EVOLUTION OF SNORING

Does the Snoring Airway Worsen if Left Untreated?

The series of endoscopic pictures shown above were obtained from the same patient. The first series from October 4, 1996 shows:

• Marked collapse of the airway with Muller's maneuver
• Very good airway dilation in response to jaw thrust.

An ambulatory sleep study performed at that time showed Moderately Severe Obstructive Sleep Apnea. The patient was recommended to undergo treatment with a dental appliance or CPAP. The patient did not follow - up with the recommendations.

The second series from March 2, 1998 shows:

• A more patulous pharynx with sagging of the lateral walls and the soft palate
• Less complete collapse of the airway on Muller's maneuver
• Much less airway response to jaw thrust.

These changes can be explained on the basis of:

• Tissue injury caused by snoring that leads to scarring and swelling of the pharyngeal tissues
• Neuropathic changes due to unchecked snoring.

An overnight oximetry shows a similar degree of desaturation as on the sleep study.

This patient can still use a dental appliance to stabilize the airway but it would have been preferable to treat this condition before potentially irreversible changes had occurred. The patient opted for CPAP.

This patient went on CPAP and showed dramatic improvement in airway function after only 10 weeks of treatment.  The third set of endoscopy pictures is from May 27, 1998.  It shows:

• A decrease in swelling.
• The airway still collapses easily with Muller's maneuver - this patient will need lifelong treatment.
• Improvement in airway muscle tone so that the airway dilates with jaw thrust.
• There is less advancement of the soft palate with jaw thrust than on the endoscopy of October 4, 1996 which indicates that there is still some impairment of the function of the palatoglossus muscles.

The fact that airway function improves with treatment means that many patients with OSA who have been compliant with their CPAP can switch to using a dental appliance that advances the mandible provided that they can breathe well through their nose and their airway dilates with jaw thrust. Studies clearly show that most patients would choose a dental appliance over CPAP for treatment of their OSA.

The series of endoscopic pictures were obtained from the same patient. The first series of November 15, 1997 shows the airway before treatment. The second series of April 6, 1998 shows the airway after treatment with CPAP for 5 months. The third series of July 22, 1998 shows the airway after 8 treatment with CPAP for 8 months.  This is another example of how treatment of OSA with CPAP can result in a striking improvement in the appearance and function of the upper airway. These pictures show the following:

• A decrease in airway swelling.
• Continued severe collapse of the airway with Muller's maneuver - the patient will need lifelong treatment.
• Improvement in airway muscle tone so that the airway dilates with jaw thrust. The initial exam actually showed lateral collapse of the airway on jaw thrust.

The BMI was stable at 41.7 during this period of time. The patient is now on a weight loss program.  This patient still has a small airway because of morbid obesity. Morbid obesity causes compression of the lateral pharyngeal walls. CPAP remains the treatment of choice for this patient.

This example further emphasizes the fact that airway function improves with treatment using CPAP. Furthermore, many patients who have been compliant with their CPAP for extended periods can eventually switch to using a dental appliance that advances the mandible in place of the CPAP. The duration of CPAP use required to achieve this goal appears to be in the range of 3 - 9 months. Concurrent weight loss would accelerate the process by increasing the lateral dimension of the airway.