie: The decision of how to treat a person, really, is based on individual factors. One: do they have any other cardiovascular risk factors? We know that sleep apnea, or untreated sleep apnea, can increase the risk of heart disease and stroke, but it’s just one of the many factors that can do that. We know that smoking can contribute; being overweight; having high cholesterol; high blood pressure; a strong family history of heart disease. All of these things contribute to heart disease, as does sleep apnea.
Certainly, if a patient has several of those risk factors together, we’re going to strongly urge an aggressive treatment strategy. However, if sleep disorder breathing, or sleep apnea, is their only risk factor for heart disease, we have more time to figure out an individualized treatment plan for that patient.
Dr. Linda Austin: So, give me some examples of some of the forms that that treatment might take, depending on what you find.
Dr. M. Boyd Gillespie: All patients with sleep disorder breathing, whether it’s snoring or sleep apnea, should have a full evaluation of their upper airway. We know that this disorder is caused by collapse of tissues in the upper airways blocking the breathing passage. So, an appointment with an ear, nose, and throat physician is often very helpful. We do a complete evaluation from the tip of the nose down to the vocal cords. This will help us identify the areas that are most likely involved in snoring and sleep apnea.
We look at the nasal septum, the nasal tissues, whether or not there’s weak cartilage in the nose causing collapse. We also look at the floppiness of the palate, and the uvula; the little piece of tissue that hangs down at the back of the throat. Also, does the patient have enlarged tonsils that may be contributing? Does their jaw, or mandible, seem small, and perhaps contributing to this? Do they have a large tongue? This evaluation helps us figure out what the most likely sites of blockage are. Certain sites respond better to certain therapy than others. So, based on the likely locations of the sleep disorder breathing, we can make a treatment plan for that patient.
Dr. Linda Austin: It sounds like some of those would be hard to treat. I mean, if you have a big tongue, you have a big tongue, right?
Dr. M. Boyd Gillespie: That’s correct. If a patient has sleep disorder breathing and has a big tongue, they often do best with medical therapies, and nonsurgical therapies, such as CPAP. CPAP is a breathing mask that some patients will wear at night that actually provide some pressure to the airway and more-or-less forces the air down into the windpipe, and into the lungs, during breathing. And that works quite well in patients with a large tongue.
However, there are also other devices that work well in this population, such as bite guards, or mandibular advancement devices. These are special dentures that fit on the teeth that actually help move the jaw forward, and as a result, pull the tongue forward, away from the back of the throat, thereby opening the airway.
Dr. Linda Austin: What are some of the other sorts of anatomic problems in which CPAP is helpful?
Dr. M. Boyd Gillespie: CPAP is a great treatment. CPAP can typically address all the levels of blockages in a patient with sleep disorder breathing. It does this by providing air, under pressure, that actually provides what we call a pneumatic splint, or a pressure splint, that pushes the tissue out of the way and allows an open airway during breathing. CPAP is the primary treatment for sleep disorder breathing. Unfortunately, some patients cannot tolerate this long-term. And those are the patients that typically need a surgical evaluation.
Some patients can’t tolerate it because the pressures are too high. And often, in that population, we find that there’s some sort of nasal deformity that blocks the airflow and causes the pressure on the mask to be very high to open their airway. So, sometimes a minor surgical procedure can help lower the pressures on the mask, and help them use their mask more successfully.
Dr. Linda Austin: So, am I right in thinking, then, that there must be variety of surgical interventions along the path of the nasal passages, down into the throat, just all depending on where the abnormality is? It’s not a one size fits all approach to surgery?
Dr. M. Boyd Gillespie: That’s true. It depends on several factors: the patient’s anatomy, and the level and severity of their problem. For instance, patients who just have snoring; this would be a patient who’s keeping themselves or their bed partner awake at night, who does not have sleep disorder breathing, may respond to some office-based surgical procedures that we have available. It can often be done under local therapy. However, if a patient has more severe apnea and is not tolerating CPAP therapy, or weight loss therapy, over a period of time, they’ll often need to be addressed, surgically, in the OR to remodel their upper airway to help them breathe better.
Dr. Linda Austin: We haven’t talked about weight loss therapy yet. How much can being overweight contribute? In other words, how many pounds overweight can you begin to see a contribution to snoring due to being overweight?
Dr. M. Body Gillespie: Typically, ten percent above ideal body weight. Once you get above that, you can have increased rates of snoring. That said, we do see, unfortunately, nowadays, a lot of people who are overweight; it’s more common in our society. And I think a lot of people get discouraged with the idea of weight loss. What I try to reinforce with my patients is that if they can lose ten percent of their body weight, they can profoundly improve their cardiovascular health, and reduce snoring and sleep apnea. For instance, if I see a gentleman who weighs 250 pounds in my office, he may be 70 pounds heavier than his ideal body weight. However, if he loses ten percent, or 25 pounds; get down to 225, he’s already recognized 80 percent of the cardiovascular benefits of weight loss. I try to get my patients to start with small efforts to try to lose that first 20, or 25, pounds, because they can recognize extreme benefits from that.
Dr. Linda Austin: That’s really encouraging. Can allergies play a role in sleep apnea?
Dr. M. Boyd Gillespie: Allergies are recognized as a medical condition that can affect sleep at night. They can make snoring worse, and make apnea worse. The reason for this is that with allergies, the nasal membranes become inflamed and more boggy at night. And naturally, often, when we lay our heads down at night, blood pools in our nose and in our head, and doesn’t drain off as well, so our nose tends to swell up at nighttime anyway. And if you have allergies, it can make that worse. So, often, using an allergy nose spray prior to bedtime can improve snoring and sleep at night. Certainly, anybody who has snoring or sleep disorder breathing who has allergies, we want to make sure that their allergies are well under control.
Dr. Linda Austin: Can sleep medications, or sedating medications, make snoring worse?
Dr. M. Boyd Gillespie: Sedatives can make snoring and sleep apnea worse. The sedative that’s most commonly used is alcohol. Often, patients will have a glass of wine, or two glasses of wine, at night. Alcohol has a relaxing effect on the tissues of the throat and upper airway, and can make snoring worse. So, if someone’s a snorer and has a nightly alcoholic beverage, I do try to get them to abstain for awhile to see if that makes a significant difference in their snoring. Other sleep aids can have a similar effect. They can be sedative, making the tissues more relaxed and floppy; some don’t. It really depends on the individual medication, and your doctor can go over that with you in greater detail.
Dr. Linda Austin: How about other medical causes of snoring?
Dr. M. Boyd Gillespie: One of the things we see a lot in patients with snoring and sleep apnea is acid reflux disease. A lot of people think of acid reflux as being the typical burning in the chest after eating a heavy meal. However, more commonly, what we see in patients with sleep apnea is some irritation of the throat due to an acid reflux event that occurs during the night. Typical symptoms of this are hoarseness of the voice, throat irritation, phlegminess in the morning, a feeling that something’s stuck in the throat; and this symptom can occur in up to 50 percent of patients with snoring or sleep disorder breathing. The acid that comes up and irritates the throat causes the membranes of the throat to swell and can make snoring and sleep apnea worse. So, recognizing this condition, and treating it, can improve sleep at night.
Dr. Linda Austin: How about bed position; lying on your back, lying on your stomach, lying on your side, do you have recommendations about that?
Dr. M. Boyd Gillespie: One nice thing about sleep studies is that we can determine the body position that’s effecting snoring and sleep apnea. We score it based on what position your body is in. We find that, often, patients do have worse snoring on their back, and worse apnea on their back, compared to their side. This is an experience that husbands and wives, and bed partners, commonly have when they ask their spouse to roll over to help reduce the snoring.
Dr. Linda Austin: Right. And then they end up black and blue in the morning from being elbowed.
Dr. M. Boyd Gillespie: That’s correct. But there are special positioning pillows that can help people with mild disease.
Dr. Linda Austin: Dr. Gillespie, thanks so much for talking with us today.
Dr. M. Boyd Gillespie: Thank you very much.
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