Does Sinus and/or Nasal Surgery Help with Sleep Apnea?

Bluntly, the answer is not really... Although it may make sense that improving nasal airflow should help with obstructive sleep apnea, the reality is that it does not make a profound difference. Indeed, there was a study in 2014 that looked into this question.

In this study, 3 groups of patients were looked at divided into patients with mild, moderate, or severe obstructive sleep apnea (OSA). These patients underwent sinus surgery, septoplasty, and turbinate reduction.

What was found was that patients with severe OSA with a mean AHI of 52 would go down to 43 (normal being less than 5) after surgery. Moderate OSA with a mean AHI of 22 down to 20. Patients with mild OSA did not have any significant changes to AHI at all.

In other words, for patients with moderate or severe OSA, although the AHI does decrease somewhat, it does not decrease enough that it really makes any clinical difference. Patients with moderate or severe OSA still had OSA... and still would need to use a CPAP or equivalent machine after surgery to correct their sleep apnea.

Although at first blush, these results may not make sense, it actually does make sense when you consider sleep apnea to be a multi-level disorder affecting not just the nose, but the throat as well.

For example, the back of the tongue may fall backwards obstructing the airway causing sleep apnea. Correcting nasal factors would have absolutely ZERO impact on tongue factors of OSA.

In order to determine where these other anatomic factors may be that may contribute to OSA, a sedated or sleep endoscopy is often performed. Watch the video below.

Granted, patients may STILL wish to pursue sino-nasal surgery due to discomfort with their sinuses and nasal breathing... but patients need to be aware that their OSA may still remain essentially unchanged!

Sino-nasal surgery may also help with CPAP compliance as lower pressures may be required to address OSA compared to before surgery. Why? Because the nasal passages are more open after surgery so it is easier to push air into lungs when using CPAP.

Reference:
Effects of Endoscopic Sinus Surgery and Nasal Surgery in Patients with Obstructive Sleep Apnea. Otolaryngol Head Neck Surg. 2014 Mar 31;151(1):171-175. [Epub ahead of print]

Read More

Sleep Apnea Increases Risk of Cancer

Obstructive sleep apnea has been getting accused of causing all sorts of medical problems including hypertension, stroke, heart disease, heart attacks, peripheral vascular disease, etc. We can also add cancer now.

According to Australian researchers, moderate to severe sleep apnea increases the risk of cancer by 2.5 times and death from cancer by 3.4 times. They also reported that sleep apnea increases risk of death (any cause) by 4.2x and stroke by 3.7x.

This conclusion was reached evaluating 397 subjects with obstructive sleep apnea with 20 years follow-up. Of course, further study is needed to confirm these findings.

If sleep apnea is suspected, the first step is to get a sleep study. Surgical options can also be considered which may encompass UPPP, base of tongue reduction, etc.

Source:
Sleep Apnea and 20-Year Follow-Up for All-Cause Mortality, Stroke, and Cancer Incidence and Mortality in the Busselton Health Study Cohort. Journal of Clinical Sleep Medicine 2014;10(4):355-362.

Read More

Infant Sound Machines for Sleep May Cause Hearing Loss

As a father of two young kids who still use a sound machine to help them sleep, I was quite curious about a recent paper that warned that such devices may cause permanent hearing loss. Researchers compared a total of 65 sounds produced by 14 machines and measured the maximum sound level at a distance of 30 cm (crib-rail placement), 100 cm (beside crib placement), and 200 cm (across room placement).

Why is placement important?

When it comes to risk of hearing loss due to loud noise exposure, there are three factors that come into play: 1) how loud is it; 2) how close is it; 3) how long are you exposed to it. Clearly, a person is at a higher risk for permanent hearing loss the louder a sound is, the closer the sound is, and the longer one is exposed to the loud sound.

When it comes to infant sound machines, two of the three risk factors are typically present given such machines are usually placed in or on the crib (close) and is typically played all night (duration).

Alarmingly, 3 machines produced sound levels 85+dBA which exceeds current occupational limits (if exposed for 8+ hours) for adults in the workplace which would mandate use of hearing protection. All 14 machines were capable of producing noise 50+dBA at distances of 30 and 100cm. 13 machines were capable of 50+dBA at 200 cm.

Which machines were tested? Beyond stating "procured from major online and brick-and-mortar infant-accessory stores," the machines were not identified. I wonder if the authors were fearful of lawsuits from sound machine manufacturers and as such, kept it anonymous.

Of course, one can always try contacting the ENT department at University of Toronto where this research was done and get an off-the-record answer.

Given lack of identification, the main steps a parent can take to minimize noise-induced hearing loss is to:

1) place sound machines as far away from infants as possible
2) set volume as low as possible
3) limit duration of sound machine usage


Reference:
Infant Sleep Machines and Hazardous Sound Pressure Levels. Published online March 3, 2014 (doi: 10.1542/peds.2013-3617)

Read More

Chin Strap May Help with Snoring

There is a relatively simple (and cheap) device that may help some people who snore called a chin strap. This lowly, humble, and low-tech device may benefit patients who typically snore when:

1) Lays on back, but not on side
2) Mouth-breathes when sleeping (but suffers no nasal obstruction)
3) Does not suffer from severe obstructive sleep apnea
4) Appears to be "slack-jawed" when sleeping (chin pushed back relative to upper jaw creating a pseudo-overjet dental appearance)

How (or more importantly why) does this device work?

When a person sleeps who also mouth-breathes AND has a chin that falls backwards, it also causes the tongue to fall back against the back wall of the throat causing a partial narrowing. It also causes the overall throat diameter to decrease causing the throat mucosa to loosen creating the perfect environment for snore production: a partially narrow airway resulting in negative pressure due to increased respiratory effort which triggers any loose mucosa to vibrate causing a snore sound.

A chin strap can be used to force the mouth closed into a more normal position (chin in normal forward position with teeth in normal occlusion). By preventing the chin from falling backward, it would prevent the tongue from falling backward. By preventing the tongue from falling backward, the partial airway narrowing could be avoided. By preventing the airway from narrowing, the throat mucosa would be more taught and less prone to vibrate as well as prevent increased respiratory effort and a "negative" pressure environment.

Where can you get one? There's a whole bunch that can be purchased on Amazon.com.

So there you have it... Of course, keep in mind that the chin-strap will NOT work for everybody as the snore production could be due to other factors unrelated to the chin, tongue, mouth position.

Read More

OSA is a Risk for Sudden Cardiac Death

Mayo Clinic researchers have determined that not only does OSA (obstructive sleep apnea) lead to increased risk of stroke, cardiac arrest, hypertension, vascular disease, etc but it can also increase the risk of sudden cardiac death, usually due to a fatal cardiac arrhythmia. This conclusion was reached after tracking thousands of men and women with sleep apnea for up to 15 years of whom 142 had sudden cardiac deaths or arrests who were resuscitated.

These sudden cardiac arrests occurred mainly at night, 60 years of age or older, with AHI scores of 20 or greater, and having low blood levels of oxygen. When oxygen saturation was 78% or less, the risk of sudden cardiac arrest increased by 80%. Normal oxygen saturation is 95-100%.

Unfortunately, the study failed to address whether those who used a CPAP machine (continuous positive airway pressure) or underwent surgical intervention to correct the OSA had a reduced risk of sudden cardiac death.

Such surgical intervention to treat OSA include UPPP and base of tongue reduction. Sedated endoscopy may be required to determine where the obstruction occurs anatomically before deciding on a surgical course of action.

Source:
Sleep Apnea May Boost Risk of Sudden Cardiac Death. WebMD 6/11/13

Reference:
Obstructive Sleep Apnea and the Risk of Sudden Cardiac Death: A Longitudinal Study of 10,701 Adults. J Am Coll Cardiol. 2013;():. doi:10.1016/j.jacc.2013.04.080

Read More

T&A Helps with Pediatric Obstructive Sleep Apnea (But Watchful Monitoring OK Too!)

Researchers published in the New England Journal of Medicine that removal of the tonsils and adenoids absolutely helps with sleep apnea in kids along with improvements in behavior, quality-of-life, overall well-being as well as significantly greater reduction in symptoms... but apparently putting off surgery does no significant harm as well from a purely cognitive perspective.

464 children ages 5-9 years of age were randomly split into surgery or watchful monitoring groups (children with severe sleep apnea was excluded from the study). Although surgery helped in all measures tested, what surprised the researchers was that nearly half the children (46%) in the watchful monitoring group also spontaneous improved over a 7 month period of time without surgery. Furthermore, there was no difference between groups on a Developmental Neuropsychological Assessment.

Overall, surgery WAS beneficial, but it is notable that even without surgery, cognitive development was found to be no different than not doing surgery and nearly half improved to point surgery was no longer clinically indicated.

More relevant to clinicians and parents... what were the exact factors that led nearly 50% of kids with sleep apnea to improve over 7 months?

Was it a certain medication? Overall head growth? Treatment of allergies?

If there WAS an intervention, can it be replicated to all kids as something to try prior to surgical consideration?


Reference:
A Randomized Trial of Adenotonsillectomy for Childhood Sleep Apnea. May 21, 2013 DOI: 10.1056/NEJMoa1215881

Read More

Infographic on Obstructive Sleep Apnea (OSA)

Check out this great infographic by Aviisha Medical Institute (generated from information by PubMed.gov, Medscape, and BioMed Central) on the numerous adverse consequences that can arise from the onset of Obstructive Sleep Apnea (OSA). [Thanks to @hobsonent who brought it to my attention.]

Here's another one regarding how important sleep is:

Read More

Snoring is Bad for the Heart? Not so fast...

This past week, media has both aired and published a story regarding new research that suggests snoring WITHOUT obstructive sleep apnea may lead to potential increased risk of heart disease as well as stroke.

Apparently, researchers in Michigan examined the data of 913 patients between the ages of 18 and 50 who had undergone a sleep study between 2006 and 2012. None had been diagnosed with sleep apnea, but did have significant snoring. These patients underwent an ultrasound that measured the thickness of the carotid artery inner lining. The thicker the inner lining of the carotid artery, the higher the risk for carotid artery disease and stroke.

The researchers found that in their patient population, the carotid arteries were thicker in snorers than in non-snorers. In fact, these abnormal changes were comparable to smokers, diabetics, and patients with hypertension.

Unfortunately, their findings have not yet been published (though submitted to the journal Laryngoscope), but was presented at the Combined Sections Meeting of the Triological Society in Scottsdale, Arizona held between January 24-26, 2013.

However, this is not the first study to show a link between snoring and heart disease. Hungarian researchers in 2008 reported that loud snorers were at significantly higher risk for stroke and heart disease in their study population of 12,642 subjects.

Contradictory Research: Snoring is NOT Bad for the Heart

Now, before every snorer goes into a panic regarding the fact that they snore, even if there are no problems with obstructive sleep apnea confirmed on sleep study, consider this...

Australian researchers published findings in 2012 that snoring did NOT increase risk for heart disease and mortality regardless of whether the patient suffered from sleep apnea or not. Their population study group consisted of 380 subjects.

What's Going On?

Admittedly, the burden of epidemiological evidence does suggest a link between snoring alone and potential increased risks for stroke and heart disease. But the very factors that predispose to snoring are also associated with other diseases that confound a conclusive relationship. Such other confounding factors include obesity, hypertension, diet, age, smoking, and alcohol consumption. When ignoring snoring-related health issues, there are numerous other confounding factors including periodontal disease, personality, stress, sedentary lifestyle, etc.

A study I would like to see to help clear the confusion regarding the risk of snoring would be to examine a large population of subjects who snore, but who are all skinny, non-smokers, non-alcohol drinkers, not diabetic, do not have high blood pressure, eat a balanced healthy diet, do not have a type A personality, good teeth, exercise daily, and lead a relatively stress-free life.

Any takers???

Assuming Snoring DOES Lead to Elevated Risk

The simplistic reason this may occur is due to acoustic and vibrational trauma that gets transmitted from the airway to the carotid arteries located nearby in the neck. Such snore-induced vibrational trauma leads to micro-injury to the inner lining of the carotid artery leading to thickening.

With thickening, the carotid arteries in essence become more narrow leading to increased risk of stroke.

Such vascular injury can also lead to increased levels of catecholamines that can lead to similar changes elsewhere in the body including the heart.

Of course, there are more complex variables at play which requires more complex answers, but that's beyond the scope of this blog.

Treatment

Snoring is unfortunately a complex problem to fix and does require some testing to fully evaluate and treat successfully. Such tests include fiberoptic laryngoscopy, sleep study and sedated endoscopy.


Source:
Snoring May Be as Bad as Smoking for Your Heart. Medical Daily 1/24/13

References:
Cardiovascular Disease and Health-Care Utilization in Snorers: a Population Survey. Sleep 2008 Mar;31(3):411-6.

Snoring Is Not Associated With All-Cause Mortality, Incident Cardiovascular Disease, or Stroke in the Busselton Health Study. Sleep. 2012 Sep 1;35(9):1235-40. doi: 10.5665/sleep.2076.

Read More

Deaths Associated with Codeine Usage in Young Kids

For decades, surgeons have provided young children with prescriptions for pain control after tonsillectomy and/or adenoidectomy surgery, most commonly tylenol with codeine (otherwise known as tylenol #3). Millions upon millions of such prescriptions have been filled and taken without any problems, but there is now a growing concern that such narcotics may be causing more harm than good in a small percentage of kids and perhaps an even greater percentage where it absolutely does nothing. Furthermore, it has now become the subject of an FDA investigation.

Why the sudden concern?

There has been a small but increasing number of children who have suffered anoxic brain damage and even fatalities due to respiratory suppression associated with codeine use. This association was not figured out until recently as such unfortunate incidences were initially felt to be due to medication overdosage, poor care, and/or surgical error.

But now, it is felt that such adverse events were probably due to the administration of codeine itself.

What's going on?

All of the children who died following codeine administration had extra copies of the liver enzyme CYP2D6 which metabolizes codeine to its more potent form morphine [study]. Referred to as ultra-rapid metabolizers, these children metabolize codeine so rapidly to morphine that it leads to respiratory depression or arrest. Substituting codeine for hydrocodone, oxycodone, or other opioids is also unsafe as such narcotics are also metabolized by CYP2D6 and cause even more problems because the CYP2D6 metabolites of hydrocodone and oxycodone are even more potent than morphine. (Of course, on the flip side, there are patients who have minimal CYP2D6 functionality which leads to minimal if any pain relief with codeine.)

Although rare, there has been an increasing number of case reports describing children who have died after receiving codeine for post-operative pain, particularly after tonsillectomy. The most recent report published in 2012 documented the cases of three children who died after receiving standard treatment with tylenol with codeine after tonsillectomy between 2010 and 2011. However, these are only the known documented cases.

Given how rare, changing prescribing patterns may not be warranted... BUT...

What about the possibility that there may be numerous other cases which are not documented or close-calls? As we all know, for every documented case, there's probably numerous other undocumented cases.

To investigate this possibility, a close proxy would be to look at malpractice lawsuits after tonsillectomy. This report did just that looking closely at lawsuits stemming from tonsillectomy complications between 1984 and 2010 and found that the incidence of codeine-related deaths was much higher than the researchers expected. They found that 18 percent of death claims and 5 percent of injury claims resulted from the use of opioids, largely codeine. Indeed, after bleeding, opioid usage was the second most common cause of death in patients after tonsillectomy.

Additionally, death and anoxic brain injury claims associated with narcotic usage were associated with the greatest indemnity with a median payment of more than $900,000 per case.

Though likely impossible to do retrospectively, it would have been interesting to see whether all these children in these lawsuits had multiple CYP2D6 copies or not.

Alternatives to Narcotics

First, there is the question whether tylenol with codeine even helps with pain. Apparently not according to one study. In fact, children who took tylenol alone resumed a normal diet more quickly than kids who received codeine.

In fact, tylenol with codeine is associated with adverse side effects (nausea, dizziness, vomiting, etc) in up to 79% of children who take it [link].

Ibuprofen may also be given for pain control. Though ibuprofen theoretically can increase risk of bleeding due to its anti-platelet activity, numerous studies have not found this to be true.

Given codeine helps minimally with pain and tylenol alone seems to provide adequate pain control, why even given narcotics, especially given the small but significant risk of death associated with this drug?

Pain Control Protocol

Based on all these findings, we feel that narcotics for pain control after tonsillectomy for kids under 7 years of age is not recommended.

Rather, the following protocol is what we will now be implementing:

Tylenol and Ibuprofen over-the-counter as needed to help with pain control. The dosing is weight-based and exact dosing for a given child can be found on the bottle. These medications can be given alternating between Tylenol and ibuprofen every 3-4 hours (Tylenol first, followed by ibuprofen 3-4 hours later, followed by Tylenol 3-4 hours after that, etc). A prescription for a single dose of steroids is also provided which is meant as a one-time dose that can be given anytime 3 days after surgery if the child suddenly seems to have significantly more pain that is not controlled with Tylenol and ibuprofen. Pain in this scenario is often due to inflamed tissues that can be quickly minimized with steroids.

Source:
FDA Drug Safety Communication: Codeine use in certain children after tonsillectomy and/or adenoidectomy may lead to rare, but life-threatening adverse events or death. FDA 8/15/12

Post-Operative Pain in Children Undergoing Tonsillectomy. ENT Today. Sept 2012.

FDA Investigates Codeine Safety After Children’s Deaths. ABC News. 8/15/12

References:
More codeine fatalities after tonsillectomy in North American children. Pediatrics. 2012 May;129(5):e1343-7. Epub 2012 Apr 9.

Preventing opioid-related deaths in children undergoing surgery. Pain Med. 2012 Jul;13(7):982-3; author reply 984. doi: 10.1111/j.1526-4637.2012.01419.x. Epub 2012 Jun 13.

Complications and legal outcomes of tonsillectomy malpractice claims. Laryngoscope. 2012 Jan;122(1):71-4. doi: 10.1002/lary.22438. Epub 2011 Nov 10.

Acetaminophen versus acetaminophen with codeine after pediatric tonsillectomy. Laryngoscope. 2000 Nov;110(11):1824-7.

Non-steroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD003591.

Read More

CPAP + Oral Appliance (All-In-One) Device for OSA

A dentist colleague of mine informed me of a new device that combines CPAP mask with an oral appliance for patients with obstructive sleep apnea (CPAP Pro + Mandibular Advancement).

The unique benefits of this combo device are several-fold:

• No straps
• Keeps mouth closed
• Addresses tongue collapse that obstruct the airway by bringing jaw forward
• Can sleep in any position

This device does need to be fitted by a dentist. (For Virginia residents, Dr. Jason Woodside is familiar with this product.)

Of course, it is relatively new and we'll see if patients love this combo CPAP mask more than the traditional masks that have been on the market.

For those patients who do NOT have a problem with tongue collapse, but prefer the no-straps solution of the oral appliance, the company does make a mouthguard that fits only the upper teeth.

Read More

Singulair May Help Cure Mild Sleep Apnea in Children

Singulair (generic montelukast as of Aug 2012) is a medication often prescribed for asthma as well as allergies and works by blocking the leukotriene receptor. This mechanism is different than that found in common allergy medications like claritin and benadryl which work by blocking the histamine receptor (anti-histamine).

Singulair has also incidentally been found to possibly help reduce the size of tonsils and adenoids. Given this beneficial affect, singulair may be a helpful intervention in those kids with mild obstructive sleep apnea or nasal obstruction due to adenoid hypertrophy avoid surgical intervention (tonsillectomy and adenoidectomy).

The most recent research published in Sept 2012 suggests that singulair may lessen symptoms in children with non-severe apnea and potentially allow them to skip the surgery.

In the study, 46 children with non-severe sleep apnea received singulair or a placebo for 12 weeks. The kids who received the drug showed improvements in their sleep apnea, their sleep-related symptoms, and the size of their adenoids compared to the placebo group. There were no side effects seen among kids who took the study drug.

Beyond singulair, steroid nasal sprays have also been found helpful to reduce adenoid size.

Singulair can be given from the age of 1 year old.

References:
Leukotriene modifier therapy for mild sleep-disordered breathing in children. Am J Respir Crit Care Med. 2005 Aug 1;172(3):364-70. Epub 2005 May 5.

Leukotriene pathways and in vitro adenotonsillar cell proliferation in children with obstructive sleep apnea. Chest. 2009 May;135(5):1142-9. Epub 2008 Dec 31.

The role of mometasone furoate aqueous nasal spray in the treatment of adenoidal hypertrophy in the pediatric age group: preliminary results of a prospective, randomized study. Pediatrics. 2007 Jun;119(6):e1392-7. Epub 2007 May 28.

Intranasal corticosteroids for nasal airway obstruction in children with moderate to severe adenoidal hypertrophy. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD006286.

Read More

Sleep Apnea Surgery Malpractice Lawsuit

In November 2009, a patient underwent multi-level surgery to treat her mild-moderate obstructive sleep apnea by a Houston, TX otolaryngologist.

The surgery included:

• Uvulopalatopharyngoplasty (UPPP)
• Tonsillectomy (typically considered part of UPPP)
• Adenoidectomy
• Hyoid Myotomy
• Genioglossus Advancement

She unfortunately experienced some unspecified complications stemming from this surgery which apparently has not helped with her obstructive sleep apnea either. A malpractice lawsuit commenced and final judgement is still pending.

Let's take a closer look at the incomplete information provided.

The patient suffered from mild-moderate obstructive sleep apnea which typically means a AHI score of around 15 (< 5 is normal).

For this level of severity, simultaneous multi-level surgery is not typically performed. Rather such extensive surgery is reserved for severe obstructive sleep apnea.

Also unclear is whether any objective studies were performed prior to surgery to try and localize the levels of obstruction that required correction. Such preoperative studies include a sedated endoscopy as well as trial of CPAP usage.

Assuming patient tried and failed to use CPAP and had objective evidence for multi-level obstruction, what did each of the surgical procedures do?

UPPP, tonsillectomy, adenoidectomy address mouth-level obstruction.

Hyoid myotomy and genioglossus advancement address tongue-level obstruction (the tongue can fall backward while sleeping causing obstruction).

Complications can occur for each of these procedures mainly dealing with bleeding, hematoma, infection, or abscess formation. Swallowing problems can also occur with the hyoid myotomy and genioglossus advancement.

Read more information on obstructive sleep apnea.

Source:
Sleep apnea surgery leads to malpractice lawsuit. Southeast Texas Record. 1/23/12

Read More

Robotic Surgery for Obstructive Sleep Apnea

I came across this article the other day regarding use of the daVinci robot to perform base of tongue surgery for obstructive sleep apnea.

For those who don't know, the daVinci robot system made by Intuitive Surgical is a robotic system whereby the surgeon directs the arms of the robot to perform surgery in difficult-to-access areas of the body.

My feeling is that using a robot to perform sleep apnea surgery is way overkill akin to using a $50,000 sniper rifle to kill an ant on the wall.

Everything the daVinci robot can do can also be done without the robot with equivalent patient outcomes. In fact, without the robot, the surgery can be performed more quickly, efficiently, and with less anesthesia than with the robot.

The article also describes sedated (sleep) endoscopy to determine WHERE the obstruction occurs during sleep. The areas of obstruction can than be precisely addressed surgically. Again, this does not require a robot. In fact, I would hazard to say that even the surgeons quoted in the article does not use the robot to perform this procedure.

There are occasions where the robot may be helpful with ENT surgical procedures, but this is not one of them.

Reference:
N.J. surgeons on the cutting edge in fight against sleep apnea.

Read More

The "Morning Person" Gene

German scientists have potentially discovered a genetic reason why some people are morning people whereas others are night-owls.

The gene called ABCC9 dubbed "morning person" gene was identified by analyzing 4251 individuals who reported their sleeping pattern.

The ABCC9 variant type and number of copies significantly affected the number of hours of sleep. To confirm this finding, scientists modified the ABCC9 gene in the fruit fly and obtained similar results.

The gene codes for a protein that senses the energy metabolism of a cell, but how this relates to sleep is unclear. The gene is also associated with other conditions including heart disease and diabetes which probably helps explain why quality of sleep seems to be associated with these disease processes.

In the past, it was thought that poor sleep "caused" cardiovascular problems, but just maybe, sleep problems and heart problems are caused by a common genetic trigger rather than one causing the other.

Reference:
A K(ATP) channel gene effect on sleep duration: from genome-wide association studies to function in Drosophila. Mol Psychiatry. 2011 Nov 22. doi: 10.1038/mp.2011.142. [Epub ahead of print]

Read More

New Video on "Where" Snoring Comes From and Treatment

Our office has produced a new video describing "where" snoring comes from determined by a simple procedure known as sedated or sleep endoscopy.

At its most basic definition, snoring is noise produced from a vibrating mucosal surface in the upper airway.

Though snoring can be defined simply, the tough question is WHERE are these vibrating mucosal surfaces? Because unless one can define WHERE the snoring is coming from, successful treatment can't be pursued definitively.

An office exam performed while a patient is awake is suboptimal as the patient is awake... and not snoring. As such, it is an educated guess where the snoring problem is stemming from.

To this end, there are three main levels where snoring can be produced and the best way to localize a snore is to perform the exam while the patient is asleep (induced by anesthesia) and snoring!

1) Nose
2) Mouth
3) Throat
4) All of the above

Watch the video to see how each of these areas can contribute to a person's snore as well as treatment options.

Read More