It is said that snoring and sleep apnea fall upon a continuum, with snoring being an early stage or precursor to sleep apnea on the far right. Most people suffering from sleep apnea also snore.
Lets look at both.
Everyone knows someone who snores. You cannot ignore them. Snoring is much more than an annoyance however as it involves turbulent airflow in the pharynx or throat. This turbulence can lead to a drop in blood oxygen levels of up to 10%. Snoring is caused by the vibration of tissue in the pharynx producing the characteristic sound and is associated with an increase in throat cancer in susceptible people (including smokers).
Snoring occurs in all ages and affects men and women equally. Obesity is a factor as fat deposits in the throat can make snoring worse. Anatomical problems such as large turbinates, adenoids, blocked nasal passages, and tonsils can also result in snoring. People with small lower jaws (retrognathism)or narrow upper jaws often snore. In children, allergies can result in narrowing of the upper jaw and mouth breathing. This narrowing forces the tongue and lower jaw back resulting in paediatric snoring.
Snoring is so commonplace that in England, realtors often refer to a spare bedroom as the “snoring room”!
Obstructive Sleep Apnea
Obstructive Sleep Apnea (or OSA) occurs during sleep when the tongue completely blocks the airway, which prevents normal breathing while asleep. Falling oxygen levels cause the body to produce more red blood cells (to carry more oxygen) causing the blood to thicken (polycythemia). The body also responds by sending a massive amount of adrenaline through the body, stimulating the heart. It responds with a rise in blood pressure and heart rate and an increase in the output of the heart, attempting to pump the now thickened blood, to deliver more oxygen. This significantly stresses the heart. The adrenaline increase also wakes the patient with a loud gasp of choking sensation (termed an apnea event). This can occur many times throughout the night and prevent restful sleep. This surge of adrenaline stresses the heart and enlargement of the right ventricle of the heart occurs (the adrenaline forces the heart to pump more thick blood under higher pressure). Patients with OSA often have high blood pressure that often does not respond to medications.
Sleep deprivation caused by repeated waking prevents cleansing of the brain while sleeping and beta-amyloids and tao proteins, byproducts of brain activity, are not removed. These proteins are sticky and can clump together (called a plaque) damaging adjacent neurons. Amyloid plaques are one of the hallmark findings on MRIs of Alzheimer’s patients and are associated with loss of cognitive function.
Sleep deprivation also results in daytime tiredness and loss of productivity. Learning new tasks is impaired as is memory.
Paediatric Sleep Apnea
Sleep Apnea is most common in young children under the age of 5, in males over 40, and in women after menopause. There are numerous cases that fall outside the norms due to excessive weight or abnormal anatomy of the throat region. Childhood obesity is a leading cause of sleep apnea in children. Untreated allergies, as discussed, lead to narrowing of the upper jaw, retrusion or pulling back of the mandible and tongue. This often results in blocking of the airway.
Symptoms in children can differ from adults considerably. For example, the daytime sleepiness associated with OSA in adults is not always seen in children. Instead, they often exhibit excitation and hyperactivity. Some research suggests that ADHD can be caused by sleep disorders such as OSA. If placed on Ritalin, it can make their apnea worse by only masking the problem! And the most common side effect of Ritalin is rapid, uneven heart rate. Considering the child is receiving multiple blasts of adrenaline in their sleep already during apnea events, this cannot be good for their developing cardiac muscle. SIDS (Sudden Infant Death Syndrome) is suspected to be a result of untreated OSA in infants and is the leading cause of death in children under the age of 1 in the USA. Again, research is ongoing and we will likely see more on this in the next few years. Untreated OSA or Upper Airway Resistance Syndrome in young children can alter the development of their face (lengthening it and causing the lower jaw to retrude or pull back) and affect their posture, concentration, and memory if not treated. Early interception of orthodontic malocclusions is imperative in children with OSA or UARS, to increase the size of the oral cavity (expansion appliances, ALF appliances, etc.), advance the mandible and correct deep overbites (Twin Blocks, ALF appliances, etc), and retrain and balance their jaw and neck musculature to normal breathing to avoid the development of scoliosis or facial asymmetry.
The photos above show the characteristic “Adenoid Facies” development. The lips are open, the tongue postures forward and mouth breathing is the primary breathing pattern. The shoulders roll and the child often has a “dopey” appearance. They cannot help it as they must assume this posture to breathe. If left untreated, OSA and UARS can seriously alter normal growth and development. Children with OSA are often labeled as trouble makers if they exhibit hyperactivity or aggressive behavior. If they exhibit sleepiness, they are not learning properly and may be labeled as lazy. Both scenarios result in a negative learning environment that can affect a child for the rest of their life.
In adolescents and young children, it is imperative to treat allergies which can cause swelling of the nasal membranes and enlargement of the tonsils and adenoids. This is a primary cause of OSA in children and adolescents. Treatment of enlarged tonsils and adenoids is by removing them and the results can be dramatic and are the treatment of choice for these children.
In teenagers, the fatigue associated with OSA causes impairment similar to being over the legal limit with alcohol. Teens with untreated OSA are much more likely to have car accidents. They are much more likely to partake in risky behaviors due to the changes in personality caused by OSA. Learning is impaired due to poor concentration and fatigue in school. Sports are often avoided as they do not have the energy to participate and weight gain can occur. Again, treatment of allergies, removal of enlarged tonsils and adenoids, correction of anatomical defects such as deviated septum all can help to alleviate OSA in this group. Orthodontic treatment (braces) is often necessary, to correct narrow palates and crowding, if early interceptive treatment was not initiated earlier on. We have successfully used fixed ALF appliances with full braces on hundreds of teens to increase their palate width increasing tongue space, with excellent results. This increase in tongue space can improve the airway reducing the risk of OSA. It should be noted that stable expansion of the palate with orthodontic treatment is only possible in growing adolescents.
OSA is a very serious disorder affecting an estimated 100,000,000 people in the world by the World Health Organization (WHO). These numbers are likely conservative as many people with OSA do not get it investigated and simply live with it until a health crisis occurs. It is a significant cause of motor vehicle accidents (here in Canada, 1 in 3 accidents on our major highway is due to drivers falling asleep at the wheel), industrial accidents, and can significantly shorten one’s lifetime. The big 3 with OSA are heart attack, stroke, and sudden death. Treatment is a far better option.