Patient information brochure OSAS.

Snoring and obstructive sleep apnea (OSA)

A healthy sleep consists of five to six sleep cycles of an hour and a half, in which both deep sleep and the so-called Rapid Eye Movement sleep (REM sleep), also known as dream sleep, play an important role. With obstructive sleep apnea, the quality of this healthy sleep is disrupted. Snoring means that a sawing, rushing, or humming sound is made when breathing during sleep. This sound can be so loud that a partner, housemate, or neighbor can be bothered by it. Obstructive sleep apnea means that in addition to snoring, there are also apneas (breathing stops of 10 seconds or longer), in combination with complaints such as severe fatigue, falling asleep during the day, and concentration problems. We speak of OSA if five or more breathing pauses per hour are measured, averaged over the night.

How do snoring and OSA develop? During breathing, the air (red line in image figure 1 below) goes through the nasal cavity (1), the throat cavity (2) to the lungs (3).

Snoring is caused by a narrowing of the airway in the passage between the entrance of the nose (nostrils) and the vocal cords. During inhalation, this narrowing creates negative pressure in the throat, causing the soft palate with the uvula, the tongue, and the walls of the pharynx to be pulled toward each other and vibrate. This is what produces the snoring sound.

Snoring sounds can be compared to air escaping from an inflated balloon: a large amount of air flows very quickly through a narrow passage, causing this narrow part to vibrate and make sound.

With Obstructive Sleep Apnea (OSA), in addition to snoring, there are also apneas—pauses in breathing that last longer than 10 seconds. During an apnea, the tongue and/or the soft palate with the uvula and/or the throat wall are completely sucked together, resulting in a total blockage of the airway: a cessation of breathing.

A diagnosis of OSA is made when someone:

• Has a cessation of breathing more than 5 times per hour at night AND
• Is sleepy or fatigued during the day AND
• There is no other reason for the severe daytime sleepiness or fatigue, such as sleep deprivation or insomnia.

These pauses in breathing are expressed in the Apnea-Hypopnea Index (AHI):

• Snoring: Fewer than 5 breathing stops per hour
• Mild sleep apnea: 5 to 15 breathing stops per hour
• Moderate OSA: 15 to 30 breathing stops per hour
• Severe OSA: More than 30 breathing stops per hour

Position-dependent sleep apnea (pOSA) occurs when the number of apneas while sleeping on one’s back (supine position) is twice as high as in non-supine positions.

Important Note: There is no danger of suffocation. The brain issues an alarm signal, causing the patient to sleep less deeply or even wake up. The muscles in the soft palate and the tongue tighten, pulling the pharynx open so that normal breathing can resume. The patient then falls back asleep until the next apnea occurs.

Symptoms Caused by Snoring and OSA

• Snoring
• Breathing stops, which can wake up the patient and/or their partner
• Waking up feeling unrefreshed
• Extreme fatigue
• Concentration difficulties
• Involuntarily falling asleep during the day
• Waking up with a headache

Due to the apneas and alarm signals from the brain, sleep quality is poor. The patient is barely, if at all, able to reach a deep enough sleep. The sleep apnea patient wakes up unrefreshed and experiences daytime sleepiness. This does not just mean being tired; it means truly and involuntarily falling asleep—for example, during a conversation, while reading the newspaper, or sometimes even during activities like driving. This can lead to dangerous situations, not only for the patient but also for others. Because sleep is so poor, daytime concentration is impaired, and the patient can be very forgetful.

Possible Physical Consequences of Untreated OSA

• High blood pressure (hypertension)
• Increased risk of a heart attack
• Increased risk of a stroke
• Increased risk of becoming overweight
• Forgetfulness and concentration difficulties
• Impotence

Due to the alarm signals from the brain, fluctuations in blood pressure occur; this strains the heart and blood vessels, which can lead to chronic high blood pressure.

The increased risk of weight gain occurs because an imbalance can develop between two hormones (ghrelin and leptin) produced by the stomach wall. Ghrelin stimulates appetite, while leptin signals that you are full. Disrupted sleep increases ghrelin and decreases leptin release.

Note: This is a chicken-and-egg story. Being overweight increases your risk of OSA, but OSA can also make it harder to lose weight. Both should therefore be treated simultaneously.

Thus, snoring is not just annoying for the partner; apneas are also harmful to the health of the patient. The body and mind receive less rest. A sleep apnea patient cannot recover as well at night, meaning it could be said that this patient “wears out” faster. Consequently, the life expectancy of someone with pronounced and untreated sleep apnea is shorter.

Who Snores and Has Obstructive Sleep Apnea?
Snoring occurs at all ages and increases with age. About one in ten children snores. Apneas also occur in children with very large tonsils and/or adenoids.

In adulthood, about one in five men and one in ten women snore every night. Men therefore snore more than women. In women, snoring and sleep apnea increase after menopause. Snoring usually begins between the ages of 30 and 40. At an older age, more people snore, and the snoring sound is louder. This is because the lining of the pharynx thickens with age due to the accumulation of fatty tissue, making the diameter of the airway smaller. Furthermore, just like the skin, mucous membranes become slacker at an older age, making them vibrate more easily.

What Factors Promote Snoring and Obstructive Sleep Apnea?
Snoring and obstructive sleep apnea are promoted by conditions that narrow the airway between the nasal entrance and the vocal cords:

• Enlarged tonsils and/or adenoids: This occurs mainly in children.
• Sleeping on the back: This causes the soft palate, uvula, and tongue to drop backward.
• Anatomy: A naturally long and slack soft palate and uvula.
• Muscle relaxation: Weakening of the muscles of the soft palate, uvula, and tongue due to overtiredness and aging.
• Overweight/Obesity: Fatty tissue also deposits in the walls of the pharynx and in the tongue.
• Alcohol and medications: Alcohol and certain medications (sleeping pills, sedatives) reduce muscle tone, causing them to relax.
• Irritation: Smoking or acid reflux (due to a hiatal hernia) can cause continuous irritation of the throat, thickening the wall of the pharynx and narrowing the passage.
• Nasal congestion: Blockage due to swelling of the nasal mucosa (with colds and allergies) or polyps (fluid-filled growths of the nasal mucosa), which creates excessively low air pressure in the pharynx during inhalation.

Lifestyle Guidelines to Prevent Snoring and OSA

• Avoid alcohol consumption starting two hours before bed.
• Quit smoking.
• Aim for a healthy body weight with a good BMI by eating healthily and getting enough exercise. A rule of thumb is that your height (above one meter) in centimeters equals your ideal weight (in kilograms). To calculate BMI, you can visit the Netherlands Nutrition Centre (Voedingscentrum) website.
• Maintain a regular sleep and lifestyle pattern.
• Avoid sleeping pills and sedatives if possible.
• Sometimes the simplest solution for snoring is fitting the bed partner with earplugs or noise-canceling earplugs.

How Is the Cause Diagnosed?
The ENT specialist (Ear, Nose, and Throat doctor) will ask about your symptoms and lifestyle factors such as smoking, alcohol consumption, medication use, or weight gain. After this, the ENT specialist will examine your nose and throat to assess where narrowings are located. An appointment will then be made to perform a sleep study, also known as a polygraphy (PG).

What is a Polygraphy?
To determine whether you experience only snoring or also obstructive sleep apnea, an overnight measurement must be performed during sleep. This is called a polygraphy, or PG. Using electrodes, your blood pressure and blood oxygen levels are recorded. The study also measures how often apneas occur and how loudly you snore.

To determine if there is position-dependent sleep apnea (pOSA), the study tracks how often the patient lies on their back versus other positions, and measures the AHI in both the supine and non-supine positions.

What Treatment Options Are Available?
It is important to realize that if only snoring is diagnosed, health insurers will cover the diagnostics but not the treatment. If OSA is diagnosed, the treatment falls under covered medical care. In principle, there are four treatment methods in addition to the lifestyle advice mentioned above:

1. Position Therapy with the Sleep Position Trainer (SPT)
Two-thirds of patients, particularly those with mild OSA, suffer from position-dependent OSA. The goal of treatment with the Sleep Position Trainer (SPT) is to minimize the time the patient spends sleeping on their back. The treatment is non-invasive and involves wearing a band around your waist at night containing a small, flat device that records your body position. If you lie on your back, the device emits a vibration, similar to that of a mobile phone. The majority of patients learn to roll off their back in this way without waking up.

2. Mandibular Repositioning Device (MRA)
Another non-surgical treatment for snoring and OSA is the use of a type of brace—a plastic appliance worn over the teeth of the upper and lower jaw at night. This prosthesis is called an MRA: Mandibular (mandibula = lower jaw) Repositioning Device.

The device ensures that the lower jaw cannot drop backward during sleep. Because the tongue is attached to the lower jaw, it stays better in place and is less likely to collapse into the throat. This also applies to the epiglottis and, to a lesser extent via attached muscles, the soft palate. The airway at the back of the throat remains more open during sleep, making snoring and apneas less likely to occur. An MRA is effective for treating snoring and OSA caused by obstruction at the level of the base of the tongue and epiglottis, and to a lesser extent at the level of the soft palate and uvula.

Good to know:

• The prosthesis does not need to be worn every night if there is only snoring, but only when sleeping with someone who is bothered by it.
• The prosthesis must be purchased even though it is not clear beforehand whether it will be tolerated. Some people find wearing the prosthesis too uncomfortable and choose not to use it.
• Pain in the jaw joints (TMJ) can occur during the adjustment period.
• This method can be applied to patients with full dentures if two or more implants are present in the lower jaw.
• A dentist or oral surgeon specialized in fitting an MRA must evaluate your teeth. An X-ray of your teeth will be taken first. This specialist will fit the MRA and handle your follow-up appointments.
• If you only snore and the costs are not covered by insurance, you should expect an expense of 700 to 1,200 euros, depending on the type of prosthesis.

3. Surgery by the ENT Specialist
In children, snoring and OSA can often be resolved by removing the tonsils and/or adenoids. In adults, the surgeries performed in the hospital are:

• At the level of the soft palate: BRP (also called ESP)
• At the level of the tongue: thermotherapy of the base of the tongue

Barbed Reposition Pharyngoplasty (BRP), also called Expansion Sphincter Pharyngoplasty (ESP)
In this surgery, the soft palate is tightened using a special dissolvable suture. This suture has tiny barbs, which is where the name “barbed wire” comes from. In principle, the uvula is left untouched. If you still have your tonsils, they will be removed at the same time. This operation widens the transition from the nose to the throat, and snoring disappears in a significant portion of patients.

The surgery also has disadvantages:

• Swallowing is very painful immediately following the surgery. This sometimes lasts up to two weeks, meaning patients often cannot work during this time.
• A dry sensation or a feeling of a lump in the throat can sometimes remain.
• Pronouncing a hard “g” sound (as spoken in Dutch) may change.
• In exceptional cases, the soft palate can become too short, meaning the back of the nasal cavity can no longer close properly. When drinking, fluid may come out through the nose. This is usually a temporary problem; occasionally, surgery is required to lengthen the soft palate slightly.

Thermotherapy of the base of the tongue
In less common cases where snoring and obstruction originate at the back of the tongue, radiofrequency energy can be used to stiffen the back of the tongue through controlled scarring.

Sometimes, we refer you to a specialized center for a procedure that can be useful for a limited, selected group of OSA patients: Hypoglossal Nerve Stimulation (Upper Airway Stimulation, UAS) via a pacemaker, which keeps the airway open at night. Currently, this surgery is only performed at OLVG West in Amsterdam and at the St. Antonius Hospital in Nieuwegein. There is also the option of extensive surgery by an oral surgeon, where the lower and upper jaws are moved forward (maxillomandibular advancement). This usually requires pre- and/or post-treatment by an orthodontist.

4. CPAP (Positive Airway Pressure Mask)
For patients with severe OSA and frequent breathing stops, using a positive airway pressure mask is often the best treatment method. This is called CPAP, an abbreviation for Continuous Positive Airway Pressure.

This involves wearing a mask connected by a hose to a device that acts like a reverse vacuum cleaner. The device continuously pumps air into the nose and throat during both inhalation and exhalation. This creates positive pressure, preventing the walls of the pharynx from collapsing. As a result, far fewer breathing stops occur, and snoring usually disappears as well.

The fitting of and care surrounding CPAP is managed through the pulmonology department. Sleeping with CPAP requires adaptation and time, especially in the beginning. However, for many individuals with pronounced daytime sleepiness who manage to sleep with the CPAP for a sufficient number of hours, a significant improvement in sleep quality and daytime functioning will be noticeable.

Making a Treatment Choice
To help you make a decision, a consultation card (option grid) has been created. Consultation cards are explicitly intended as a tool for the conversation between doctor and patient to promote shared decision-making in the care process. Patients can also take the consultation card home to quietly review all options again after the consultation.

Conclusion
It is not possible to describe all the details of snoring and obstructive sleep apnea in this information brochure. It may be that despite the explanation from your ENT specialist or pulmonologist, you still have questions or would like more information. Do not hesitate to contact your doctor and ask for further clarification. They will be happy to assist you.