A comparison of physician and patient perception of the problems of habitual snoring

Perspectives on paediatric sleep-disordered breathing in the UK: a qualitative study

Objective

There is limited understanding of treatment pathways for paediatric sleep-disordered breathing. This study explored current UK pathways and what is important to well-being for parents and children.

Method

The study comprised in-depth qualitative interviews (n = 22) with parents of children (2–9 years) with symptoms of sleep-disordered breathing referred to a regional ENT clinic (n = 11), general practitioners who might refer these children to ENT (n = 5) and hospital doctors involved in treating these children (n = 6). Interviews were audio recorded, transcribed verbatim, anonymised and analysed thematically.

Results

General practitioners rarely identify seeing children with sleep-disordered breathing; conversely hospital doctors identify unsuspected issues. Parents are worried their child will stop breathing, but routes to referral and diagnosis are not straightforward. Modern technology can aid investigation and diagnosis. Patient weight is an issue for general practitioners and hospital doctors. Adenotonsillectomy is the treatment of choice, and information on paediatric sleep-disordered breathing is needed.

Conclusion

Guidelines for the management of paediatric sleep-disordered breathing are needed.

Obstructive sleep apnea: personal, societal, public health, and legal implications

Introduction Obstructive sleep apnea (OSA) is a widely prevalent sleep-related breathing disorder, which leads to several life-threatening diseases. OSA has systemic effects on various organ systems. Untreated OSA is associated with long-term health consequences including hypertension, heart disease, diabetes, depression, metabolic disorders, and stroke. In addition, untreated OSA is reported to be associated with cognitive dysfunction, impaired productivity at the workplace and in an increased risk of motor vehicle accidents (MVAs) resulting in injury and fatality. Other consequences of OSA include, but are not limited to, impaired vigilance, daytime somnolence, performance deficits, morning headaches, mood disturbances, neurobehavioral impairments, and general malaise. Additionally, OSA has become an economic burden on most health systems all over the world. Many driving license regulations have been developed to reduce MVAs among OSA patients. Methods Studies of the personal, societal, public health, and legal aspects of OSA are reviewed. Data were collected through the following databases: MEDLINE, Google Scholar, Scopus, SAGE Research Methods, and ScienceDirect. Conclusion OSA leads to worsening of patients' personal relationships, decreasing work productivity, and increasing occupational accidents as well as MVAs. The costs of undiagnosed and untreated OSA to healthcare organizations are excessive. Thus, proper management of OSA will benefit not only the patient but will also provide widespread benefits to the society as a whole.

Evaluation of Potential Predictors of Outcome of Laser-Assisted Uvulopalatoplasty for Snoring

OBJECTIVE: Laser-assisted uvulopalatoplasty (LAUP) is a common treatment for snoring, but up to 50% of patients obtain little or no sustained benefit. We investigated whether pre-operative measurements from lateral cephalometry, acoustic rhinometry, analysis of snoring sounds, and body mass index (BMI) could predict which snorers benefited from LAUP.

STUDY DESIGN AND SETTING: Fifty-five snoring patients were assessed pre- and 6 months post-LAUP. Snoring severity was assessed by objective sound level recorded during polysomnography, and a Snoring Symptoms Inventory (SSI) questionnaire.

RESULTS: The outcome of surgery was assessed by changes in objective sound measurements and in SSI, 6 months after LAUP.

CONCLUSIONS: Relationships between the predictive measurements and outcome were at best only weak and none had sufficient predictive value to be useful in clinical practice.

EBM rating: C-4

The Development of a Snoring Symptoms Inventory

OBJECTIVES: To develop a patient-derived snoring questionnaire, the Snoring Symptoms Inventory (SSI), and explore its structure and relationship to the Epworth Sleepiness Scale (ESS); and to assess the sensitivity of the SSI to change.

STUDY DESIGN AND SETTING: The SSI was developed from an open-ended questionnaire given to 120 habitual snorers. The 25 symptoms reported compose the SSI. This study examines 261 subsequent snorers assessed between April 1998 and August 2002, who completed both the SSI and the ESS. Fifty-five of them underwent laser uvulopalatoplasty and their preoperative and postoperative SSI results were compared.

RESULTS: The total SSI score is the key outcome derived. Principal component analysis identified two further dimensions, one contrasting family/social with work-related problems and another comparing physical problems with embarrassment. The total score correlated weakly with the ESS. Laser uvulopalatoplasty significantly reduced patients' overall symptom severity and family and socially related problems.

CONCLUSION: The SSI is a comprehensive and sensitive measure for assessing snoring, making it a useful clinical outcome tool for snoring treatment.

SIGNIFICANCE: The SSI is a new, useful snoring questionnaire.

EBM rating: B-2b

Polyvinylidene fluoride sensor-based method for unconstrained snoring detection

We established and tested a snoring detection method using a polyvinylidene fluoride (PVDF) sensor for accurate, fast, and motion-artifact-robust monitoring of snoring events during sleep. Twenty patients with obstructive sleep apnea participated in this study. The PVDF sensor was located between a mattress cover and mattress, and the patients' snoring signals were unconstrainedly measured with the sensor during polysomnography. The power ratio and peak frequency from the short-time Fourier transform were used to extract spectral features from the PVDF data. A support vector machine was applied to the spectral features to classify the data into either the snore or non-snore class. The performance of the method was assessed using manual labelling by three human observers as a reference. For event-by-event snoring detection, PVDF data that contained 'snoring' (SN), 'snoring with movement' (SM), and 'normal breathing' epochs were selected for each subject. As a result, the overall sensitivity and the positive predictive values were 94.6% and 97.5%, respectively, and there was no significant difference between the SN and SM results. The proposed method can be applied in both residential and ambulatory snoring monitoring systems.

Sleep and health implications of snoring: A populational analysis

OBJECTIVES/HYPOTHESIS

Determine the prevalence of snoring and if snoring is associated with negative effects on sleep patterns and other health conditions.

STUDY DESIGN

Cross-sectional analysis of large-scale national risk-factor survey.

METHODS

The Behavioral Risk Factor Surveillance System for the 2012 sleep health component was analyzed to determine the relationships between respondents' sleep patterns including average hours slept, days of insufficient sleep, falling asleep while driving, and the presence of snoring. The associations between snoring and coronary artery disease, stroke, and depressive disorder were also determined.

RESULTS

Among 8,137,604 weighted respondents (raw N = 22,745), 52.8% (95% confidence interval, 51.9%-53.8%) reported that they snored. Males were more likely to report snoring than females (59.0% vs. 46.9%, respectively, P < .001) and increasing body mass index was associated with a higher prevalence of snoring (normal weight, 36% snoring vs. obese, 71%; P < .001). Snorers reported decreased sleep time, more lack of sleep days, and unintentional falling asleep days than nonsnorers (6.97 vs. 7.15 hours, 9.1 vs. 7.6 days, and 3.3 vs. 2.1 days, respectively; all P < .001). Snorers were more likely to have fallen asleep while driving than nonsnorers (odds ratio, 1.49; P < .001). Snorers also demonstrated increased odds ratios for coronary artery disease and depressive disorder (odds ratios 1.40 and 1.39; respectively, P < .001), but not for stroke (P = .421).

CONCLUSIONS

Self-reported snoring is associated with significant negative sleep pattern behaviors as well as coronary artery disease and depressive disorders. Further study of snoring as a risk factor for poor sleep and other diseases is warranted.

LEVEL OF EVIDENCE

2c

The Role of Sleep in Interpersonal Conflict

This research examined the impact of a basic biological process—namely, sleep—on relationship conflict, specifically testing whether poor sleep influences the degree, nature, and resolution of conflict. In Study 1, a 14-day daily experience study, participants reported more conflict in their romantic relationships following poor nights of sleep. In Study 2, we brought couples into the laboratory to assess the dyadic effects of sleep on the nature and resolution of conflict. One partner’s poor sleep was associated with a lower ratio of positive to negative affect (self-reported and observed), as well as decreased empathic accuracy for both partners during a conflict conversation. Conflict resolution occurred most when both partners were well rested. Effects were not explained by stress, anxiety, depression, lack of relationship satisfaction, or by partners being the source of poor sleep. Overall, these findings highlight a key factor that may breed conflict, thereby putting relationships at risk.

Sexual and relationship satisfaction among persons with young-onset Parkinson's disease

INTRODUCTION

Parkinson's disease (PD) presents unique personal and social challenges, particularly for those with onset before the age of 50 years.

AIM

The aim of this article is to evaluate sexual and non-sexual aspects of relationship satisfaction among persons with young-onset PD and their partners.

MAIN OUTCOME MEASURES

The main outcome measures were Index of Sexual Satisfaction (ISS) and Golombok-Rust Inventory of Marital State (GRIMS).

METHODS

Persons with PD (PWP) and partners who attended the 2005 National Parkinson Foundation Young Onset Network Conference were asked to complete a survey. Each survey included demographics, a clinical history questionnaire, the Beck Depression Inventory (BDI), ISS, and GRIMS.

RESULTS

Sixty PWP (63% men, 85% in a relationship) responded to the survey. Median age was 50 years (range 29-62), with a median age at symptom onset of 43 years (range 17-55). ISS scores indicated clinically significant sexual dissatisfaction in 37%. Relationship dissatisfaction measured by the GRIMS was scored as "poor" or worse in 57%. Depressive symptomatology was severe in 19% and mild in 33%. Sexual dissatisfaction (ISS) correlated with relationship dissatisfaction (GRIMS) (correlation coefficient [CC] = 0.58, P < 0.001). Relationship dissatisfaction (GRIMS) correlated with depressive symptomatology (BDI) (CC = 0.38, P = 0.007). No correlations were found with any demographic or disease characteristics. Thirty-two couples (both the PWP and their partner) completed the surveys. Sexual and relationship dissatisfaction among PWP paralleled that of their partner (ISS: CC = 0.48, P = 0.005; GRIMS: CC = 0.61, P < 0.001). Depressive symptomatology of the PWP correlated with their partners' relationship dissatisfaction (CC = 0.46, P = 0.010).

CONCLUSIONS

In this study, sexual and relationship dissatisfaction were prevalent among young-onset PD patients. PD patients were similar to their partners in their level of sexual and relationship dissatisfaction. The degree of dissatisfaction did not correlate with demographics or self-reported disease characteristics. Self-reported depressive symptomatology among PD patients was adversely associated with both their and their partner's relationship satisfaction. Wiel

Single dose injection snoreplasty: investigation or treatment?

INTRODUCTION

Many surgical and nonsurgical procedures have been designed for the treatment of snoring due to palatal flutter. All work in some, but not all, snorers. The difficulty lies in making the definitive diagnosis of palatal flutter as the cause of snoring, and in deciding which patients should undergo which treatment, which in some cases are relatively radical.

AIMS

This study aimed to assess the usefulness of injection snoreplasty in differentiating palatal flutter from other forms of snoring. This was done in the hope of determining which patients would benefit from definitive palatal surgery such as uvulopalatopharyngoplasty and laser-assisted uvuloplasty.

MATERIALS

Sixty consecutive patients referred for habitual snoring were treated with sodium tetradycil sulphate during their first consultation visit. No patients were excluded and none refused the treatment. Forty patients received a single 1 ml dose of 1 per cent sodium tetradycil sulphate, and twenty patients received a single 1 ml dose of 3 per cent sodium tetradycil sulphate under topical anaesthesia. Visual analogue snoring scales were completed by the patient and their partner six weeks, three months, six months and 12 months after the procedure.

RESULTS

Forty of the 60 patients showed improvement in snoring and therefore were considered for definitive surgery. Four of the 60 patients found the investigation unpleasant and did not want any further treatment. Of the 40 patients who showed improvement, 29 maintained this at one year. The other 11 underwent uvulopalatopharyngoplasty or laser-assisted palatoplasty. All patients had successful snoring scale outcomes following the surgery.

CONCLUSION

A significant number of the patients, 62 per cent, were demonstrated to have significant improvement in the short term. Single dose injection snoreplasty seems not only to be an effective investigation but may constitute a safe and simple treatment within the clinic. At the very least, patients in whom the palate appears not to be the problem are prevented from undergoing painful, unpleasant surgery. Our results support the use of injection snoreplasty, both as an investigation and in some patients as a treatment, for habitual snoring.

Marital quality and the marital bed: examining the covariation between relationship quality and sleep

The majority of adults sleep with a partner, and for a significant proportion of couples, sleep problems and relationship problems co-occur, yet there has been little systematic study of the association between close relationships and sleep. The association between sleep and relationships is likely to be bi-directional and reciprocal-the quality of close relationships influences sleep and sleep disturbances or sleep disorders influence close relationship quality. Therefore, the purpose of the present review is to summarize the extant research on (1) the impact of co-sleeping on bed partner's sleep, (2) the impact of sleep disturbance or sleep disorders on relationship functioning, and (3) the impact of close relationship quality on sleep. In addition, we provide a conceptual model of biopsychosocial pathways to account for the covariation between relationship functioning and sleep. Recognizing the dyadic nature of sleep and incorporating such knowledge into both clinical practice and research in sleep medicine may elucidate key mechanisms in the etiology and maintenance of both sleep disorders and relationship problems and may ultimately inform novel treatments.

Snoring noise pollution—the need for objective quantification of annoyance, regulatory guidelines and mandatory therapy for snoring

Habitual snoring without episodes of apnea or hypoventilation and without respiratory related arousals is considered to be annoying and without any need for treatment. However, studies seem to suggest an enormous psychosocial impact of annoyance for the bed partner. Apart from subjective questionnaires there still exists no generally accepted mode of measurement that can describe snoring objectively. We therefore adapted methods developed for environmental medicine and established a new snore score using psycho-acoustic parameters. For quantification of snoring noise we conducted nocturnal measurements in 19 habitual snorers. Free-field snore sounds were acquired with two low-cost non-contact microphones and transferred to a PC (sampling frequency 11 kHz). The data were recorded, analysed and stored automatically using a MATLAB script. Following the analysis of sound characteristics and levels, the score was computed from relevant parameters containing the rating level (L(R)), maximum level, two percentile levels for frequent maxima (L(5)S; L(1)) and snoring time. The determined values substantially exceeded the prescribed limits defined by WHO noise guidelines, and mainly affected the equivalent continuous sound exposure level, rating level and the immission standard values of brief noise peaks, whose maximum was exceeded by up to 32 dB(A). The Berlin snore score illustrated the objective acoustic annoyance on a scale from 0 to 100. It allows inter-individual comparison and objectifies the need for therapy. The clinical applicability of evaluating the reduction of snoring after surgical therapy is discussed exemplarily. The presented measuring method was found to be suitable for quantifying snoring noise and can be easily integrated into existing polysomnographic applications. In the case of habitual snoring with objective evidence of psychosocially disturbing acoustic annoyance, health fund providers should assume the costs of mandatory medical therapy.

Comparison of uvulopalatopharyngoplasty, laser-assisted uvulopalatoplasty and cautery-assisted uvulopalatoplasty in the treatment of primary snoring

OBJECTIVE

Our aim was to compare the postoperative pain and surgical results of uvulopalatopharyngoplasty (UPPP), laser-assisted uvulopalatoplasty (LAUP), and cautery-assisted uvulopalatoplasty (CAUP) procedures in the treatment of primary snoring.

METHODS

54 patients were stratified according to a modified Friedman staging system (MFSS) for sleep-disordered breathing. Tonsil size (1, 2, 3) and palatal position scale (grade 1-2) and body mass index <30 according to the MFSS were included for standardization. Three workgroups consisting of 18 patients each were formed and UPPP, LAUP and CAUP procedures were performed. The success of the surgical procedures was evaluated by applying the Epworth Sleepiness Scale to the patients, and the patients' bed partners were asked to evaluate the snoring level preoperative and 45 days after the operation to determine any improvement in snoring complaints. Patients were followed for postoperative pain, secondary infection, bleeding, permanent velopharyngeal insufficiency and nasopharyngeal stenosis.

RESULTS

Snoring was relieved in 83.3% of UPPP and CAUP groups and in 88.8% of LAUP 45 days after operation. The mean pain duration was 5.71 days for the UPPP patients, 6.28 days for the LAUP patients and, 4.12 days for the CAUP patients. The mean pain score was 2.1 for the UPPP patients, 2.38 for the LAUP patients, and 1.6 for the CAUP patients. Only 1 patient was hospitalized due to pain in the LAUP group.

CONCLUSION

The effectiveness of UPPP, LAUP and CAUP procedures were found to be similar (more than 83%). Postoperative pain was mostly seen in LAUP and UPPP cases. The CAUP procedure was easy and the least painful.

The management of simple snoring

Simple snoring is a very common problem that presents a number of different challenges. The initial difficulty is in confirming the presence of snoring, next one must exclude any other nocturnal respiratory pathology and finally a decision as to an appropriate treatment must be made. There are many different ways of achieving these objectives, but no one-way has a clear advantage in terms of both accuracy and cost effectiveness. In this review the authors do not intend to give a didactic method for the management of simple snoring but to discuss the pros and cons of various different options in order to help physicians make a choice based on local priorities.