Snoring

Ronchopathy (Greek ronchus - snoring, wheezing) is a chronic progressive disease manifested by obstruction of the upper respiratory tract and chronic respiratory failure, leading to syndromic shifts in the body of a compensatory and decompensatory nature. A distinction is made between primary snoring (benign, simple, normal), pathological snoring (chronic, regular, habitual, unusual), snoring.

Epidemiology

Epidemiological studies have shown that snoring is widespread among the world's population. Snoring affects 20% of the general population and 60% of people over 40 years of age. In Finland, habitual snoring is observed in 30% of the population aged 40 to 69 years, in Sweden - in 15.5% of the population aged 30 to 69 years. The prevalence of snoring among Koreans is 35.2%, among French men - 32%, among Singaporeans aged 30-60 years - 48%.

Men are most prone to snoring. A study conducted among the European population showed that 50% of men and 2-3% of women snore regularly. In a large-scale study conducted in Wisconsin, 44% of men and 28% of women snore habitually. In America, 31% of men and 17% of women snore; in Japan, 16% of men and 6.5% of women.

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Causes snoring

The etiological factor of snoring is infection - inadequate damage by the microbial flora of the upper respiratory tract is noted. Inadequate damage is manifested by pathological inflammation in the structures of the lymphoepithelial pharyngeal ring, mucous membranes of the lateral wall of the nose, pharynx, and oral cavity. Inflammation occurs with hypertrophy, contributing to an increase in the volume of tissue structures involved in the formation of the walls of the upper respiratory tract, which leads to a narrowing of the lumen in the initial section of the respiratory tract. In this case, obstruction in the upper respiratory tract is complex and progressive: complex nature is due to simultaneous narrowing of the respiratory lumen in the nasal cavity, pharynx, mouth; progressive nature - a steady increase in tissue hypertrophy.

Clinical experience allows us to conclude that in individuals with snoring, the occurrence and chronicity of inflammation in the cavities of the upper respiratory tract in response to microbial invasion begins in childhood, mainly before the age of 12. The site of development of focal inflammation is the lymphoid tissue associated with the mucous membrane of the upper respiratory tract - the Pirogov-Waldeyer lymphoepithelial pharyngeal ring.

The implementation of the pathogenic action of the main causal factor (infection) is facilitated by certain conditions, which include:

• hypertrophy of the structures of the Pirogov-Waldeyer lymphoepithelial pharyngeal ring, tongue;
• congenital and acquired violation of the normal anatomy of the maxillofacial skeleton;
• violation of the tonic and contractile mechanisms of the muscular structures of the upper respiratory tract;
• obesity.

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Pathogenesis

In conditions of mechanical damage to the structures of the walls of the upper respiratory tract that form and provide lumen, a complex set of changes occurs that determine chronic respiratory failure.

Due to the change in the geometric characteristics of the upper respiratory tract, the aerodynamics in the respiratory system is rebuilt. The change in aerodynamic indicators during wakefulness objectifies the fact of a violation (decrease) of ventilation in the upper respiratory tract during the day.

Physiological response to decreased ventilation in the airways is a change in the breathing pattern and a decrease in blood oxygenation. Clinical manifestation of a change in the breathing pattern in the examined individuals with snoring is the transition from nasal breathing to mouth breathing and a change in the breathing rhythm. As a rule, in individuals with snoring during the daytime while awake, there is a slowdown and deepening of compensatory and decompensatory respiratory movements. A study of the oxygen status of arterial blood revealed hypoxemia of the hypoxemic type in 77% of patients with snoring during the daytime while awake and in 90% of patients at night while sleeping. In 7% of those examined at night while sleeping, hypoxemia transformed into a new pathological condition - hypoxia.

Hypoxemia, hypoxia, and changes in breathing patterns revealed against the background of chronic obstruction of the upper respiratory tract allow us to speak of chronic respiratory failure in individuals with snoring.

In conditions of chronic respiratory failure with snoring, a number of natural changes occur in various parts of the body, among which are:

• disturbances in the cardiac conduction system and myocardial contractility;
• changes in the circulatory system, manifested by an increase in pressure in the general circulation and in the pulmonary artery system, the formation of hypertrophy of the right parts of the heart;
• changes in the blood system, manifested by erythrocytosis, an increase in the content and concentration of oxygen in erythrocytes, an increase in the potential capacity of the oxygen carrier in the blood, an increase in hematocrit, etc.;
• disturbances in the functioning of the lower respiratory tract, manifested by the development of irreversible pulmonary obstruction;
• a chronic metabolic disorder characterized by excessive development of adipose tissue, progressing as the disease worsens.

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Symptoms snoring

The clinical picture of snoring consists of specific signs that can be combined into groups.

The first group of signs characterizes pathological processes that form a narrowing of the lumen of the initial section of the respiratory tract.

• Deformations of the nasal septum:
  • simple curvatures (deviations);
  • diffuse thickenings;
  • partial thickening of the nasal septum (ridges, spikes);
  • partial thickenings on the ploughshare.
• Chronic rhinitis:
  • chronic simple rhinitis;
  • hypertrophic rhinitis (fibrous form);
  • hypertrophic rhinitis (cavernous form);
  • hypertrophic rhinitis with vasomotor-allergic component: polypous form.
• Acquired adhesions (synechiae) in the nasal cavity.
• Inspiratory retractions of the wings of the scythe,
• Diseases of the paranasal sinuses:
  • parietal hyperplastic sinusitis;
  • maxillary sinus cyst;
  • chronic inflammation of the ethmoid labyrinth.
• Chronic tonsillitis.
• Hypertrophy of the palatine tonsils.
• Hypertrophy of the soft palate:
  • initial form of hypertrophy;
  • obvious hypertrophy;
  • hypertrophy in obese people.
• Scar-changed soft palate.
• Chronic granular pharyngitis.
• Chronic lateral pharyngitis.
• Folded hypertrophy of the pharyngeal mucosa.
• Chronic adenoiditis, adenoid vegetations.
• Hypertrophy of the tongue.
• Infiltration of the fatty tissue of the walls of the pharynx, tongue, and peripharyngeal space.

The second group characterizes the impairment of respiratory function and is represented by clinical and laboratory signs of insufficiency of the external respiratory system.

• Snoring in sleep:
  • benign with a sound intensity of 40-45 dB, appears intermittently when lying on the back;
  • pathological with a sound level of 60-95 dB in the frequency range of 1000-3000 Hz appears during 5 nights a week;
  • loud pathological noise with a sound power of 90-100 dB appears every night.
• Difficulty breathing through the nose.
• Shortness of breath (change in breathing rate).
• Apnea (cessation of breathing during sleep),
• Feeling short of breath at night.
• Waking up with a feeling of lack of air,
• Arterial hypoxemia of the hypoxemic type.
• Reduction of partial oxygen pressure in capillaries,
• Decreased blood oxygen saturation.
• Changes in the oxyhemoglobin dissociation curve.

The third group of signs characterizes functional disorders of organs and systems in conditions of chronic respiratory failure.

• Lack of freshness in the morning, feeling of drowsiness; headache.
• Daytime sleepiness, attacks of imperative sleepiness.
• Arterial hypertension.
• Obesity.
• Cardiovascular disorders.
• Changes in hemic factors:
  • erythrocytosis;
  • increase in the concentration of hemoglobin in the red blood cell.

Forms

Snoring is divided into degrees of severity, each of which is characterized by its own characteristics of the development of the main clinical symptoms.

1. Mild degree. Benign snoring begins to transform into pathological. Loud constant snoring occurs when the patient lies on his back and stops after changing his body position. Quality of life is not changed.
2. Moderately severe. Pathological snoring is constant in all body positions, disturbs neighbors in bed. Apnea may be observed. Signs of impaired quality of life appear due to breathing disorders during sleep. Restless sleep, with awakenings. In the morning, there is no feeling of freshness, there is heaviness in the head; it takes a certain time to "get going", to become active. During the day - drowsiness.
3. Severe degree. Loud pathological snoring forces relatives and bedmates to sleep in other rooms. Characterized by sleep apnea syndrome, frequent awakenings in sleep due to lack of air, a feeling of suffocation, forced body position in sleep (semi-sitting, sitting, with the head tilted down).

Significant impairments in quality of life are observed due to sleep breathing disorders and the development of complications of hypoxemic genesis. General moderate drowsiness alternates with attacks of imperative daytime sleepiness: the patient falls asleep while driving, eating, talking, watching TV, during work, active production activity decreases, difficulties arise in performing professional duties, when visiting public places due to falling asleep with snoring breathing. Complications of hypoxemic genesis appear, such as general obesity, polycythemia, arterial hypertension, hypertension in the pulmonary circulation, cardiac disorders. Cases of fatal outcome with apnea are not uncommon.

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Diagnostics snoring

Snoring is diagnosed at the pre-hospital stage. It is based on identifying characteristic clinical signs, which include snoring, sleep apnea, changes in quality of life, and detection of diseases leading to obstruction of the upper respiratory tract. Snoring and changes in quality of life are socially significant signs: they undergo stages of progression, which allows determining the stage (phase) of the disease. Diseases of the upper respiratory tract in people with snoring are usually represented by a group of chronic diseases, the elimination of which determines the formation of an effective treatment program. Diagnostics is based on questionnaires, otolaryngological examination, study of biological markers, consultations with a therapist and pulmonologist.

The questionnaire, which includes a number of questions to the patient, his relatives and roommates, allows to assess the state of breathing during the daytime while awake and at night while sleeping, as well as the evolution of snoring, the quality of sleep, the state of health in the morning upon waking up, the severity of general and imperative sleepiness while awake. The questionnaire allows to identify clinical signs of complications of snoring, such as obesity, high blood pressure, heart rhythm disturbances, etc. An important component of the questionnaire is to identify signs of disease progression.

Laboratory research

Biological markers of snoring are quantitatively determined biological parameters such as partial pressure of oxygen, carbon dioxide, pH in arterial blood, total hemoglobin, erythrocytes.

Markers allow detection of chronic hypoxemic hypoxemia - a sign of impaired gas exchange function of the lungs: compensation of hypoxemia by hemic factors.

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Instrumental research

Otorhinolaryngological examination, including endoscopy of the ENT organs, active rhinomanometry, anthropometric examination of the pharynx and soft palate, allows us to detect diseases accompanied by nasal and pharyngeal obstruction, characterize the obstruction and changes in aerodynamic parameters in the upper respiratory tract.

Indications for consultation with other specialists

Consultations with a therapist and pulmonologist are conducted to assess the condition of the distal respiratory tract, heart function, blood pressure profile, and the state of metabolism, which is manifested by excessive development of adipose tissue.

Differential diagnosis

Snoring should be differentiated from chronic obstructive bronchitis, which in some patients may manifest as obstructive sleep apnea syndrome. Conducting X-ray and bronchological studies allows us to exclude chronic obstructive bronchitis.

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Treatment snoring

The scope and direction of snoring treatment are determined by the existing concept of the pathogenesis of the disease. Based on the fact that snoring is a combined and progressive obstruction of the upper respiratory tract, its basic therapy is the expansion of the respiratory lumen in the proximal parts of the respiratory tract and the creation of conditions for physiological breathing in the nasal cavity and pharynx. Normalization of the patency of the respiratory tract in conditions of hypertrophy and abnormal development of the structures that form their walls is possible only by a radical surgical method, therefore the main thing is to achieve the final goal - restoration of the patency of the upper respiratory tract and getting rid of snoring.

Non-drug treatment for snoring

Conservative therapy, which, in addition to complex therapy, can influence the course of the disease, improve the general condition of the patient, and reduce the severity of snoring, includes:

• weight loss up to 5 kg per year;
• quitting smoking;
• avoiding drinking alcohol, sleeping pills and other medications that affect the activity of the respiratory center before bed;
• gymnastic exercises to increase the tone of the muscles of the soft palate, uvula, and pharynx;
• taking homeopathic medicines in the form of tablets, nasal drops;
• sleeping on your side, stomach, creating conditions for uncomfortable sleeping on your back;
• the use of devices in the form of chin braces, cervical collars, devices for holding the upper and lower jaws in a closed position to prevent the tongue from falling back, and nasal airways;
• CPAP therapy (continuous, positive, airways, pressure).

Surgical treatment of snoring

The following types of surgical interventions are considered methods of surgical treatment of patients with ronchopathy:

• uvulopalatopharyngoplasty;
• submucous resection of the nasal septum;
• lower conchotomy (unilateral or bilateral);
• bilateral tonsillectomy;
• dissection of adhesions in the nasal cavity;
• endonasal dissection of the ethmoid labyrinth cells and polypotomy of the nose on both sides;
• removal of adenoid vegetations.

A mandatory condition for uvulopalatopharyngoplasty, leading to lasting results, is tonsilectomy, which is necessary to strengthen the lateral walls of the pharynx by suturing the base of the palatine arches with the underlying tissues of the intercostal region.

The use of gentle methods to get rid of snoring in the form of individual interventions in outpatient settings, such as cryodestruction, the use of laser, radiofrequency incisions on the soft palate, as well as the removal of excess mucous membrane of the soft palate, do not provide the desired effect, and in some cases worsen pharyngostenosis.

The hospitalization period for a full surgical intervention is 5-7 days.

Further management

Recommendations in the postoperative period include quitting smoking, a healthy lifestyle with sufficient physical activity, and an annual weight loss of 5 kg.

Prevention

Prevention of snoring includes medical and general hygiene measures. Medical measures are aimed at preventing and promptly eliminating the obstructive condition in the upper respiratory tract. The complex of medical preventive measures for snoring includes:

• adenotomy (advisable at the age of 3-5 years);
• tonsillotomy and tonsillectomy (at the age of 8-12 years);
• plastic surgery on the nasal septum (at the age of 17-20 years);
• early sanitation of foci of chronic infection in the ENT organs and oral cavity;
• timely surgical correction of congenital and acquired deformation of the external nose;
• a technique for moving the upper and lower jaw forward in order to eliminate retro- and micrognathia of the lower jaw.

General hygienic prevention of snoring is aimed at reducing (eliminating) risk factors for respiratory disorders during sleep and includes such measures as:

• control and reduction of body weight;
• quitting smoking;
• abstaining from drinking alcohol before bedtime;
• exclusion of the use of muscle relaxants, benediazepines, barbiturates, antidepressants;
• creating conditions for uncomfortable sleeping on the back by inserting a ball or tennis ball into a pocket sewn onto the back of the pajamas;
• sleeping in a bed with the head end elevated;
• sporty lifestyle.

Forecast

The period of general disability of the patient is 14-21 days. The prognosis of snoring is determined by the continued action of the main factors - a progressive decrease in the airway lumen in the upper respiratory tract and an increase in respiratory failure. Hypoxemia contributes to hematological disorders, hypertension, cardiac arrhythmia and can lead to sudden death during sleep. Timely adequate surgical treatment can rid the patient of snoring for many years.