Snore

Rhonchopathy (Greek ronchus - snoring, wheezing) is a chronic progressive disease manifested by obstruction of the upper respiratory tract and chronic respiratory failure leading to syndromal shifts in the body of a compensatory and decompensatory nature. There are primary snoring (benign, simple, usual), pathological snoring (chronic, regular, habitual, unusual), snoring.

Epidemiology

The conducted epidemiological studies allow us to speak about the widespread spread of snoring among the population of the world. The snoring suffers 20% of the general population and 60% of those over the age of 40. In Finland, habitual snoring occurs in 30% of the population aged 40 to 69, in Sweden - 15.5% of the population from 30 to 69 years. The prevalence of snoring among Koreans is 35.2%, among French men - 32%, among Singaporeans 30-60 years - 48%,

The most predisposed to the snoring of a man. A study conducted among the European population showed that 50% of men and 2-3% of women had permanent snoring. In a large-scale study conducted in Wisconsin, habitual snoring was observed in 44% of men and 28% of women. In America, snoring affects 31% of men and 17% of women; in Japan, 16% of men and 6.5% of women.

[1], [2], [3], [4], [5], [6],

Causes of the snore

The etiological factor of snoring is infection - there is an inadequate damage to the microbial flora of the upper respiratory system. The inadequacy of 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. At the same time obstruction in the upper respiratory tract has a complex and progressive nature: a complex character is due to a simultaneous narrowing of the respiratory lumen in the nasal cavity, pharynx, mouth; progressive character - a steady increase in tissue hypertrophy.

Clinical experience suggests that in persons with snoring the occurrence and chronic inflammation in the cavities of the upper respiratory tract in response to microbial invasion begins in childhood, mainly up to 12 years. The place of development of focal inflammation is the lymphoid tissue associated with the mucous membrane of the upper respiratory tract - the lymphoepithelial pharyngeal ring of Pirogov-Valdeier.

Implementing the pathogenic action of the main causative factor (infection) is facilitated by certain conditions, which include:

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

[7], [8]

Pathogenesis

In the conditions of mechanical damage of the structures of the walls of the upper respiratory tract, forming and providing a lumen, a complex complex of changes arises that determines chronic respiratory failure.

Due to changes in the geometric characteristics of the upper respiratory tract, aerodynamics in the respiratory system is reconstructed. The change in aerodynamic indices during wakefulness objectifies the fact of the violation (reduction) of ventilation in the upper parts of the respiratory tract during the day.

The physiological response to a decrease in ventilation and airways is the change in the respiratory regime and the decrease in oxygenation of the blood. The clinical manifestation of changes in the respiratory regime in the examined individuals with snoring is the transition from nasal breathing to breathing with the mouth and a change in the rhythm of breathing. As a rule, in people with snoring during the daytime when awake, there is a slowing and deepening of respiratory movements of compensatory and decompensatory nature. The study of the oxygen status of arterial blood revealed hypoxemia of the hypoxemic type in 77% of patients with snoring during the daytime with wakefulness and in 90% of patients at night in sleep. In 7% of those examined at night in a dream, hypoxemia was transformed into a new pathological state - hypoxia.

Hypoxemia, hypoxia, as well as changes in the respiratory regime, revealed on the background of chronic obstruction of the upper respiratory tract, allow us to speak of chronic respiratory failure in persons with snoring.

In conditions of chronic respiratory failure, a number of regular changes occur in various parts of the body, among which:

• disorders in the conduction system of the heart and myocardial contractility;
• changes in the circulatory system, manifested by increased pressure in the general circulatory system and in the pulmonary artery, the formation of hypertrophy of the right 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 .;
• violations in the functioning of the lower respiratory tract, manifested by the development of irreversible obstruction of the lungs;
• chronic metabolic disorder, manifested by excessive development of adipose tissue, progressing as the disease worsens.

[9], [10], [11], [12]

Symptoms of the snore

The clinical picture of snoring consists of specific features that can be combined into that group.

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

• Deformities of the septum of the nose:
  • simple curvatures (deviations);
  • diffuse thickening;
  • partial thickening of the septum of the nose (crests, thorns);
  • partial thickenings on the vomer.
• Chronic rhinitis:
  • rhinitis chronic simple;
  • rhinitis hypertrophic (fibrous form);
  • rhinitis hypertrophic (cavernous form);
  • Rhinitis is hypertrophic with a vasomotor-allergic component: a polypous form.
• Acquired adhesions (synechiae) in the nasal cavity.
• Inspiration of the wings of the spit,
• Diseases of the paranasal sinuses:
  • parieto-hyperplastic maxillary sinusitis;
  • cyst of the maxillary sinus;
  • chronic inflammation of the trellis labyrinth.
• Chronic tonsillitis.
• Hypertrophy of palatine tonsils.
• Hypertrophy of the soft palate:
  • the initial form of hypertrophy;
  • obvious hypertrophy;
  • hypertrophy in obese people.
• Scarred-modified soft palate.
• Chronic granulosis pharyngitis.
• Chronic lateral pharyngitis.
• Folded hypertrophy of the pharyngeal mucosa.
• Chronic adenoiditis, adenoid vegetations.
• Hypertrophy of the tongue.
• Infiltration of adipose tissue of the pharyngeal wall, tongue, okolohlotochechnoy space.

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

• Snoring in a dream:
  • benign with a sound power of 40-45 dB appears unstable when positioned on the back;
  • pathological with a sound power of 60-95 dB in the frequency range of 1000-3000 HZ appears for 5 nights a week;
  • a loud pathological with a sound power of 90-100 dB appears every night.
• Difficulty with nasal breathing.
• Dyspnea (change in respiratory rate).
• Apnea (cessation of breathing in sleep),
• Feeling of lack of air at night.
• Awakening from a feeling of lack of air,
• Arterial hypoxemia of the hypoxemic type.
• Reduction of the partial oxygen tension in the capillaries,
• Reducing the saturation of blood with oxygen.
• Change in dissociation curve of oxyhemoglobin.

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

• Lack of morning freshness, feelings of rash; headache.
• Drowsiness during the day, attacks of imperative sleepiness.
• Arterial hypertension.
• Obesity.
• Cardiovascular disorders.
• Change in hemic factors:
  • erythrocytosis;
  • an increase in the concentration of hemoglobin in the erythrocyte.

Forms

Snoring is divided into severity levels, each of which has its own characteristics of the development of the main clinical symptoms.

1. An easy degree. A benign snore begins to transform into a pathological one. Loud constant snoring manifests itself in the position of the patient on the back and stops after changing the position of the body. Quality of life is not changed.
2. The moderate degree. Snoring is a pathological permanent in all positions of the body, disturbs the neighbors by dreaming. Apnea may occur. There are signs of a violation of the quality of life due to a violation of breathing in a dream. Sleep restless, with awakenings. In the mornings there is no feeling of freshness, there is a heaviness in the head; It takes a certain amount of time to "disperse" and come to an active state. During the day - drowsiness.
3. Heavy degree. Loud pathological snoring causes relatives and neighbors to sleep in other rooms. Characteristic of the syndrome of nighttime apnea, frequent awakening in a dream due to lack of air, sensation of suffocation, forced position of the body in a dream (semi-sitting, sitting, with a head inclined downwards).

There are significant violations of the quality of life due to breathing disorders in the sleep and development of complications of hypoxemic genesis. General mild drowsiness alternates with attacks of imperative daytime sleepiness: the patient falls asleep at the wheel, while eating, talking, watching TV, during work, active production activity decreases, difficulties arise in performing professional duties, visiting public places due to falling asleep with snoring breathing. There are complications of hypoxemic genesis, such as general obesity, polycythemia, arterial hypertension, hypertension in a small circle of circulation, and cardiac arrhythmias. Cases of death in cases of apnea are common.

[13], [14]

Diagnostics of the snore

Diagnosis of snoring is carried out at a prehospital stage. It is based on the identification of characteristic clinical signs, which include snoring, nighttime apnea, a change in the quality of life, the identification of diseases leading to obstruction of the upper respiratory tract. Snoring and changing the quality of life are socially significant signs: they undergo stages of progression, which makes it possible to determine the stage (phase) of the disease. Diseases of the upper respiratory tract in persons with snoring are, as a rule, a group of chronic diseases, the elimination of which determines the formation of an effective treatment program. Diagnosis is based on questionnaires, otorhinolaryngological examination, study of biological markers, consultations of the therapist and pulmonologist.

The questionnaire, which includes a number of questions to the patient, his relatives and neighbors on joint nuu, allows to assess the state of breathing during the daytime while awake and at night in a dream, as well as the evolution of snoring, sleep quality, well-being in the morning when waking up, the severity of the general and imperative sleepiness during wakefulness. The questionnaire allows you to find out the clinical signs of complications of snoring, such as obesity, increased blood pressure, heart rhythm disturbances, etc. An important component of the questionnaire is the identification of signs of disease progression.

Laboratory research

Biological markers of snoring are quantifiable biological parameters, such as the partial voltage of oxygen and carbon dioxide. PH in the arterial blood, total hemoglobin, erythrocytes.

Markers can detect chronic hypoxemic hypoxemia - a sign of impaired gas exchange function of the lungs: compensating hypoxemia with hemic factors.

[15], [16], [17], [18], [19]

Instrumental research

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

Indications for consultation of other specialists

Consultations of the therapist, pulmonologist are carried out with the purpose of an estimation of a condition of a distal department of respiratory ways, functions of heart, a profile of arterial pressure; the state of metabolism, manifested by excessive development of adipose tissue.

Differential diagnosis

Snoring should be differentiated from chronic obstructive bronchitis, which in a number of patients may manifest as obstructive sleep apnea. Carrying out x-ray and bronchological examinations allows to exclude chronic obstructive bronchitis.

[20], [21], [22], [23]

Treatment of the snore

The volume and direction of treatment for snoring 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, the 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. Normalize the patency of the airways in conditions of hypertrophy and abnormal development of the structures that form their walls, can only be a radical surgical method, so the main is to achieve the ultimate goal - restoring the patency of the upper respiratory tract and getting rid of snoring.

Non-pharmacological treatment of snoring

Conservative therapy, capable of affecting the course of the disease in the octane of complex therapy, improving the general condition of the patient, reducing the severity of snoring, includes:

• decrease in body weight to 5 kg per year;
• to give up smoking;
• the refusal to use alcohol before bedtime, hypnotics and other drugs affecting the activity of the respiratory center;
• gymnastic exercises to increase the tone of the muscles of the soft palate, tongue, pharynx;
• taking homeopathic medicines in the form of tablets, drops in the nose;
• sleep on the side, abdomen, creating conditions for uncomfortable sleep on the back;
• the use of devices in the form of braces for the chin, cervical collar, devices for holding the upper and lower jaw and closed state to prevent tongue and nasal airways;
• CAP-therapy (English continuous - permanent, positive positive, airways - airways, pressure - pressure).

Surgical treatment of snoring

The methods of operative treatment of patients with rhonchopathy include the following types of surgical interventions:

• uvulopalato-pharyngoplasty;
• submucosal resection of the septum of the nose;
• lower connotomy (one-sided or bilateral);
• bilateral tonsillectomy;
• dissecting synechia in the nasal cavity;
• endonasal opening of cells of the latticed maze and polypotomy of the nose from both sides;
• removal of adenoid vegetation.

A prerequisite for uvulopalatopharyngoplasty, leading to persistent results, is the tonsillar necrosis necessary to strengthen the side walls of the pharynx by stitching the base of the palatine arches with the underlying tissues of the intercostal region.

The use of sparing methods for getting rid of snoring in the form of separate interventions in outpatient settings, such as cryodestruction, the use of laser, radio frequency incisions on the soft palate, and the removal of excess mucous membrane of the soft palate, do not give the proper affect, and in some cases aggravate pharyngostenosis.

The terms of hospitalization with a full scope of surgical intervention are 5-7 days.

Further management

Recommendations in the postoperative period include excluded smoking, a healthy lifestyle with sufficient physical activity, an annual decrease in body weight of 5 kg.

Prevention

Prophylaxis of snoring includes therapeutic and general hygiene measures. Therapeutic measures are aimed at preventing and timely removal of the obstructive condition in the upper respiratory tract. The complex of therapeutic preventive measures of snoring includes:

• adenotomy (advisable at the age of 3-5 years);
• tonsillotomy and tonsillusctomy (aged 8-12 years);
• plastic surgery on the septum of the nose (aged 17-20 years);
• early sanation 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 jaws forward in order to eliminate retro and micrognathy of the lower jaw.

General hygienic prevention of snoring is aimed at weakening (excluding) risk factors for respiratory disorders in sleep and includes such activities as:

• control and weight loss;
• to give up smoking;
• abstaining from alcohol before bedtime;
• Exclusion of the use of muscle relaxants, benzodiazepines, barbiturates, antidepressants;
• creating conditions for uncomfortable sleep on the back by investing in a sewn on the back pajamas of a ball pocket, a tennis ball;
• sleep in the bed, the head end of which is raised;
• sports lifestyle.

Forecast

The total incapacity for work 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 respiratory clearance in the upper respiratory tract and an increase in respiratory failure. Hypoxemia promotes hematological disorders, hypertension, cardiac arrhythmia and can lead to sudden death during sleep. Properly conducted adequate surgical treatment can save the patient from snoring for many years.