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Effects of Oropharyngeal Exercises on Snoring: A Randomized Trial

Authors:

Abstract

Snoring is extremely common in the general population and may indicate obstructive sleep apnea (OSA). However, snoring is not objectively measured during polysomnography, and no standard treatment is available for primary snoring or when snoring is associated with mild forms of OSA. This study determined the effects of oropharyngeal exercises on snoring in minimally symptomatic patients with a primary complaint of snoring and diagnosis of primary snoring or mild-to-moderate OSA. Patients were randomized for 3 months of treatment with nasal dilator strips plus respiratory exercises (Control) or daily oropharyngeal exercises (Therapy). Patients were evaluated at study entry and end by sleep questionnaires (Epworth, Pittsburgh) and full polysomnography with objective measurements of snoring. We studied 39 patients (age: 46±13 years, body mass index: 28.2±3.1 kg/m2, apnea hypopnea index (AHI): 15.3±9.3 events/hour, Epworth: 9.2±4.9, Pittsburgh: 6.4±3.3). Control (n=20) and Therapy (n=19) groups were similar at study entry. One patient from each group dropped out. Intention-to-treat analysis was used. No significant changes occurred in the Control group. In contrast, patients randomized to Therapy experienced a significant decrease in the Snore Index (snores > 36dB /h): 99.5 [49.6-221.3] vs. 48.2 [25.5-219.2], P = .017 and Total Snore Index (total power of snore/h): 60.4 [21.8-220.6] vs. 31.0 [10.1-146.5], P = .033. Oropharyngeal exercises are effective in reducing objectively measured snoring and are a possible treatment for a large population suffering from snoring. Clinical trial registered with www.clinicaltrials.gov (NCT01636856).
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Text word count: 2475 (limit: 2500)
Abstract word count: 237
Effects of oropharyngeal exercises on snoring: a randomized trial
Short title:
Oropharyngeal exercises and snoring
Vanessa Ieto, PhD
1
; Fabiane Kayamori
1
; Maria I. Montes, MD
2
; Raquel P. Hirata,
MS
1
;
Marcelo G. Gregório, MD, PhD
1
; Adriano M. Alencar, PhD
3
; Luciano F. Drager, MD, PhD
1
; Pedro R. Genta, MD, PhD
1
; Geraldo Lorenzi-Filho, MD, PhD
1
Authors’ affiliations:
1
Sleep Laboratory, Pulmonary Division, Heart Institute (InCor), University of São Paulo
Medical School, São Paulo, Brazil
2
Neurology Department, University of Antioquia, Medellín, Colombia
3
Physics Institute, University of São Paulo, São Paulo, Brazil
Address for Correspondence: Geraldo Lorenzi-Filho, Sleep Laboratory, Insitituto do
Coração, Av. Eneas Carvalho de Aguiar, 44
São Paulo, Brazil, Zip Code 05403-900
E-mail: geraldo.lorenzi@gmail.com
Correspondence and requests for reprints should be addressed to Geraldo Lorenzi-
Filho, MD, PhD, Sleep Laboratory, Pulmonary Division, Heart Institute (InCor), University
of São Paulo Medical School, Av. Dr. Enéas de Carvalho Aguiar, 44, CEP 05403-904,
São Paulo, Brazil. E-mail: geraldo.lorenzi@incor.usp.br
Conflict of Interest Statement: The authors have reported to CHEST that no potential
conflicts of interest exist with any companies/organizations whose products or services
may be discussed in this article.
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Funding information: This work was supported by Fundação de Amparo à Pesquisa
do Estado de São Paulo (FAPESP) and Conselho Nacional de Desenvolvimento
Científico e Tecnológico (CNPq).
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Abstract
Background: Snoring is extremely common in the general population and may indicate
obstructive sleep apnea (OSA). However, snoring is not objectively measured during
polysomnography, and no standard treatment is available for primary snoring or when
snoring is associated with mild forms of OSA. This study determined the effects of
oropharyngeal exercises on snoring in minimally symptomatic patients with a primary
complaint of snoring and diagnosis of primary snoring or mild-to-moderate OSA.
Methods: Patients were randomized for 3 months of treatment with nasal dilator strips
plus respiratory exercises (Control) or daily oropharyngeal exercises (Therapy). Patients
were evaluated at study entry and end by sleep questionnaires (Epworth, Pittsburgh)
and full polysomnography with objective measurements of snoring. Results: We studied
39 patients (age: 46±13 years, body mass index: 28.2±3.1 kg/m
2
, apnea hypopnea
index (AHI): 15.3±9.3 events/hour, Epworth: 9.2±4.9, Pittsburgh: 6.4±3.3). Control
(n=20) and Therapy (n=19) groups were similar at study entry. One patient from each
group dropped out. Intention-to-treat analysis was used. No significant changes
occurred in the Control group. In contrast, patients randomized to Therapy experienced
a significant decrease in the Snore Index (snores > 36dB /h): 99.5 [49.6-221.3] vs. 48.2
[25.5-219.2], P = .017 and Total Snore Index (total power of snore/h): 60.4 [21.8-220.6]
vs. 31.0 [10.1-146.5], P = .033. Conclusions: Oropharyngeal exercises are effective in
reducing objectively measured snoring and are a possible treatment for a large
population suffering from snoring.
Clinical trial registered with www.clinicaltrials.gov (NCT01636856).
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Abbreviation List
AHI: apnea hypopnea index
BMI: body mass index
OSA: obstructive Sleep Apnea
DAC: digital audio recorder
dB: decibel
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Introduction
Obstructive sleep apnea (OSA) is a common condition characterized by recurrent
upper airway obstruction during sleep.
1,2
Snoring is one of the most common symptoms
associated with OSA and is caused by vibration of soft tissues obstructing the pharynx
during sleep.
3,4
Among patients with OSA, snoring is common (70-95%), and there is an
association between snoring intensity and OSA.
5,6
On the other hand, subjects who
suffer from snoring do not necessarily have OSA. The prevalence of snoring in the
general population varies widely (from 15 to 54%) mainly because most studies rely on
subjective reports.
7-10
Self-perception of snoring is imprecise
11
and is largely dependent
on subjective reports from bed partners.
12
The social problems caused by snoring are
most likely underestimated. Snoring is frequently denied, because it is a stigmatizing
symptom that is poorly perceived by the beholder. In addition to the social problems
caused by snoring, the vibration of the upper airway associated with snoring may
contribute to pharyngeal neurogenic lesion,
13
progression of carotid artery
atherosclerosis due to vibration transmitted locally,
7
as well as sleep disruption when
associated with respiratory event-related arousal.
14
Despite the evidence that snoring is
a major burden to our society, the management of patients with primary snoring or
patients with mild forms of OSA has been poorly investigated.
The treatment of primary snoring varies widely and includes general
measurements, such as avoiding alcohol and sedatives, avoiding the supine position,
weight reduction, treatment of nasal problems, palate and upper airway surgeries, and
use of a mandibular advancement device.
15,16
However, the vast majority of the studies
have not objectively measured snoring, and results are based on subjective
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questionnaires.
17
Therefore, new forms of treatment for snoring are necessary. Recent
studies show that training the upper airway muscles either by playing a wind instrument
(didgeridoo)
18
or oropharyngeal exercises
19
can ameliorate moderate OSA. A recent
meta-analysis demonstrated that oropharyngeal exercises provides a reduction in AHI of
50% in adults and decreases snoring.
20
Oropharyngeal exercises are therefore an
attractive possibility to treat patients suffering from snoring. In the present randomized
controlled study, we tested the effects of oropharyngeal exercises on the snoring of
minimally symptomatic patients with primary snoring and mild-to-moderate OSA. In
contrast to most studies on this subject, snoring was measured objectively.
Methods
Patients
We considered eligible patients between 20 and 65 years of age referred to the
Sleep Laboratory InCor-HCFMUSP, with a primary complaint of snoring and a recent
diagnosis of primary snoring or mild-to-moderate OSA. Patients with body mass index
(BMI) ≥40 kg/m
2
, smokers, history of alcohol abuse, edentulous, severe nasal
obstruction, hypertrophic tonsils grade 3 or 4, craniofacial malformations, on regular use
of hypnotic medications, and severe comorbidities were excluded. The local ethics
committee approved the study, and all patients gave written informed consent
(CAPPESQ 0140/11).
Polysomnography
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All patients were evaluated by full polysomnography as previously described
21
with
the inclusion of a snore recording. Snore sound was captured by microphone, located at
1m from the surface of the bed, of a digital audio recorder (DAC), ZoomH4n. The clocks
of the snoring recorder and the polysomnography computer were synchronized. Since
snoring is a predominantly low-frequency sound, a band pass filter between 80 and
300Hz was used. Snoring was automatically detected by using an algorithm with an
intensity threshold cutoff of 36dB. The World Health Organization guidelines indicate
that indoor continuous sound pressure level above 30dB should be avoided during
sleep.
22
Our threshold was based on pilot studies in our sleep laboratory that evaluated
the best threshold to discriminate between snoring and ambient sounds. In addition, all
automatically detected snoring sounds were listened to and validated by one single
researcher in a blinded fashion (V.I.). Results are expressed as Snore Index (total
number of snores/total sleep time) and Total Snore Index (sound intensity power
generated by all snoring episodes/total sleep time, expressed in arbitrary unit/10
7
).
Primary snoring, mild OSA, and moderate OSA were defined as an AHI<5; ≥5 and <15;
and ≥15 and ≤30 events/h, respectively. The investigator who scored the sleep study
was blinded to the group allocation. Apnea was defined as the complete cessation of
airflow for at least 10 seconds; hypopnea was defined as a significant reduction (>30%)
in respiratory signals for at least 10 seconds associated with an oxygen desaturation
≥3%.
23
Questionnaires
Snoring of the patient was evaluated by the patient as well as by the bed partner
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(whenever present) using questions derived from the Berlin questionnaire: snoring
frequency (ranging from 0: never to 4: every day) and snoring intensity (1: similar to
breathing to 4: very loud).
24
Subjective daytime sleepiness and quality of sleep were
evaluated with the Epworth questionnaire
25
and Pittsburgh sleep quality questionnaire
26
,
respectively.
Control Group
Patients were instructed to use nasal dilator strips during sleep, to perform nasal
lavage with saline solution 3 times a day and to perform deep breathing exercises
through the nose while sitting.
Therapy Group
Patients were instructed to perform nasal lavage 3 times a day followed by
oropharyngeal exercises for approximately 8 minutes. The oropharyngeal exercises
from our previous study
19
were simplified and included: (1) push the tip of the tongue
against the hard palate and slide the tongue backward (20 times); (2) suck the tongue
upward against the palate, pressing the entire tongue against the palate (20 times); (3)
force the back of the tongue against the floor of the mouth while keeping the tip of the
tongue in contact with the inferior incisive teeth (20 times); (4) elevation of the soft
palate and uvula while intermittently saying the vowel "A" (20 times). After gaining
control and coordination of movement (typically after 3-5 weeks), elevation of the soft
palate and uvula was performed without vocalization for 5 seconds; (5) recruitment of
the buccinator muscle against the finger that is introduced in the oral cavity, pressing the
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buccinator muscle outward (10 times each side); (6) alternate bilateral chewing and
deglutition using the tongue in the palate, without perioral contraction, whenever
feeding. The patients were instructed to incorporate this mastication pattern whenever
they were eating.
Experimental Design
After fulfilling entry criteria, patients were randomized for 3 months to either Control
or Therapy group. The two groups attended weekly visits. The Therapy group performed
oropharyngeal exercises under supervision. The Control group performed exercises of
deep breathing through the nose under supervision. The Control group received nasal
dilators once a week, and the number of units used in the previous week was counted.
All patients were also asked to keep a diary to record compliance to the 8-minute set of
exercises prescribed 3 times a day of either oropharyngeal exercises (Therapy) or deep
breathing exercises (Control) The patient had to mark with a pen whether the assigned
exercise section for that period of the day was performed (“yes”) or not. The diary was
returned to the investigator once a week and provided information about patient
compliance in the previous week. Compliance was expressed as a percentage and
calculated as the number of sections answered with "yes” divided by the total number of
sections on the week. Anthropometric measures, questionnaires, and polysomnography
with recording of snoring were performed at the beginning and end of the study. The
primary outcome was snoring analysis as expressed by the snore index and the total
snore index.
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Statistical Analysis
Statistical analysis was performed using SPSS 20.0 and R statistic software.
Normality was assessed using the Kolmogorov-Smirnov test. We anticipated a 50%
reduction in objective snoring in patients randomized to oropharyngeal exercises based
on our previous research.
19
We included 38 patients (β=80%, α=95%). Data are
presented as mean and standard deviation or median (25-75%) percentile when
appropriate. Baseline characteristics were compared using 2-tailed unpaired t tests or
Mann-Whitney test when appropriate. Paired t test or Wilcoxon test was performed to
evaluate within-group changes over the study period. Repeated measures analysis of
variance (ANOVA) was used to compare the interaction between the 2 groups (Control
and Therapy) and the 2 moments (baseline and after 3 months). In addition, we used
the generalized estimation equation (GEE) to determine the influence of the time in a
supine position on the results. Comparisons were performed by intention-to-treat
analysis. Missing data at study termination were repeated from baseline according to
Last Observation Carried Forward methods
27
. A value of P < .05 was considered
significant.
Results
We recruited 156 patients and 117 were excluded, leaving 39 patients in the final
analysis. The reasons for exclusion were described in Figure 1. One patient in each
group withdrew from the study after randomization. The demographic and sleep
characteristics and symptoms of the population, according to the group assigned, are
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presented in Table 1. Patients assigned to control and therapy groups had similar
baseline characteristics (Table 1). The demographic characteristics, questionnaires,
polysomnographic and snore characteristics of the patients assigned to control or
oropharyngeal exercises at baseline and after 3 months are presented in Table 2. The
percentage of adhesion the exercises according to the weekly diaries was >75% for all
patients and was on average 85±8%. No changes occurred in the Control group in all
variables during the study period, except on the subjective frequency of snoring reported
by the patient. No changes in BMI or abdominal circumference during the study period
were observed in patients randomized to oropharyngeal exercises (Table 2). In contrast,
patients treated with oropharyngeal exercises had a small but significant decrease in
neck circumference after 3 months (Table 2). Snoring perception as reported by the bed
partner also decreased (Table 2). Objectively measured Snore Index (Figure 2) and
Total Snore Index (Figure 3) did not change in the control group and decreased
significantly in the patients assigned to oropharyngeal exercises. The mean AHI of the
population studied was relatively low at study entry (15.3±9.3 events/h) and did not
change significantly in either group. However, in the subgroup of patients with moderate
OSA at study entry, AHI decreased significantly in the patients assigned to
oropharyngeal exercises (n=8, AHI: 25.4 [22.1-28.7] vs. 18.1 [15.4-24.1], P = .017,
baseline and study termination, respectively) (Figure 4).
Discussion
This randomized controlled study was designed to objectively measure the
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effects of oropharyngeal exercises on snoring in patients with primary snoring and mild-
to-moderate OSA. We showed that 3 months of oropharyngeal exercises significantly
reduced both the frequency of snoring by 36% and the total power of snoring by 59%.
The objective decrease in snoring was associated with a decrease in the perception of
snoring by the bed partner but not by the patient.
This study shows the beneficial effects of oropharyngeal exercises in a
population that is poorly evaluated by the scientific community. The population studied
was composed of middle aged and overweight patients who were disturbed by snoring,
were on average not sleepy (Epworth= 9,2±4.9) and did not present severe OSA
(AHI=15.3±9.3 events/h). This group of patients benefit from a sleep study because
severe OSA is ruled out. However they typically do not receive standardized medical
follow up. The prevalence and significance of snoring in the general population varies
widely in epidemiological studies (from 15 to 54%).
7-10
It is plausible, although not
proven, that every night vibration of the palate caused by snoring may contribute to
upper airway neurogenic lesion
13
and progression of mild forms of OSA.
28
In addition,
primary snoring (ie, AHI<5 events/h) may be associated with disrupted sleep due to
respiratory events, related arousals,
14,29
or progression of carotid atherosclerosis due to
vibration.
7
Independent of the possible health problems aggravated by snoring, most
patients with mild forms of OSA must have some degree of social burden generated by
snoring.
30,31
For instance, a Goggle search using the key words “snoring” and
“treatment” showed over 5 million results, indicating that snoring is a major burden to the
society.
In contrast to well established metrics like the apnea-hypopnea index, snoring is
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not a standard measurement during full polysomnography.
32
In a previous study, our
group proposed a simple and accurate method to identify OSA based on time intervals
between snoring events.
33
In this study, we objectively quantified the frequency and
intensity of snoring. We used a similar distance of the microphone to the patient (1m)
34,35
and adopted the Snore Index to express our results as previously reported.
34,36-38
In
addition, we used the Total Snore Index to represent the total snore intensity power
generated during sleep. The objective reduction in snore indexes among patients
randomized to oropharyngeal exercises occurred in conjunction with an improvement in
the perceived snoring evaluated by the bed partner. Our study is in line with previous
studies that showed the beneficial effects of different forms of oropharyngeal exercises,
such as didgeridoo playing,
18
singing,
39,40
and specific oropharyngeal exercises
19
on
upper airway physiology during sleep. Upper airway exercises have been also used to
treat children and teenagers with promising results.
41,42,43
Our study was based on
exercises previously reported by our group. We extended our previous study by
reducing the number of exercises by 50% that were applied for 3 months.
Our study has strengths and limitations. First, the oropharyngeal exercises are
based on an integrative approach and therefore do not allow determining the effects of
each specific exercise on the overall result. Moreover, these exercises are derived from
oral motor techniques to improve speech and/or swallowing activity, an area that lacks
the empirical support necessary for evidence-based practices
44
. As compared to our
previous study that evaluated the effects of oropharyngeal exercises on moderate OSA,
the number of exercises proposed in the present study was reduced by 50%. In contrast
to the original study, we found no overall significant reduction in AHI after oropharyngeal
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exercises, which could be due to a reduction in the exercises protocol
19
. However, our
clinical experience accumulated over the last 5 years has shown that reducing the
number of exercises does not affect the effectiveness of therapy. Moreover, there was a
significant reduction in AHI of patients with moderate OSA at study entry randomized to
oropharyngeal exercises. The most likely explanation is that a "floor effect" in the AHI
prevented the observation of any effect on this metric among patients with mild or no
OSA at study entry. Our results point out that snoring rather than AHI is probably the
best metric to follow patients with mild forms of OSA in whom the most significant
complaint is snoring. On the other hand, we acknowledge that there are no standard
methods to measure snore and the field needs to be developed. Finally, there is a
perceived concept that exercises are difficult to incorporate. To this end, the simplified
protocol is a feasible series of 8 minutes (3 times a day) that could be more easily
incorporated into daily activities, such as immediately after tooth brushing or commuting
to work.
In conclusion, oropharyngeal exercises can reduce the objective measurements of
frequency and intensity of snoring. This set of oropharyngeal exercises is a promising
treatment for large populations suffering from snoring that are currently largely ignored
by the medical community.
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Acknowledgments:
Fundação Zerbini, São Paulo, Brazil.
This work was supported by Fundação de Amparo à Pesquisa do Estado de São Paulo
(FAPESP) and Conselho Nacional de Desenvolvimento Científico e Tecnológico
(CNPq).
Author contributions:
VI: contributed to study design, data collection and analysis, and manuscript draft. She
takes responsibility for the integrity of the work as a whole, from inception to published
article.
FK: contributed to data collection.
Dr. MIM: contributed to analysis and interpretation.
RPH: contributed to data collection, analysis, and interpretation.
Dr. MGG: contributed to data collection, analysis, and interpretation.
Dr. PRG: contributed to study design and manuscript draft.
AMA: contributed to study design and manuscript draft.
Dr. LFD: contributed to study design and manuscript draft.
Dr. GL-F: contributed to study design and manuscript draft.
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Table 1 - BASELINE DEMOGRAPHIC CHARACTERISTICS, QUESTIONNAIRES,
POLYSOMNOGRAPHIC AND SNORE CHARACTERISTICS OF THE PATIENTS ASSIGNED TO
CONTROL OR OROPHARYNGEAL THERAPY
Control
(n=20)
Therapy
(n=19)
P
value
Demographic characteristics
Male, n(%) 11 (55%) 11 (57.9%) 1.000
Age, yr 45 ± 13 48 ± 14 .458
BMI, kg/m
2
28.3 ± 2.5 28.1 ± 2.7 .818
Neck circumference, cm 38.0 ± 3.5 38.0 ± 2.6 .994
Abdominal circumference 94.3 ± 10.2 93.9 ± 5.7 .872
Polysomnography
TST, (hs) 6.2 ± 0.6 6.1 ± 0.8 .755
Sleep efficiency, (%) 84.4 ± 7.5 86.0 ± 9.7 .565
Arousal index, events/h 15.3 ± 5.4 20.0 ± 10.2 .080
AHI, events/h 15.1 ± 9.5 15.6 ± 9.3 .875
SpO
2
min 85.1 ± 5.8 85.5 ± 7.5 .844
Desaturation Index, events/h 12.3 ± 8.7 10.8 ± 8.8 .600
Snoring measures
Snore index, events/h 180.6 ± 203.1 156.1 ± 164.4 .682
Total snore index, events/h 54.4 [3.5-386.6] 60.4 [21.8-220.6] .613
Questionnaires
Patient
Pittsburgh sleep quality 6.9 ± 3.4 6.0 ± 3.2 .427
Epworth Sleepiness Scale 9.0 [7.0-13.5] 7.0 [3.0-11.0] .154
Subjective snore intensity 3.0 ± 1.0 2.3 ± 1.1 .037
Subjective snore frequency 4.0 [3.0-4.0] 3.0 [2.0-4.0] .070
Bed partner n=12 n=13
Subjective snore intensity 3.5 [2.3-4.0] 4.0 [2.5-4.0] .858
Subjective snore frequency 4.0 [3.0-4.0] 4.0 [3.0-4.0] .698
Definition of abbreviations: BMI=body mass index; TST=total sleep time;
AHI=apnea hypopnea index; SpO
2
min=lowest oxygen saturation;
Plus-minus values are mean ± SD. Epworth Sleepiness Scale, Subjective snore frequency,
Subjective snore intensity, and Total Snore Index are presented as median [25–75%] because
of skewed distribution
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Table 2 –DEMOGRAPHIC CHARACTERISTICS, QUESTIONNAIRES, POLYSOMNOGRAPHIC AND
SNORE CHARACTERISTICSOF THE PATIENTS ASSIGNED TO CONTROL OR OROPHARYNGEAL
THERAPY ON BASAL AND AFTER 3 MONTHS
Control (n=20) Therapy (n=19)
Baseline 3 months p Baseline 3 months P
Demographic characteristics
BMI, kg/m
2
28.3 ± 2.5 28.2 ± 3.5 0.453 28.1 ± 2.7 28.2 ± 2.8 .469
Neck
Circumference, cm 38.0 ± 3.5 37.9 ± 3.4 0.628 37.9 ± 2.5 37.5 ± 2.4 .000*
Abdominal
Circumference, cm
94.3 ±10.2 94.6 ± 10.4 0.673 93.9 ± 5.7 93.7 ± 4.5 .687
Questionnaires performed with the patient
Pittsburgh 6.9 ± 3.4 6.4 ± 3.9 0.459 6.0 ± 3.2 4.0 ± 2.6 .004
Epworth 9.0 [7.0-13.5] 8.0 [3.5-12.5] 0.190 7.0 [3.0-11.0] 7.0 [4.0-10.0] .084
Subjective Snore
Intensity 3.0 [2.0-4.0] 3.0 [2.0-3.0] 0.083 2.0 [2.0-3.0] 2.0 [1.0-2.0] .155
Subjective Snore
Frequency 4.0 [3.0-4.0] 3.5 [2.0-4.0] 0.010 3.0 [2.0-4.0] 2.0[1.0-4.0] .030
Questionnaires performed with bed partner
Subjective Snore
Intensity 3.5 [2.3-4.0] 3.0 [2.0-4.0] 0.194 4.0 [2.5-4.0] 1.0 [1.0-2.0] .003*
Subjective Snore
Frequency 4.0 [3.0-4.0] 3.5 [3.0-4.0] 0.180 4.0 [3.0-4.0] 2.0[1.5-3.0] .004*
Polysomnography
TST, hs 6.2 ± 0.6 6.2 ± 1.1 0.894 6.1 ± 0.8 6.5 ± 0.9 .079
Sleep efficiency, % 84.4 ± 7.5 85.0 ± 11.1 0.776 86.0 ± 9.7 86.3 ± 8.6 .825
Arousal index 15.3 ± 5.4 16.9 ± 5.2 0.239 20.0 ± 10.2 6.2 ± 1.4 .077
Lowest oxygen
saturation 85.1 ± 5.8 84.0 ± 7.6 0.325 85.5 ± 7.5 83.8 ± 8.9 .120
Desaturation Index 12.3 ± 8.7 12.1 ± 6.9 0.881 10.8 ± 8.8 9.7 ± 6.0 .437
Questionnaires
Patient
Pittsburgh 6.9 ± 3.4 6.4 ± 3.9 0.459 6.0 ± 3.2 4.0 ± 2.6 .004
Epworth 9.0 [7.0-13.5] 8.0 [3.5-12.5] 0.190 7.0 [3.0-11.0] 7.0 [4.0-10.0] .084
Subjective Snore
Intensity 3.0 [2.0-4.0] 3.0 [2.0-3.0] 0.083 2.0 [2.0-3.0] 2.0 [1.0-2.0] .155
Subjective Snore
Frequency 4.0 [3.0-4.0] 3.5 [2.0-4.0] 0.010* 3.0 [2.0-4.0] 2.0[1.0-4.0] .030
Bed partner n=12 n=13
Subjective Snore
Intensity 3.5 [2.3-4.0] 3.0 [2.0-4.0] 0.194 4.0 [2.5-4.0] 1.0 [1.0-2.0] .003*
Subjective Snore
Frequency 4.0 [3.0-4.0] 3.5 [3.0-4.0] 0.180 4.0 [3.0-4.0] 2.0[1.5-3.0] .004*
Definition of abbreviations: BMI=body mass index; TST=total sleep time;
* P < .05 for the comparisons using repeated measures analysis of variance (ANOVA): compare the
interaction between the 2 groups (Control and Therapy) and the 2 moments (baseline and after 3 months)
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Figure Legends
Figure 1. Flow diagram of the progress through the phases
Figure 2. Individual values for Snore Index. In the control group, the Snore Index from
baseline to 3 months was similar. In contrast, the Snore Index significantly declined in
the group randomized to oropharyngeal exercises. There were group X time interaction
effects (P = .017). Short horizontal lines and bars are mean ± SD. NS = not significant
Figure 3. Individual values for Total Snore Index. In the control group, the Total Snore
Index from baseline to 3 months was similar. In contrast, the Total Snore Index
significantly declined in the group randomized to oropharyngeal exercises. There were
group X time interaction effects (P = .033). Short horizontal lines and bars are mean ±
SD. NS = not significant
Figure 4. Individual values for Apnea Hypopnea Index (AHI) at baseline and after 3
months. There were no statistical differences on AHI in either group. However, the
subgroup of patients with moderate obstructive sleep apnea (OSA) (15 ≤ AHI 30)
randomized to oropharyngeal exercises had a significantly decreased AHI. In the control
group, the AHI from baseline to 3 months (from 25.3 [22.1-29.8] to 22.1 [18.2-28.1]
events/h) was similar. In contrast, the AHI significantly declined in the group randomized
to oropharyngeal exercises (from 25.4 [22.1-28.7] to 18.1 [15.4-24.1] events/h; P =
.017). Short horizontal lines and bars are medians (25–75%), because of skewed
distribution
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Figure 1. Flow diagram of the progress through the phases
254x190mm (72 x 72 DPI)
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Figure 2. Individual values for Snore Index. In the control group, the Snore Index from baseline to 3 months
was similar. In contrast, the Snore Index significantly declined in the group randomized to oropharyngeal
exercises. There were group X time interaction effects (P = .017). Short horizontal lines and bars are mean
± SD. NS = not significant.
313x168mm (150 x 150 DPI)
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Figure 3. Individual values for Total Snore Index. In the control group, the Total Snore Index from baseline
to 3 months was similar. In contrast, the Total Snore Index significantly declined in the group randomized to
oropharyngeal exercises. There were group X time interaction effects (P = .033). Short horizontal lines and
bars are mean ± SD. NS = not significant.
247x153mm (150 x 150 DPI)
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Figure 4. Individual values for Apnea Hypopnea Index (AHI) at baseline and after 3 months. There were no
statistical differences on AHI in either group. However, the subgroup of patients with moderate obstructive
sleep apnea (OSA) (15 ≤ AHI ≤ 30) randomized to oropharyngeal exercises had a significantly decreased
AHI. In the control group, the AHI from baseline to 3 months (from 25.3 [22.1-29.8] to 22.1 [18.2-28.1]
events/h) was similar. In contrast, the AHI significantly declined in the group randomized to oropharyngeal
exercises (from 25.4 [22.1-28.7] to 18.1 [15.4-24.1] events/h; P = .017). Short horizontal lines and bars
are medians (25–75%), because of skewed distribution.
247x122mm (72 x 72 DPI)
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... A nonsurgical treatment for primary snoring is myofunctional therapy (MT) 11 , which aims to improve posture, sensitivity, proprioception, tone, and mobility of the orofacial and pharyngeal muscles 12 . In a randomized controlled trial, Ieto et al. (2015) 13 tested the effects of MT on snoring and observed a reduction in the bed partner's perception of snoring, frequency of snoring, and total snore index. ...
... The participants were randomized 2:1 using an electronic system. The experimental group performed the exercises of the protocol proposed by Ieto et al. (2015) 13 and the control group followed the protocol of Kayamori (2015) 15 . ...
... The increase of BMI in the experimental group after treatment, although not statistically significant, together with the lower adherence rate in this group when compared to the control group, raises the question regarding the influence of these factors on the efficacy of MT in the treatment of snoring in the population studied. There was a significant increase of neck circumference after treatment, in contrast to previous studies that reported a reduction of neck circumference in the MT group after treatment 13,15,17 . We may assume that this increase in neck circumference is a consequence of the increase in BMI found in both the experimental and the control group after the treatment period. ...
Article
Full-text available
Objective: To analyze the effectiveness of myofunctional therapy (MT) in the treatment of habitual snoring in obese patients. Material and methods: This randomized clinical trial consisted of an experimental group (n=14) that underwent MT and a control group (n=26) that performed nonspecific exercises for the treatment of snoring. The Epworth sleepiness scale (ESS), Pittsburgh sleep quality index (PSQI), and short-form health survey (SF-36) were applied before and after treatment. Snoring was assessed subjectively by asking the partner about improvement after treatment. The SnoreLab app was used for objective assessment. Results: There was no significant effect of MT on any of the SnoreLab variables analyzed when groups, time points or covariates (adherence, age, body mass index [BMI], neck circumference, and sex) were compared. Neck circumference (cm) and the Pittsburgh sleep quality index score were significantly higher after treatment. There was no change in the Epworth sleepiness scale score after treatment. A correlation was found between BMI and the Pittsburgh sleep quality index and between BMI and the functional capacity component of the SF-36. Patient adherence was similar between groups. Discussion: Apps for recording snoring are a useful tool to be explored. MT exerted no significant effect on habitual snoring in obese patients despite the reduction of the snore score in the experimental group. Therapy applied without exclusion criteria based on the severity of sleep breathing disorders and pharyngeal characteristics fails to achieve the results necessary to treat habitual snoring in obese patients.
... Since Guimaraes et al. [21] published their results of myofunctional therapy (MFT), this approach has been presented as a promising complementary treatment modality, supported by increasing published evidence. MFT has shown a reduction in snoring, the apnea-hypopnea index (AHI), oxygen desaturation, and daytime sleepiness [22][23][24][25]. As it can be difficult for our patients to access a professional speech therapist, we recommend them to carry out a home-based therapy with oropharyngeal exercises, using a mHealth app (Airway Gym ® ) which has demonstrated acceptable rates of adherence and results [26][27][28][29]. ...
Article
Full-text available
Ankyloglossia (tongue-tie) is a condition of the oral cavity in which an abnormally short lingual frenulum affects the tongue’s mobility. Literature on the correlation between ankyloglossia and obstructive sleep apnea (OSA) is scarce. The main objective of this study was to report our preliminary experience in adult OSA patients before and after ankyloglossia treatment, using drug-induced sleep endoscopy (DISE) to evaluate the upper airway modifications resulting after treatment, and to present a systematic review of the impact of ankyloglossia and its treatment on OSA adults. We found that, after frenotomy, regarding the DISE findings, and according to the VOTE classification, two of the three patients showed an improvement in tongue level, from 2A-P (complete anteroposterior collapse) to 1ap (partial anteroposterior collapse). The third patient showed no changes in his UA after frenotomy, neither worsening nor showing improvement. Thus, the results of this study suggest that frenotomy in OSA patients with ankyloglossia could reduce tongue collapse, probably by allowing the tongue to take into the physiological position in the oral cavity. These patients should undergo speech therapy and oropharyngeal exercises prior to any surgical procedure, in order to avoid glossoptosis and to improve the quality of life and sleep apnea results.
... Myofunctional therapy (MT) consists of isotonic and isometric exercises aimed at the oral and oropharyngeal structures, with the purpose of increasing muscle strength, tone, endurance, and coordinated movements of the pharyngeal and peri pharyngeal muscles. Recent studies have shown the effectiveness of MT in reducing snoring, apnea-hypopnea index (AHI), daytime sleepiness, and sleep quality [3,4]. MT also helps reposition the tongue, improves nasal breathing, and increases muscle tone in both pediatric patients and adults with OSA [5,6]. ...
Article
Full-text available
Myofunctional therapy (MT) is a recent treatment option for obstructive sleep apnea (OSA). The Iowa Oral Performance Instrument (IOPI) is a useful but expensive tool for measuring tongue strength in patients with OSA. We validated the Tongue Digital Spoon (TDS) to monitor tongue hypotonia in patients with OSA. Measurements with the IOPI and TDS were compared in patients with OSA before and after MT for tongue hypotonia. Baseline mean tongue strength measured with the IOPI in patients with moderate and severe OSA were 35.36 ± 9.05 and 33.83 ± 12.05, respectively, and that with the TDS were 168.55 ± 42.8 and 129.61 ± 53.7, respectively. After MT, mean tongue strength significantly improved: measured with the IOPI in patients with moderate and severe OSA were 53.85 ± 10.09 and 55.50 ± 9.64 (p = 0.8), and that with the TDS were 402.36 ± 52.92 and 380.28 ± 100.75 (p = 0.01), respectively. The correlation between the IOPI and TDS was high (r = 0.74; p = 0.01 pre-treatment, and r = 0.25; p = 0.05 post-treatment). The TDS is a useful tool for monitoring the efficacy of MT in patients with short-term OSA. Future randomized studies will determine the effectiveness of MT for the treatment of OSA.
... An updated review of current literature on MFT in OSA should be included in future guidelines for adult OSA. de Felício et al. (2018) reviewed 11 articles showing that the benefits of MFT include reduced AHI and arousal index, and improved daytime sleepiness and sleep quality. In their randomized trial, Ieto et al. (2015) showed that patients diagnosed with primary snoring and mildto-moderate OSA who underwent daily oropharyngeal exercises for 3 months had a decreased snore index compared with the control group. Guimarães et al. (2009) showed significant improvement in OSA severity and symptoms (i.e., snoring frequency and intensity, daytime sleepiness, AHI) after 3 months of oropharyngeal exercise therapy in patients with moderate OSA. ...
Article
Purpose: This article presents a narrative review of current recommendations for the clinical evaluation and management of adult patients with obstructive sleep apnea (OSA) to identify points missing from a myofunctional perspective. Methods: The authors reviewed current official guidelines for adult patients with OSA, searching clinical evaluation and treatment recommendations for myofunctional therapy. Results: None of the current guidelines for evaluation of adult OSA recommend performing a myofunctional evaluation. Only two guidelines consider myofunctional therapy (MFT) as a treatment modality for adult patients with OSA. Conclusion: Despite the role of the pharyngeal dilator muscles as an essential contributor to the pathogenesis of OSA, this review has shown that myofunctional assessment is still not a standard recommendation in current guidelines for adult OSA. Recent guidelines occasionally include MFT as a therapeutic tool for OSA. To strengthen the knowledge base and evidence for including MFT treatment for adult patients with OSA, the authors encourage physicians to incorporate myofunctional evaluation into their regular clinical practice.
... A group in Brazil has also reported that a defined upper airway muscle exercise regimen could improve sleep-disordered breathing among participants although the mechanisms behind this finding are unclear [26]. Other studies have found that corresponding oropharyngeal exercises can alleviate moderate OSA [27]. The former paper was a systematic review and meta-analysis where the authors stipulated that these positive effects were caused by a change in oropharyngeal muscle tone. ...
Article
Full-text available
Introduction: Obstructive sleep apnea (OSA) is a common disorder with major neurocognitive and cardiovascular sequelae. The treatment of symptomatic patients with mild OSA remains controversial given that adherence to positive airway pressure (PAP) has historically been suboptimal. With this notion in mind, we assessed a daily transoral neuromuscular electrical stimulation (NMES) device for individuals with mild OSA. Methods: The sample represents a subset of participants with a baseline AHI 5-14.9 events/hour, drawn from a parent study which also included participants with primary snoring. Outcome measures for the current study included changes in apnea-hypopnea index (AHI), Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI) and snoring levels before and after use of the NMES. RESULTS: Among 65 participants (68% men) with median age of 49 years (range 24 to 79) and median BMI of 27.7 kg/m2 (range 20 to 34), the NMES device was used daily for 6 weeks. We observed a significant improvement in the AHI from 10.2 to 6.8 events/hour among all participants and from 10.4 to 5.0 events/h among responders. Statistically significant improvements in the ESS, PSQI, objectively measured snoring, and bed partner-reported snoring were observed. Adherence among all participants was 85%. Discussion: This NMES device has the benefit of being a treatment modality of daytime therapy which confers a high level of tolerability and patient acceptance. It alleviates the need for an in situ device during sleep and leads to improvements in OSA severity, snoring, and subjective sleep metrics, potentially crucial in mild OSA. Further studies are needed to define which individuals may benefit most from the device across the wider spectrum of OSA severity and assess long-term therapeutic outcomes. Trial registration: ClinicalTrials.gov Identifier: NCT03829956.
Article
Full-text available
Primary snoring impacts a significant portion of the adult population and has the potential to significantly impair quality of life. The purpose of these guidelines is to provide evidence‐based recommendations to assist Australasian practitioners in the management of adult patients who present with primary snoring without significant obstructive sleep apnoea. The Timetable, Methodology and Standards by which this Position Statement has been established is outlined in the Appendix S1. The main recommendations are: Weight loss, and reduced alcohol consumption should be recommended, where appropriate If clinical judgement dictates, benzodiazepine and opioid reduction or avoidance may be advised Positional therapy should be considered in supine dominant snorers In dentate patients, Mandibular advancement devices (MAD) should be recommended as a first line treatment following assessment by both an appropriate Dentist and Sleep physician Continuous positive airway pressure (CPAP) devices may be recommended in patients with primary snoring in those already committed to their use or willing to try Surgical treatment of primary snoring by an appropriately credentialled surgeon may be advised and includes nasal (adjunctive), palatal and other interventions This position statement has been designed based on the best available current evidence and our combined expert clinical experience to facilitate the management of patients who present with primary snoring. It provides clinicians with a series of both non‐surgical and surgical options with the aim of achieving optimal symptom control and patient outcomes. This is the first such set of recommendations to be established within Australasia and has also been reviewed and endorsed by the Australasian Sleep Association.
Article
Study objectives the mechanical efficiency of upper airway (UA) muscles are pivotal in maintaining UA stability. We aimed to investigate if different tongue training approaches could differently induce signs of neuroplastic in the corticomotor pathways and upper airway stability changes. Methods 36 Sprague-Dawley rats were trained daily for eight weeks to lick an isotonic force-sensing disc at targeting forces using 30-50% of maximal achieved lick force (MALF) for tongue task training (TTT) or targeting force set above 50%, 60% and 70% of MALF progressively for tongue strength training (TST). Corticomotor excitability was dynamically assessed by GG response to transcortical magnetic stimulation (TMS) at different sessions. GG EMG activity, GG ultrastructure and myosin heavy chain (MHC), UA dynamics were assessed after eight weeks. Results After 4 weeks, GG TMS latencies decreased in both tongue training groups when compared with the control group (p<0.05) and this excitability was more stable in TTT group. After 8 weeks, both GG TMS response and EMG activity revealed increased excitability in TTT and TST groups. The apoptotic pathological morphology changes of GG ultrastructure were observed in TST group, but not TTT. Percentage of GG MHC type I fibers in TST group was higher than the control and TTT groups (p<0.05). The UA Pcrit decreased significantly in TTT group (p<0.05) and tend to decrease in TST group (p=0.09). Conclusion TTT could improve the UA stability and induce the neuroplastic changes more efficiently without training-induced muscle injury, while TST revealed a fatigue-resistance change in GG.
Objective This study aims to explore the effects of comprehensive swallowing intervention on obstructive sleep apnea (OSA) and dysphagia in stroke patients. Methods We performed a randomized controlled trial in stroke patients with obstructive sleep apnea (OSA) complicated by dysphagia, divided into treatment group and control group. The treatment group underwent comprehensive swallowing intervention and received swallowing care for 4 weeks, while the control group received only swallowing care. Outcome measurements were obtained at baseline and after the 4-week intervention, evaluated by polysomnography (PSG), videoendoscopic swallowing study (VFSS) synchronized surface electromyography (sEMG), oropharyngeal magnetic resonance imaging (MRI) and swallowing assessment scales. Results Sixty patients with stroke (30 treatment and 30 control) were eligible to participate in this study. There were no significant differences in any assessment between two groups at baseline. After a 4-week intervention, compared with to control group, there was a significant decrease in the apnea-hypopnea index (AHI) and oxygen desaturation index (ODI), and increased mean and minimal oxygen saturation (SaO2), amplitudes of suprahyoid muscle group (ASUPMG) and subhyoid muscle group (ASUBMG). Moreover, the posterior palatal distance (PPD), posterior lingual distance (PLD) and minimal cross-sectional area (MCSA) were obviously elevated in the treatment group. Additionally, the scores of Gugging swallowing screen (GUSS) and VFSS were significantly increased in the treatment group, compared to control group. Conclusions The comprehensive swallowing intervention had therapeutic effects on OSA and dysphagia after stroke, and the mechanism was related to enhancing oropharyngeal muscle strength and changing upper airway structure.
Article
Objectives: To organize an assessment instrument with questionnaires and myofunctional orofacial/oropharyngeal assessment for OSA patients and correlate it with the upper airway obstructive site detected during drug-induced sleep endoscopy (DISE). Material and Methods: 29 OSA patients aged 22-65 years with an indication to undergo DISE to evaluate an alternative treatment to PAP and signed the consent form. Patients over 65 years old with maxillofacial deficiency and BMI>30 were excluded. The subjects answered the Pittsburgh, Berlin (snore), and Epworth questionnaires. The myofunctional orofacial/oropharyngeal assessment comprised soft palate, palatine pillars, and uvula (structure and mobility), tonsils (size), mandible (bony bases), hard palate (depth and width), tongue (posture, volume, width, and height), floor of mouth (mylohyoid), tongue suction and sustaining (mobility), “lowering of the back of the tongue” (stimulus), which were scored by three speech-language pathologists with expertise. DISE was scored according to VOTE classification. The statistical analysis (t-test) compared groups without and with obstruction in VOTE with questionnaires and myofunctional orofacial/oropharyngeal assessment. Results: The following were significantly different: snoring frequency (p=0.03) with VOTE/velopharynx; intensity (p=0.02) and frequency of snoring (p=0.03) with VOTE/lateral wall of oropharynx; suction the tongue and sustain (p=0.02) with VOTE/velopharynx; hard palate depth (p=0.02) and width (p=0.05) with obstruction VOTE/epiglottis; tonsils volume (p=0.05) with VOTE/epiglottis; tongue posture (p=0.00) with obstruction VOTE/epiglottis; floor of the mouth (p=0.02) with VOTE/epiglottis. Conclusion: Higher snoring frequency and intensity was observed in patients with obstruction at the velopharynx and oropharyngeal lateral wall. Obstruction at the velopharynx was associated with poor tongue ability to suck the tongue against the hard palate. Obstruction at the epiglottis had structural and functional associations, including the oropharyngeal lateral wall, affected by the palatine tonsils size, depth and width of the hard palate, tongue position, and flaccidity of the floor of mouth. Considering that this is a preliminary study, the data should be carefully verified and not generalized.
Article
Objective To determine whether combined transoral robotic surgery and postoperative oropharyngeal rehabilitation are effective for reducing the severity of obstructive sleep apnea. Study Design A quasi-experimental study enrolled participants without blinding between May 2019 and April 2021. Setting Single-center study at National Cheng Kung University Hospital. Methods Patients with moderate to severe obstructive sleep apnea who were otherwise healthy were recruited from the ear, nose, and throat department at National Cheng Kung University Hospital. The group undergoing transoral robotic surgery with oropharyngeal rehabilitation (n = 18) received a 12-week intervention consisting of home-based rehabilitation exercises following surgery; the transoral robotic surgery group (n = 17) received surgery only; and the control group (n = 15) received conservative treatment, such as continuous positive airway pressure therapy or other oral appliance therapy. Polysomnography data and tongue muscle performance were measured before and after the interventions. Results The group that underwent transoral robotic surgery with oropharyngeal rehabilitation exhibited significantly improved tongue protrusion strength as compared with the transoral robotic surgery–only group, as well as significantly improved apnea-hypopnea index in the supine position vs the control group. Conclusion In this study, we demonstrated the synergistic effects of transoral robotic surgery and postoperative oropharyngeal rehabilitation for adult patients with obstructive sleep apnea. Objective records should be used to monitor home-based rehabilitation exercises and examine the lasting synergistic effects.
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BACKGROUND: Snoring is a common problem that poses a high risk for obstructive sleep apnea (OSA). We studied the contribution of risk factors for OSA in snorers referred for full-night polysomnography (PSG). METHODS: A questionnaire was administered to subjects referred for PSG in the period from April 2002 to March 2005. RESULTS: There were 191 (84%) snorers identified by 227 PSG studies. They had a mean age of 48.1±9.8 years, (age range, 23-73 years) and 78.5% were males. OSA as indicated by a respiratory disturbance index (RDI) of >5 events/hour was seen in 126 (66%) subjects. In males, 72.7% had OSA, with a mean RDI of 43.0±26 events/hour, versus 39% with OSA in females with a mean RDI of 27.8±26.5 events/hour (P<0.001). The OSA group had a higher mean Epworth Sleepiness Scale (ESS) (P<0.001), a larger mean neck circumference (P<0.01), an increased mean age (P<0.05), and more witnessed apneas (P<0.001) but not choking (P=0.096). The mean increase in body mass index was linked to OSA only in females (P<0.05) but not in the overall study (P=0.507). Multivariate analysis showed that ESS, male gender, and a history of witnessed apnea were associated with OSA, while controlling for obesity, large neck circumference, age, and history of choking. CONCLUSION: In screening snorers for PSG, male gender, ESS and a history of witnessed apneas were the most important predictors of OSA, but other factors should be considered in referring snorers for PSG. In males, obesity did not contribute to the risk of OSA in our study population.
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Purpose: This study evaluated the efficacy of oropharyngeal exercises in children with symptoms of obstructive sleep apnea syndrome (OSA) after adenotonsillectomy. Methods: Polysomnographic recordings were performed before adenotonsillectomy and 6 months after surgery. Patients with residual OSA (apnea-Hypopnea Index, AHI > 1 and persistence of respiratory symptoms) after adenotonsillectomy were randomized either to a group treated with oropharyngeal exercises (group 1) or to a control group (group 2). A morphofunctional evaluation with Glatzel and Rosenthal tests was performed before and after 2 months of exercises. All the subjects were re-evaluated after exercise through polysomnography and clinical evaluation. The improvement in OSA was defined by ΔAHI: (AHI at T1 - AHI at T2)/AHI at T1 × 100. Results: Group 1 was composed of 14 subjects (mean age, 6.01 ± 1.55) while group 2 was composed of 13 subjects (mean age, 5.76 ± 0.82). The AHI was 16.79 ± 9.34 before adenotonsillectomy and 4.72 ± 3.04 after surgery (p < 0.001). The ΔAHI was significantly higher in group 1 (58.01 %; range from 40.51 to 75.51 %) than in group 2 (6.96 %; range from -23.04 to 36.96 %). Morphofunctional evaluation demonstrated a reduction in oral breathing (p = 0.002), positive Glatzel test (p < 0.05), positive Rosenthal test (p < 0.05), and increased labial seal (p < 0.001), and lip tone (p < 0.05). Conclusions: Oropharyngeal exercises may be considered as complementary therapy to adenotonsillectomy to effectively treat pediatric OSA.
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Minimally invasive surgeries of the soft palate have emerged as a less-invasive treatment for habitual snoring. To date, there is only limited information available comparing the effects of snoring sound between different minimally invasive surgeries in the treatment of habitual snoring. To compare the efficacy of palatal implant and radiofrequency surgery, in the reduction of snoring through subjective evaluation of snoring and objective snoring sound analysis. Thirty patients with habitual snoring due to palatal obstruction (apnea-hypopnea index ≤15, body max index ≤30) were prospectively enrolled and randomized to undergo a single session of palatal implant or temperature-controlled radiofrequency surgery of the soft palate under local anesthesia. Snoring was primarily evaluated by the patient with a 10 cm visual analogue scale (VAS) at baseline and at a 3-month follow-up visit and the change in VAS was the primary outcome. Moreover, life qualities, measured by snore outcomes survey, and full-night snoring sounds, analyzed by a sound analytic program (Snore Map), were also investigated at the same time. Twenty-eight patients completed the study; 14 received palatal implant surgery and 14 underwent radiofrequency surgery. The VAS and snore outcomes survey scores were significantly improved in both groups. However, the good response (postoperative VAS ≤3 or postoperative VAS ≤5 plus snore outcomes survey score ≥60) rate of the palatal implant group was significantly higher than that of the radiofrequency group (79% vs. 29%, P = 0.021). The maximal loudness of low-frequency (40-300 Hz) snores was reduced significantly in the palatal implant group. In addition, the snoring index was significantly reduced in the radiofrequency group. Both palatal implants and a single-stage radiofrequency surgery improve subjective snoring outcomes, but palatal implants have a greater effect on most measures of subjective and objective snoring. Multi-stage radiofrequency surgery was not tested. ClinicalTrials.gov NCT01955083.
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Inspiratory flow limitation (IFL) during sleep occurs when airflow remains constant despite an increase in respiratory effort. This respiratory event has been recognized as an important parameter for identifying sleep breathing disorders. The purpose of this study was to investigate how much IFL normal individuals can present during sleep. Cross-sectional study derived from a general population sample. A "normal" asymptomatic sample derived from the epidemiological cohort of São Paulo. This study was derived from a general population study involving questionnaires and nocturnal polysomnography of 1,042 individuals. A subgroup defined as a nonsymptomatic healthy group was used as the normal group. N/A. All participants answered several questionnaires and underwent full nocturnal polysomnography. IFL was manually scored, and the percentage of IFL of total sleep time was considered for final analysis. The distribution of the percentage of IFL was analyzed, and associated factors (age, sex, and body mass index) were calculated. There were 95% of normal individuals who exhibited IFL during less than 30% of the total sleep time. Body mass index was positively associated with IFL. Inspiratory flow limitation can be observed in the polysomnography of normal individuals, with an influence of body weight on percentage of inspiratory flow limitation. However, only 5% of asymptomatic individuals will have more than 30% of total sleep time with inspiratory flow limitation. This suggests that only levels of inspiratory flow limitation > 30% be considered in the process of diagnosing obstructive sleep apnea in the absence of an apnea-hypopnea index > 5 and that < 30% of inspiratory flow limitation may be a normal finding in many patients. Palombini LO; Tufik S; Rapoport DM; Ayappa IA; Guilleminault C; de Godoy LBM; Castro LS; Bittencourt L. Inspiratory flow limitation in a normal population of adults in São Paulo, Brazil. SLEEP 2013;36(11):1663-1668.
Article
A major problem in the analysis of clinical trials is missing data caused by patients dropping out of the study before completion. This problem can result in biased treatment comparisons and also impact the overall statistical power of the study. This paper discusses some basic issues about missing data as well as potential 'watch outs.' The topic of missing data is often not a major concern until it is time for data collection and data analysis. This paper provides potential design considerations that should be considered in order to mitigate patients from dropping out of a clinical study. In addition, the concept of the missing-data mechanism is discussed. Five general strategies of handling missing data are presented: 1. Complete- case analysis, 2. 'Weighting methods,' 3. Imputation methods, 4. Analyzing data as incomplete, and 5. 'Other' methods. Within each strategy, several methods are presented along with advantages and disadvantages. Also briefly discussed is how the International Conference on Harmonization (ICH) addresses the issue of missing data. Finally, several of the methods that are illustrated in the paper are compared using a simulated data set.
Article
Objective To systematically review the literature for articles evaluating myofunctional therapy (MT) as treatment for obstructive sleep apnea (OSA) in children and adults and to perform a meta-analysis on the polysomnographic, snoring, and sleepiness data. Data Sources Web of Science, Scopus, MEDLINE, and The Cochrane Library. Review Methods The searches were performed through June 18, 2014. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement was followed. Results Nine adult studies (120 patients) reported polysomnography, snoring, and/or sleepiness outcomes. The pre- and post-MT apnea-hypopnea indices (AHI) decreased from a mean ± standard deviation (M ± SD) of 24.5 ± 14.3/h to 12.3 ± 11.8/h, mean difference (MD) -14.26 [95% confidence interval (CI) -20.98, -7.54], P < 0.0001. Lowest oxygen saturations improved from 83.9 ± 6.0% to 86.6 ± 7.3%, MD 4.19 (95% CI 1.85, 6.54), P =0.0005. Polysomnography snoring decreased from 14.05 ± 4.89% to 3.87 ± 4.12% of total sleep time, P < 0.001, and snoring decreased in all three studies reporting subjective outcomes. Epworth Sleepiness Scale decreased from 14.8 ± 3.5 to 8.2 ± 4.1. Two pediatric studies (25 patients) reported outcomes. In the first study of 14 children, the AHI decreased from 4.87 ± 3.0/h to 1.84 ± 3.2/h, P = 0.004. The second study evaluated children who were cured of OSA after adenotonsillectomy and palatal expansion, and found that 11 patients who continued MT remained cured (AHI 0.5 ± 0.4/h), whereas 13 controls had recurrent OSA (AHI 5.3 ± 1.5/h) after 4 y. Conclusion Current literature demonstrates that myofunctional therapy decreases AHI by approximately 50% in adults and 62% in children. Lowest oxygen saturations, snoring, and sleepiness outcomes improve in adults. Myofunctional therapy could serve as an adjunct to other OSA treatments.
Article
Simple snoring (SS), in the absence of obstructive sleep apnoea (OSA), is a common problem, yet our understanding of its causes and consequences is incomplete. Our understanding is blurred by the lack of consistency in the definition of snoring, methods of assessment, and degree of concomitant complaints. Further, it remains contentious whether SS is independently associated with daytime sleepiness, or adverse health outcomes including cardiovascular disease and metabolic syndrome. Regardless of this lack of clarity, it is likely that SS exists on one end of a continuum, with OSA at its polar end. This possibility highlights the necessity of considering an otherwise 'annoying' complaint, as a serious risk factor for the development and progression of sleep apnoea, and consequent poor health outcomes. In this review, we: 1) highlight variation in prevalence estimates of snoring; 2) review the literature surrounding the distinctions between SS, upper airway resistance syndrome (UARS) and OSA; 3) present the risk factors for SS, in as far as it is distinguishable from UARS and OSA; and 4) describe common correlates of snoring, including cardiovascular disease, metabolic syndrome, and daytime sleepiness.
Article
Management of snoring is part of the treatment offered to patients with obstructive sleep apnea syndrome. In patients who do not have this syndrome, however, snoring should be treated according to the severity of the condition. General or specific therapeutic measures should be applied to snorers that have concomitant cardiovascular disease or unrefreshing sleep and in cases in which an individual's snoring disturbs his/her partner's sleep. The present review examines the treatments currently available for snorers and the current state of knowledge regarding each option. It will also focus on the possible indications of these treatments and evaluate their effectiveness.
Article
Background: Limited studies suggest that pubertal development may lead to a recurrence of sleep-disordered breathing (SDB) despite previous curative surgery. Our study evaluates the impact of myofunctional reeducation in children with SDB referred for adenotonsillectomy, orthodontia, and myofunctional treatment in three different geographic areas. Methods: A retrospective investigation of children with polysomnographic analysis following adenotonsillectomy were referred for orthodontic treatment and were considered for myofunctional therapy. Clinical information was obtained during pediatric and orthodontic follow-up. Polysomnography (PSG) at the time of diagnosis, following adenotonsillectomy, and at long-term follow-up, were compared. The PSG obtained at long-term follow-up was scored by a single-blinded investigator. Results: Complete charts providing the necessary medical information for long-term follow-up were limited. A subgroup of 24 subjects (14 boys) with normal PSG following adenotonsillectomy and orthodontia were referred for myofunctional therapy, with only 11 subjects receiving treatment. Follow-up evaluation was performed between the 22nd and 50th month after termination of myofunctional reeducation or orthodontic treatment if reeducation was not received. Thirteen out of 24 subjects who did not receive myofunctional reeducation developed recurrence of symptoms with a mean apnea-hypopnea index (AHI)=5.3±1.5 and mean minimum oxygen saturation=91±1.8%. All 11 subjects who completed myofunctional reeducation for 24 months revealed healthy results. Conclusion: Despite experimental and orthodontic data supporting the connection between orofacial muscle activity and oropharyngeal development as well as the demonstration of abnormal muscle contraction of upper airway muscles during sleep in patients with SDB, myofunctional therapy rarely is considered in the treatment of pediatric SDB. Absence of myofascial treatment is associated with a recurrence of SDB.