Introduction written by the editorial staff, followed by the report drafted by Dr. Michel - Updated 28/01/2010

According to your context, and the rest of your symptoms..your doctor has diagnosed a depression.

But what if the symptoms persist despite treatment ?...

According to psychiatrists and ear, nose and throat (ENT) specialists interviewed, the diagnostic work-up should be pursued because these symptoms can also indicate the presence of a sleep disorder. 

If in doubt, further consultation with sleep specialists can then be necessary. 

Few simple tests you can do yourself before reading this file:

- Ask the person close to you if you snore

- Take the test Epworth below to assess your daytime sleepiness. This survey is provided as a reference.

In case of doubt, it is essential to consult a doctor or an ENT specialist better sleep.

EXPLANATION OF SLEEP DISORDERS

by Dr. Michel - ENT surgeon in Paris - Updated January 28, 2010

Contents:

• Excessive Diurnal Sleepiness (EDS)
• Snoring
• Mechanisms of snoring
• Treatment of snoring
• Upper Airway Resistance Syndrome (UARS)
• Patients less well treated?
• Treatment of UARS
• Syndrome of Obstructive Sleep Apnea (OSA)

You are fatigued, you feel constantly tired, you fight to stay awake and be able to concentrate, you have memory problems and those around you find that you have changing moods, irritable. These symptoms can also be caused by the syndrome of Excessive Diurnal Sleepiness (EDS) that affects about 11% of the French population. (note 1)

Excessive  Diurnal Sleepiness (EDS) is characterized by involuntary drowsiness that happens at completely inappropriate moments during the day (at work, during business meetings, while driving, etc.)

This somnolence can be transitory, secondary to a time difference, or to a voluntary and temporary lack of sleep.  On the other hand, once the sleepiness continues for a long time, it can cause real health problems and merits a detailed exploration. 

• One of the most frequent causes of Excessive Diurnal Sleepiness (EDS) is Obstructive Sleep Apnea Syndrome (OSA) that affects especially middle-aged men who are overweight. This involves repeated obstructions of the soft tissue part of the airway during inspiration, resulting in respiratory arrests (apneas) and a decrease in oxygenation during sleep. The number, intensity and duration of these respiratory arrests, as well the nighttime oxygenation levels, are the parameters that can be measured to establish the severity of the OSA. Many studies have shown that patients with OSA can have cardiovascular complications. It has been shown as well that the number of auto accidents is significantly higher in patients with OSA due to their decreased state of vigilance.  
• Upper Airway Resistance Syndrome (UARS) is another cause of excessive diurnal sleepiness. This syndrome affects patients with obstructions in the nose or throat that cause a narrowing of the airway. In these patients, the neurological mechanisms allowing for « stabilization » the airway tissues during sleep are effective, preventing the collapse of the soft tissues and respiratory arrests (note 2). Notwithstanding, the effort of getting enough air into the lungs is considerable and is accompanied by micro-awakenings that fragment sleep and make it of lesser quality. 

Other causes of excessive diurnal  sleepiness exist :

• Periodic Limb Movement Disorder, often included with Restless Legs Syndrome, affects about 5% of young adults, and its frequency appears to increase with age (note 3). Two times more common in women, these parasomnias present with involuntary foot movements that occur every 30 seconds and awaken the bedmate and, sometimes, even the patient.  These movements are responsible for lightening and fragmenting sleep. The cause is a dysfunction of a cerebral neurotransmitter (striated dopamine). Certain medications used for Parkinson’s disease have shown some effectiveness in this disorder.  
• Patients suffering from depression or anxiety often sleep a lot during the day, no matter how much they have slept at night. For certain authors (note 4), depression is a cause that is at least as frequent for daytime sleepiness as obstructive sleep apnea syndrome (OSA).  
• Narcolepsy is a neurological illness characterized by a severe somnolence. It appears as real « attacks » of sleep that the patient cannot usually resist with the patient suddenly  and quickly falling asleep, only to wake up some time later. This illness starts in adolescence and thankfully is much more rare than the other causes of EDS. Test your degree of daytime sleepiness by completing the Epworth self test.

(1) : Teculescu D, Mayeux L Montaut Verient-B, Michaely JP, Wall JM. An epidemiologic study of sleep-disordered breathing in the male population of Lorraine: preliminary results. Public Health. 1998 Aug, 10 (2) :177-90. (2) : Bao G, Guilleminault C. Upper airway resistance syndrome-one decade later ". Curr Opin pulm Med. 2004 Nov; 10 (6) :461-7. (3) : Högl B, Kiechl S, Willeit J, Saletu M et al. Restless legs syndrome. A community-based study of prevalence, severity, and risk factors. Neurology 2005; 64:1920-1924. (4) : Bixler EO, Vgontzas AN, Lin HM, Calhoun SL, Vela-Bueno A, Kales A. Excessive daytime sleepiness in a general population sample: the Role of sleep apnea, age, obesity, diabetes, and depression. J Clin Endocrinol Metab. 2005 Aug; 90 (8) :4510-5. Epub 2005 Jun 7

Snoring

Snoring is a respiratory noise which occurs during sleep that is generally not perceived by the patient but which can considerably bother those around him/her.

If in the past it was just a subject for joking, today snoring is a more and more frequent cause for consultation.

On a social level, snoring can be a real problem for couples, forcing the couple to sleep in separate rooms. If its intensity is important, snoring can be very distressing for the entourage, spoiling trips or vacations among friends. Snoring is frequently associated with other obstructive respiratory problems such as Obstructive Sleep Apnea Syndrome (OSA), or Upper Airway Resistance Syndrome (UARS).

It is important to distinguish between « simple » snoring which only affects social life from that associated with OSA or UARS, which represents a real illness with the possibility of causing serious cardiovascular problems. ( 1).

1. Waller PC, Bohpal RS. Is Snoring a cause of vascular disease: An Epidemiological Review. Lancet 1989; 1:143-146

The mechanisms of snoring

It has been shown that during sleep, normal respiration is through the nasal passages

1. Under normal conditions, air goes through the nasal passages where it is humidified and filtered, then through the throat by passing behind the palate and tongue, then down the larynx and trachea to get to the lungs. Important gas exchanges happen at the pulmonary alveolar level before the air returns via the same path in reverse. In snorers, many mechanisms cause respiration to happen via the mouth rather than the nose. It has been shown that the air resistance on its way down to the lungs is greater when breathing is through the mouth than when it is through the nose.

2. Inspiratory muscles must work harder to overcome this increased resistance. In consequence, the speed of the air passing through the throat is higher and friction against tissues is increased. These forces of friction cause the vibrations of soft tissue in the throat. These tissues are those with no underlying bony or cartilaginous skeleton, in other words, the least rigid tissues that vibrate : the soft palate and uvula, the tongue and lateral walls of the throat.

• a blocked nose increases the force deployed by the lungs to make the air enter the narrowed nasal passages. If the nasal obstruction is significant, the mouth opens and the tissue vibrations appear.  
• the position of lying on one’s back indisputably facilitates snoring. In this position, the soft palate and tongue fall backwards more easily and therefore approach the back wall of the throat more closely, thereby decreasing even more the caliber of the airway. Air speed will be increased (Bernouli) which will inevitably result in a vibration of the soft tissues in question.
• Excess body weight is also traditionally associated with snoring. However, we are finding more and more snoring patients who consult ENT’s who are not overweight. This questions the role of excess weight in snoring. In contrast, the role of excess body weight in Obstructive Sleep Apnea Syndrome is undeniable and will be described in the appropriate chapter. What are the treatments which have proven effectiveness? For a treatment to be effective it needs to first be accepted and followed by the patients. For that, the benefit hoped for should be greater than the constraints of the treatment itself.

Treatment of snoring

Snoring is a multifactorial problem and needs a rigorous plan of care .Most often, treatment failures are due to an incomplete analysis of the different causes and factors responsible for the snoring. This leads to a maladapted treatment plan which most often leads to failure.

In this way, treating a soft palate without taking into account a blocked nose, or a tongue that is too large generally ends in a disappointing result. As well, proposing a surgical treatment without having tried postural treatment of an adapted hygiene and diet diminishes the chances of success.

Consequently, it appears important to us to adopt a hierarchical and  reasonable plan of treatment, taking into consideration all the elements that could be contributing to the snoring.

Several stages should be respected :

Respect a certain lifestyle : light meal without alcohol in the evening, weight loss dietary regime if excess weight

Postural treatment : avoid sleeping lying down on your back. Using certain tricks such as tennis balls sewn into the back of your pajamas or using other aides available in the marketplace that keep the patient from sleeping on his/her back can be very effective.

The effective treatment of a blocked nose is very important. It is better to detect and effectively treat all rhinitis or chronic rhino-sinusitis, a source of persistent inflammation of the mucous membranes and nasal obstruction. In certain cases, medical treatment must be continued daily in the long term.

The obstacle can be located in different places:

At the entrance, at the level of the nostrils: The region of the valve can easily close during inspiration when it has certain malformations. 

Nasal septum deviations: They can considerably narrow the nasal air passages especially if they are located at the entrance to the nose. 

In the middle part of the nose, the inferior concha: This can be the cause of important obstruction intermittently, with movements or certain positions.

At the level of the throat, many structures should be considered:

• Tonsils : If they are very large, they can be a real obstacle to breathing.
• The soft palate and the uvula can also be part of the problem is they are excessively long or lack tone.
• The tongue that is too large can be a formidable obstacle. The goal of treatment in these patients is to advance the jaw and tongue forwards during sleep to liberate the airway. Individual appliances that are custom-made can be very useful in these patients. Used at night in the mouth, they are usually well tolerated, as long as the nose is perfectly open.

Upper Airway Resistance Syndrome (UARS) 

You snore and you are tired, but you do not have apneas ? This is possible.

The explanation could be the upper airway resistance symdrome – UARS- described in 1992 by Guilleminault and his team at the Stanford Sleep Research Center, California ( 1). These researchers noticed that the diurnal sleepiness of certain patients could not be explained by either obstructive sleep apnea syndrome (OSA) or by a neuro-psychiatric illness.

All of these patients had an important degree of diurnal fatigue due to inferior quality non-restoring sleep. The cause was obstruction of the airway at the level of the nose and of the throat which resulted in repeated micro-awakening, leading to fragmented sleep.

In fact, during sleep, muscles relax and their tone diminishes. It is in these favorable conditions that the abnormal narrowing of the airways favors the appearance of real obstacles at the level of the soft tissues of the throat, which blocks the air from passing into the lungs. This constitutes a respiratory arrest. Fortunately, this arrest is brief, because the brain immediately detects the lowering of oxygen levels in the blood and commands the respiratory muscles to contract and respiration restarts.

This muscular activity triggered by the decrease of oxygen is equivalent to a « little awakening ». Even if its duration is very short, its frequent repetition is responsible for sleep fragmentation. In addition, the effort expended by these patients during sleep to get the necessary amount of air to the lungs is considerable and sleep is of lesser quality.

Are sleepy non-apneic snorers being badly taken care of ?

Is Upper Airway Resistance Syndrome (UARS) not well treated ?

Recent studies have shown that sleepy non-apneic snorers are not being correctly treated.

The first reason is that  a good number of these patients escape diagnosis. In reality, because of its serious sequelae,  physicians look for obstructive sleep apnea syndrome (OSA) as a priority. Because of this, the principal measurement taken into account by the recordings in the index of apneas and hypopneas per hour of sleep (AHI). In this way, because of their very short duration, the respiratory arrests of the patients with UARS are not counted as real apneas and the measured AHI index is therefore normal. To end up with a correct diagnosis, the measurements should take into consideration other abnormal respiratory events (RERA) that occur during sleep, and especially abnormal inspiratory efforts that awaken. If they are more frequent in a tired patient without obstructive sleep apnea, a diagnosis of UARS is made.

The second cause of the lack of treatment in these patients is linked to the inconvenience of the treatment itself. In effect, physicians often propose continuous nasal airway pressure ventilation (CPAP, or continuous positive airway pressure).

This treatment is very effective in OSA, but it can be very inconvenient and difficult to tolerate for patients with UARS. Essentially, the less the symptoms, less the tolerance for the patients to their treatment apparatus. This would explain why patients with UARS abandon their CPAP treatment more often than those will real OSA. In these latter, the improvement in their quality of life with the disappearance of the fatigue is such that they tolerate the inconvenience of the apparatus more easily than those with UARS.

Treatment of UARS (Upper Airway Resistance Syndrome)

As in all other pathology, suggested the treatment in UARS should be adapted to the severity of the illness. The benefit that the patient hopes for should be greater than the inconvenience of the treatment itself. The principle of treatment is to make the obstruction disappear which is responsible for the narrowing of the airway. Two sites should necessarily be taken into consideration : the nose and the throat.