Early diagnosis of sleep related breathing disorders

Obstructive sleep apnea (OSA) being the most frequent sleep related breathing disorder results in non-restorative sleep, an increased cardiovascular morbidity and mortality as well as an elevated number of accidents. In Germany at least two million people have to be expected. If obstructive sleep apnea is diagnosed early enough then sleep may regain its restorative function, daytime performance may be improved and accident risk as well as cardiovascular risk may be normalised. This review critically evaluates anamnestic parameters, questionnaires, clinical findings and unattended recordings during sleep regarding their diagnostic accurracy in recognising OSA

The role of upper airway morphology in obstructive sleep apnea

Obstructive sleep apnea (OSA) is a highly prevalent sleep-related breathing disorder, characterized by repetitive complete and/or partial obstructions of the upper airway during sleep. It is suggested that impaired upper airway morphology is a fundamental pathophysiological trait of OSA. However, the exact role of the upper airway morphology in the pathogenesis and treatment of OSA is still not well known. Therefore, the general aim of this thesis was to evaluate the role of upper airway morphology in the pathogenesis of different OSA phenotypes and in the effects of mandibular advancement device (MAD) therapy. Upper airway morphology was investigated by cone beam computed tomography (CBCT). No significant differences in the upper airway morphology between positional and non-positional OSA (chapter 2), nor between Dutch and Chinese patients with mild to moderate OSA (chapter 3) were found. Further, miniscrew-assisted orthodontic treatment with premolar extractions increased upper airway dimensions in young adults with Class II malocclusion (chapter 4). Finally, no significant differences in the changes in upper airway dimensions between two types of MADs in situ (chapter 5), nor between responders and non-responders (chapter 6) with mild to moderate OSA were found. Therefore, it was concluded that the upper airway morphology does not play a significant role in the pathogenesis of different OSA phenotypes and in the treatment effects of MADs. Future research involving both anatomical and non-anatomical factors is needed to better understand the pathogenesis and treatment outcomes of OSA

Sleep medicine and dentistry

Many health care professionals and patients are unclear of the role that dentists may play in the management of Obstructive Sleep Apnoea-Hypopnoea Syndrome (OSAHS.) The dentists’ role is primarily in the construction of appliances for OSAHS but in the United States of America some dentists have practices limited to “Sleep dentistry”. However, in the United Kingdom there is limited training for dentists in this field. This thesis aims to review the relevant literature that pertains to OSAHS and dentistry and then, through three studies, to look at the past, present and future involvement of dentists in OSAHS. Assessing outcome is clearly important and this thesis firstly presents patient-based findings of the long term success of mandibular advancement appliances. Secondly, the experience and views of dentists and sleep specialists, assessed by questionnaire, is presented. Finally, a prospective study of a promising screening tool (the Kushida Index) for the diagnosis of sleep apnoea is carried out

Obstructive Sleep Apnea Syndrome: Pathogenetic Aspects and Treatment

Almost twenty years ago obstmctive sleep apnea was considered to be a medical curiosity that was of little importance, and snoring was merely the subject of humor than one of serious investigation. Although the clinical manifestations of sleep apnea syndrome have been described as early as in the fat boy Joe in Charles Dickens Pickwick Papers, it was Gastaut in 1965 who provided the first detailed polygraphic description of the manifestations of this sleep related breathing disorder. Since that date countless studies have been perfornled and published, concerning all possible aspects of sleep apnea syndrome. Epidemiological and clinical research revealed that the obshuctive sleep apnea syndrome may be considered a major public health problem and that the sequelae of the syndrome may have devastating consequences for the lives of those affected, but the long telm sequelae of obstmctive sleep apnea need fmiher elucidation in well designed studies. This chapter provides a review of prevalence, pathogenesis, natural history, symptomatology, diagnosis and treatment of Obstmctive Sleep Apnea Syndrome (OSAS). First a brief description of the spectnnll of sleep related breathing disorders is given

The influence of breathing disorders on face shape: a three-dimensional study

Breathing disorders can potentially influence craniofacial development through interactions between the respiratory flow and genetic and environmental factors. It has been suggested that certain medical conditions such as persistent rhinitis and renal insufficiency may have an influence on face shape. The effects of these conditions are likely to be subtle; otherwise they would appear as an obvious visible facial feature. The use of three-dimensional imaging provides the opportunity to acquire accurate and high resolution facial data to explore the influence of medical condition on facial morphology. Therefore, the aim of the present study is to investigate the influence of breathing disorders (asthma, atopy, allergic rhinitis and sleep disordered breathing) on face shape in children. The study sample, comprising of 4784 British Caucasian children of which 2922 (61.1%) were diagnosed with a breathing disorder, was selected from the Avon Longitudinal Study of Parents and Children (ALSPAC), which had been conducted to investigate the genetic and environmental determinants of development, health and disease. Three-dimensional surface laser scans were conducted on the children when they were 15 years old. A total of 21 reproducible facial landmarks (x, y, z co-ordinates) were identified. Average facial shells were constructed for each of the different disease groups and compared to facial shells of healthy asymptomatic children. Face-shape variables (angular and linear measurements) were analysed with respect to the different breathing disorders by employing a variety of statistical methods, including t-tests, chi-square tests, principal component analysis, binary logistic regression and analysis of variance (ANOVA). The results reveal that individual breathing disorders have varying influences on facial features, including increased anterior lower face height, a more retrognathic mandible and reduced nose width and prominence. The study also shows that the early removal of adenoids and tonsils can have a significant effect on obstructive breathing, resulting in the restoration of the facial morphology to its normal shape. This was particularly evident in children with normal BMIs. Surprisingly, no significant differences in face shape were detected in children with multiple diseases (combinations of asthma, allergic rhinitis, atopy and sleep-disordered breathing) when compared to healthy children. This may indicate the multifactorial, complex character of this spectrum of diseases. The findings provide evidence of small but potentially real associations between breathing disorders and face shape. This was largely attributable to the use of high-resolution and reproducible three-dimensional facial imaging alongside a large study sample. They also provide the scientific community with a detailed and effective methodology for static facial modelling that could have clinical relevance for early diagnosis of breathing disorders. Furthermore, this research has demonstrated that the ALSPAC patient archive offers a valuable resource to clinicians and the scientific community for investigating associations between various breathing disorders and face shape

A Comprehensive study of Clinical and Psychological Factors in Snoring and Obstructive Sleep Apnoea

INTRODUCTION: In recent decades, awareness of sleep apnoea syndromes has increased both in the public mind and among medical professionals. As a result, more patients demand treatment of sleep disorders. However, the health care delivery system is unable to meet this demand. The inadequacies mainly relate to lack of infra structure and lack of skilled manpower. When great advances have been made in the medical field, provision of such facilities may appear to be simple. But, we are hampered by lack of information regarding the size of the problem. We do not know the actual prevalence of sleep disordered breathing. Another significant inadequacy relates to the absence of a comprehensive algorithm for approaching a patient with suspect OSA. The skill sets required for this algorithm are spread widely amongst various specialists, namely pulmonologists, neurologists, critical care specialists, internal medicine specialists and otolaryngologists. Supporting staff in the pulmonary, sleep and imaging laboratories must be developed. The willingness of the health insurance to assume the reimbursement of expenses will play an important role in this development. This study is an effort in meeting the first of these inadequacies namely, defining the magnitude of the burden of this disease. AIMS OF THIS STUDY: 1. To study the prevalence of snoring and sleep apnoea in the general population. 2. Comparison of clinical and psychological profiles of children suffering from snoring and sleep apnoea with non-obstructed children. 3. Study of the changes in the above profiles, after therapeutic intervention i.e. adeno tonsillectomy. PLAN AND SCOPE OF THE STUDY: The entire study was done in two parts Part I. Study of the prevalence of snoring. Part II. Interventional study of children with adeno tonsillar enlargement, before and after surgical therapy. SUMMARY OF THE PREVALENCE STUDIES: Collection of data on the prevalence of snoring and other features of sleep disordered breathing was achieved by a series of surveys with wide ranging bases, namely Pedex survey, Street survey, Households survey, Adolescent Students survey and Adult industrial workers survey. PEDEX SURVEY: In this survey, the prevalence of snoring in the general community was ascertained by a questionnaire. BMI was calculated by taking height and weight. In this Pedex survey, with a sample size of 1075 persons of all ages and economic background, the total prevalence of snoring was 19.5 %. The percentage of snorers was found to be 24.4 % in males vs. 13 % of females (higher in the males). Among the age groups, with increasing age, the prevalence of snoring increased – children: 12 %, adults: 24 %. The prevalence of snoring in children and in adolescents was found to be independent of BMI. In contrast, the adult age group showed a significant increase in snoring with increasing BMI. The prevalence of snoring was found to increase positively with increasing affluence. Children with sore throat had a significant tendency to have snoring. In the general community, awareness of the condition exists. However, many persons (snorers and non snorers alike) are not interested in getting more information. STREET SURVEY: Trained personnel interviewed persons at busy streets consecutively, and and recorded the answers in a standard survey format. In the novel street survey with a sample size of 937 persons of all ages, gender and build, the over all prevalence of snoring was 21.1 % (males 11% and females 10.1%). In this sample, the self reported prevalence and the frequency of snoring showed no significant difference between the genders. This is at variance to the conventional belief that more males snored more frequently. However, it was seen that females tend to snore less loudly than males. The method of obtaining sample subjects from the streets is found by this study to yield less appropriate data. On analysing the prevalence of the self reported snoring, it was found that no one below the age of 30 years (male and female) reported snoring, even though they constituted 43.8 percent of the sample. This is in contradiction with similar surveys and our own surveys. This method of getting subjects from the streets is commonly adopted in opinion surveys and in election predictions. This method had even been employed to estimate the prevalence data for snoring itself. With the experience gained in this survey, we find that this method of obtaining the prevalence data is not yielding correct data. A relatively comfortable environment, where the patient has the time, inclination and willingness to think and answer (not one where the subject awaits the change of signals or for the arrival of the next bus) would be appropriate. HOUSEHOLDS SURVEY: All the inhabitants of an entire housing colony in Chennai, formed the sample. A total of 398 persons (222 males and 176 females) were included in this study. In addition to the questionnaire, each person had a clinical examination. The overall prevalence of snoring in this sample was found to be quite high at 43 percent (26.4% males and 16.6% females). Among the total of 114 children below the age of 12 years, 34% were snorers. Out of the male snorers, 18.5 % snored frequently. Oropharyngeal indicators like tonsil size and Mallampatti had significantly higher scores in this sample. STUDENTS SURVEY: One of the important problems engendered by snoring and sleep apnoea is learning impairment. Hence, this part of the survey had a focus on young adult students. 198 medical students and nursing students of both gender formed the sample. The medical history and details of snoring, if any, were recorded. The subjects underwent morphological and clinical examination. This sample comprised of the students with a mean age of 20.6 years. The over all prevalence of snoring was 7.6 per cent. It is noteworthy that even persons who had a BMI below the normal i.e. below 23 snored. BMI was found to be significantly associated with snoring in this sample. It should be noted that as many as 21% of the of this study sample comprising exclusively of young students complained of excessive daytime sleepiness when they were administered the Berlin questionnaire. The association of sleepiness with snoring was found to be significant statistically. In addition, waist hip ratio was higher in all snoreers. ADULT INDUSTRIAL WORKERS SURVEY: This part of the study focused on industrial workers, who have shift duties. All the employees on shift duty in a large industrial establishment formed the subjects of this study. The subjects had their heights and weights measured. Then, each one of them filled up a questionnaire. The questions pertained to the presence of snoring, its frequency and any precipitating factors, if present. 602 employees of all ages formed this sample. All were men. Six hundred and two employees of all ages formed this sample. All were men. Among all ages, the over all prevalence of snoring was 16.8%. The prevalence of snoring is seen to increase with age. In the age group, 19- 29 years, the prevalence was 7.7%. In the age group 45-59 years, the prevalence was 21.5%. The loudness is not associated with either on age groups or on BMI status. Among the snorers, 68.2 % snored occasionally and 31.8 % snored frequently. Among the snorers, the snoring status worsened with tiredness (100%), good food (92%) and with alcohol (62%). SUMMARY OF THE INTERVENTIONAL PART OF THE STUDY: A total of 197 children of ages 3 – 15 years, attending a specialist ENT clinic for recurrent throat infections and features of obstructed airway entered this study. Several of them had adenotonsillar enlargement. Based on their snoring pattern, they were stratified into frequent snorer group and occasional snorer groups. All the children were assessed with tests for behaviour and learning. The above variables among these three groups groups were different. AGE, GENDER, BMI AND SES : These did not have any significant association with snoring, in this sample. There was also no linear relationship between the mild snorer and the habitual snorer groups in this regard. UARS, APNOEA and EDS : In this sample population of children with adeno tonsillar enlargement, the relative frequencies of UARS, Apnoea and EDS are interesting. Struggling to breathe, chest caving in or see sawing (features of UARS), breathing pauses (a feature of apnoea), sleeping during school hours, napping at home, unrefreshed sleep and continuous tiredness (features of EDS) were significantly present only in snorers and were absent or less frequent in the non snorers. When the snoring frequency is factored in, there is a further significant difference – apnoea and EDS are more frequent in the frequent snorers. Hence, when a child comes with a history of snoring, care must be taken to identify this population of frequent snorers – because it is this population which is at a higher risk. TONSIL SIZE AND ADENOID SIZE: Tonsil size was found to be significantly associated with snoring; more so with frequent snoring. Adenoid size per se (alone) was found to be of no importance in this regard. However, children with adeno tonsillar enlargement were more likely to have impaired QOL scores if they had a history of frequent snoring. In these children with adeno tonsillar enlargement, the addition of historical questionnaire data, other than snoring frequency, did not improve predictions of snoring. PHARYNGEAL DIMENSIONS IN CHILDREN WITH SNORING: The tonsil sizes and Tsai pharyngeal grades are significantly higher in all snorers. Such significance is even higher in frequent snorers. The Mallampatti score is not significant, when the total group of all snorers is considered as a whole. But, it becomes significant when the frequent snorers are segregated and considered. Hence, in every snorer, examination of the oral cavity is important. Taking a history of the frequency is equally or perhaps more important, thereby alerting the clinician to bestow a little more attention to the oral cavity examination. ASSOCIATED DISEASES: Nasal allergy, sinusitis, secretory otitis media and CSOM have signigficant associations with snoring. But, GERD did not show any positive association with snoring in this study. All the snorers, regardless of whether they are frequent snorers or occasional snorers, have a higher presence of nasal allergy and secretory otitis media. Snorers, when taken up for statistical analysis as a whole, do not show any increased presence of sinusitis or CSOM. But when the frequent snores are segregated and analysed separately, the frequent snorers were found to have a significantly higher presence of sinusitis and CSOM. A snoring child has a high possibility of having nasal allergy and secretory otitis media. Hence, in the clinical examination of snoring children, a focused effort must be made to identify whether a child has nasal allergy (including wheezing). The ears must be specifically examined for secretory otitis and CSOM. In a frequently snoring child, this becomes more imperative. CEPHALOMETRIC IMAGING AND MEASUREMENTS: In this study, out of the seven cephalometric measurements taken up for analysis, namely, Retro palatal airway space, Retro glottal airway space, Hypo pharyngeal airway space, MP-H distance, position of hyoid (Rgn–H, H-C3, and C3-Rgn), AN ratio, Lower anterior face – total facial height ratio, the former six were not associated with snoring at all. Only the LFH/TFH ratio, indicating the long face syndrome (adenoid facies), was significantly associated with snoring and snoring frequency. All the others were not significantly associated. The digitization had been done in an academic institution by a very well experienced orthodontist. Even though the airway analysis was novel and hence, relatively unfamiliar to the orthodontic practitioners, the digitization techniques are extremely familiar to them. Even then, the initial ten films had been digitized twice by two different orthodontists and cross checked. With all these precautions, the cephalometry did not yield any positive association with snoring. BEHAVIOUR: In children with snoring (all the snorer groups taken together), the behaviour scores were not different from those of non snorers. But, when the frequent snorers were specifically studied separately, the behaviour scores were found to be worse than mild snorers. And, after surgery, these worse scores of frequent scores were found to improve significantly. GENERAL LEARNING; There was no difference in the over all academic performance, as measured by the school marks between the frequent and occasional snorer groups. This might mean that the tool used (the single marker of 50% marks in the last terminal examination) lacked precision (did not measure the academic performance correctly) or that the underlying impaired learning skills have been compensated to some extent by the strenuous efforts of the student, his teachers and parents. EFFECT OF THERAPEUTIC INTERVENTION: In this sample, almost all the parameters of the QOL OSA 18 tool improved well, with the sole exception of emotional domain, which showed a marginal worsening after surgery; however, this change was very minimal (0.16 increase in the mean domain score value) and was not at all significant. Overall, the QOL scores improved after the therapeutic intervention in the snoring children. A snoring child has a high possibility of having nasal allergy, secretory otitis media. Hence, in the clinical examination of snoring children must include a pointed effort to identify whether a child has nasal allergy (including wheezing). The ears must be specifically examined for secretory otitis and CSOM. look allergy associated feature of wheezing, attention must be made to identify all snorers pointed atten and the ears must be specifically examined in a snoring child. When the frequent snorers are specifically identified and the presence of nasal allergy is looked for, The tonsil sizes and Tsai pharyngeal grades are significantly higher in all snorers. Such significance is even higher in frequent snorers. The Mallampatti score is not significant, when the total group of all snorers is considered as a whole. But, it becomes significant when the frequent snorers are segregated and considered. Hence, in every snorer, examination of the oral cavity is important; Taking a history of the frequency is equally or perhaps more important, thereby alerting the clinician to bestow a little more attention to the oral cavity examination. However, on statistical analysis did not show any significance between relative frequencies between the snorers and non snorers. The adequacy of the sample size may be the issue. In this connection, further investigations like polysomnography, oesophageal pressure studies and MSLT would have yielded assertive diagnostic labels. However, those studies could not be suggested to the patients, because of reasons like (1) their invasive nature (2) necessity for overnight hospitalization (3) non availability (4) waiting time and consequent delay in treatment (5) expensiveness and (6) the ethical issue of not suggesting any extra investigation which may not have a bearing on management of the child

Robin Sequence:Clinical implications and functional outcomes following (non-) surgical management

Robin Sequence (RS) is a congenital craniofacial abnormality characterized by mandibular hypoplasia, glossoptosis, and varying degrees of upper airway obstruction. The interaction between the various etiological causes, the great variability in clinical expression, and the lack of a uniform definition continuously pose challenges to clinicians. The aim of this thesis is to gain another step towards a better understanding of this complex and challenging condition by focusing on the clinical characteristics and functional outcomes regarding airway, feeding, swallowing, and growth in patients with RS. In this way, we attempt to add valuable information to the current knowledge of RS and therefore contribute to an improved quality of care for these patients

The Control of Snoring and Obstructive Sleep Apnoea Using a Mandibular Advancement Device

Abstract not provided

Accurate detection of sleep apnea with long short-term memory network based on RR interval signals

Sleep apnea is a common condition that is characterized by sleep-disordered breathing. Worldwide the number of apnea cases has increased and there has been a growing number of patients suffering from apnea complications. Unfortunately, many cases remain undetected, because expensive and inconvenient examination methods are formidable barriers with regard to the diagnostics. Furthermore, treatment monitoring depends on the same methods which also underpin the initial diagnosis; hence issues related to the examination methods cause difficulties with managing sleep apnea as well. Computer-Aided Diagnosis (CAD) systems could be a tool to increase the efficiency and efficacy of diagnosis. To investigate this hypothesis, we designed a deep learning model that classifies beat-to-beat interval traces, medically known as RR intervals, into apnea versus non-apnea. The RR intervals were extracted from Electrocardiogram (ECG) signals contained in the Apnea-ECG benchmark Database. Before feeding the RR intervals to the classification algorithm, the signal was band-pass filtered with an Ornstein–Uhlenbeck third-order Gaussian process. 10-fold cross-validation indicated that the Long Short-Term Memory (LSTM) network has 99.80% accuracy, 99.85% sensitivity, and 99.73% specificity. With hold-out validation, the same network achieved 81.30% accuracy, 59.90% sensitivity, and 91.75% specificity. During the design, we learned that the band-pass filter improved classification accuracy by over 20%. The increased performance resulted from the fact that neural activation functions can process a DC free signal more efficiently. The result is likely transferable to the design of other RR interval based CAD systems, where the filter can help to improve classification performance