ALL YOU NEED TO KNOW ABOUT  QUIT SNORING...

Snoring: Diagnosis and treatment. General

Snoring, should be considered a disease and not as a normal event in the lives of people, as was seen for many years.
It is as old as humanity itself. It was and is because of family problems and marital discord. Well then deserves the attention and dedication of medical specialists. The pathological significance ranges from simple snoring to the SAS (sleep apnea syndrome) being its best Pickwik syndrome. In all cases it is a varying degree of respiratory obstruction with corresponding chronic asphyxia. Patients with SAS, show tiles makes them apneas disrupt sleep, hindering people's sleep. These patients are very sleepy during the day, being able to check hypercapnia and metabolic acidosis. The anatomical location, lies at the level of the oropharyngeal structures, located between the hard palate and hyoid bone. This anatomical region is deformable elements with variations in pressure and muscle tone .- Within this region there are two areas account for most of the processes roncópatas: the velo-pharyngeal and retrobasilingual or glossopharyngeal nerves.

Etiology

Snoring is noisy breathing produced by the vibration or "flutter" of the soft tissues of the oropharynx. The S.A.S. is an interruption of breathing during sleep and often added a lingual component .- The S.A.S. is considered severe when the duration of apneas exceeding 10 seconds and there are over 30 in normal sleep 7 hours (more than 4 or 5 in one hour). 20% of the general population is snoring. Every 20 snorers, 1 have S.A.S.. In the Middle Ages husky 24% of males and 14% of women. After age 60 snore, 40% of females and 60% of men. A direct relationship between snoring patients and some cardiovascular diseases such as hypertension. 25% of hypertensive patients suffering from SAS, or are simple snorers. Many authors have demonstrated the direct relationship between snoring and hypertension.

Physiology

The quemoreflejos and mecanoreflejos are responsible for regulating breathing. There quemoreflejos plants, located in the ventral region of the brainstem, and peripheral carotid body level. The quemoreceptores are responsible for the uptake of changes in PCO2 stimulating ventilation. The peripherals, and respond to changes in PO2. The receptors are mechanoreceptors Broncho and thoracic wall and have to do with the lengthening of the respiratory rate. When decreases in PO2, PCO2 increases, this increases the respiratory rate and makes the movements are more profound than during wakefulness. In this period when crises occur SAS
Respiratory movements are due to a spinal reflex, involuntary, but can be controlled voluntarily by the cerebral cortex. During normal sleep, cortical voluntary activity disappears, being replaced by the involuntary spinal cord. The snoring, the tables have hypoxemia is cause repeated awakenings vigil, alternating the automatic control cord, with the volunteer cortex. This makes the patient presented more or less tired and sleepy during the day, as the number of interruptions you have experienced during sleep at night.

Importance of nasal breathing.

Since ancient times it was said that you breathe through your nose feels "good" and spiritually "strong." Even then they thought it was very difficult to have a totally healthy person if not breathing well through your nose. But this concept goes far beyond them because the nasal respiratory failure, is not like they used to say 20 or 30 years, harms the body because the air does not pass through the nose is not "purified", not "hot" and not "wet" .- Further studies on respiratory physiology have shown that if these three were the only functions performed by the nose, we could "close" without causing injury to the body, as there are compensation mechanisms throughout the respiratory tree .- The nose serves not only to purify, warm and humidify the air during inspiration, this is true and is important, but more important is the role of the nose during expiration. The air that enters the nose, is conditioned, even partially, by supplemental mechanisms to the respiratory tree has in its way. No compensatory mechanism to retrieve the excess energy that she escapes in every breath .- However, when the air goes through the nose, is cooler and drier. This wonderful ability to recover energy in each event is known as enthalpy expiratory nasal and no substitutions. There is only at the nose. So for the fulfillment of a normal physiological mechanism is necessary for breathing air in and out of the nose .-

Neurophysiology

Let's refer to the nerve endings from the nasal cavity that are related to control of certain brain activities .- A group of physiologists at the University of Buenos Aires, led by Prof.Affani studying the brain, they found a surprising fact: "nasal breathing against everything that had been saying so far, is of fundamental importance in the regulation of bioelectric activity and other physiological manifestations of the brain, "whose importance is only now beginning to investigate .- Remember that the nose has four different types of innervations and closely related:

1) olfactory nerve,
2) Trigeminal,
3) Nasal Vomero,
4) Terminal.

For many years we know that there is no relationship between nasal endings and parts of the brain, so much so that these parts of the brain connected with the nose were called: rhinencephalon. But with the passage of time is not properly studied the relationship between nose and brain. Most researchers made the following reasoning: "The nose and smell are stunted and sense organ in man, therefore all parts of the brain associated with the nose should not be important" .- It is true that brain structures related to the nose, the human brain involved in a smaller space than in animals but not necessarily be smaller to be less important. The respiratory center occupies a small space, yet it is so important to life.

Relationship of brain structures innervated nasal  The nerve arises in the nasal vomer vomer nasal organ, through the cribriform plate and comes to a special area of the olfactory bulb called "accessory olfactory bulb. The accessory olfactory bulb is related to and connected with:

1) pre-optic area
2) Region of the amygdala
3) Hippocampus.

The nasal vomer organ, is stunted after six months in utero and is related to the maturation of certain brain structures.
The rhea pre-optics, power to interfere with the regulation of sexual behavior, and the region of the amygdala, the regulation of behavior. The hippocampus has the highest development of the zoological scale. It plays a role in learning and memory. Through the fornix connects with the pre-optic region (Sexual Conduct), and the septal region, which has features food, reproductive and water intake. Olfactory nerves, trigeminal, terminal, form an intricate network closely related, reaching the olfactory bulb, which complies olfactory functions and nonspecific brain trigger .- Limbic structures. Broca called "limbic brain" all the structures that surround the limb of the brain. All of them are related to structures primarily rínicas and smell.

The limbic structures play a fundamental role in the field of personality. Phenomena regulate endocrine, metabolic, behavioral, pleasure and pain. They also have interference in reproductive functions and regulation of sleep and wakefulness. The mamillary bodies, intimately connected with the nasal structures, play an important role in the temporary memory (Korsakoff Sind.de). The striatum. Its basal part, the bottom of the striatum, is now known that extrapyramidal is not a structure, as feared, but a limbic structure, strongly correlated with nasal structures. The body of the striatum, comprising the putamen and caudate nucleus, plays a role in schizophrenia.

Pagogenia of snoring and SAS

Respiratory movements are due to spinal reflex involuntary but can be controlled voluntarily by the cerebral cortex. During normal sleep, the cortical activity disappears, being replaced by the core. Any changes in respiratory activity, obstruction, hypoxemia, and so on., Leads the vigil taking over the bark of voluntary control of respiration. Thus, the involved muscles regain tone and maintain patent airway .- These changes "command", medullary-cortical, or sleep-wakefulness, proven by polysomnography, are responsible for daytime symptoms in these patients. This diagnostic method, it also reveals the alterations of pharyngeal muscle activity and that these patients experience during sleep. There is a drop back of the tongue and soft palate, with a corresponding narrowing of the airway obstructive, causing apnea and replacement of the medullary respiratory control by the cortex.

Predisposing factors in the occurrence of snoring and sas

Obesity is such see the most important factor not only overweight but also by metabolic and endocrine dysfunction. Postural factors, the supine position increases the likelihood of snoring, and adopted by the majority of snorers, as this position which requires less work of breathing. Alcohol and sedatives, facilitate snoring and SAS, by depression of the respiratory center. Sex. Snorers are more men than women. Progesterone facilitates ventilation. The snoring improve with the administration of progesterone. So during menopause increases snoring and SAS.

Major sites of obstruction

Nostrils. It is important to maintain good nasal permeability correcting all the causes that disturb the air flow. The inhibition of nasal breathing not only alters the naso-pulmonary reflex, thus decreasing spontaneous alveolar dilatation, but brings other problems of various kinds (View importance of nasal breathing).
The tongue plays an important role in the development of SAS. In the supine position and for various reasons, falls backward occluding or reducing the space glossopharyngeal and sparking the crisis of SAS.
The jaw, affects only in cases of discrepancy.
The uvula and soft palate are the root cause of snoring. Reduces hypertrophy and obstructs the air space, producing a "flutter" noise and a greater or lesser obstruction with consequent increased work of breathing.
While there is a clear demonstration of the influence of these structures in the appearance of the SAS, there are notable improvements after uvulopalatoplasty.

Diagnosis of snoring

Who else practice is the male, middle-aged and especially because it does bother his girlfriend in a night's sleep. Usually not aware of that can cause damage to your health.
They have no crisis or apneas, are prone to insomnia and sleep always accuse irresistible during the day, especially if they perform tasks with a certain monotony, as the act of driving cars.
Sometimes often complain of morning headaches, decreased working capacity and cognitive performance.
The lab shows no evident changes in simple snoring, may instead show a polycythemia with or without a decrease in lung function in cases of SAS.
Polysomnography is the most complete, most complex and also the most expensive of the studies. Parameters are studied such as EEG, EOG and EMG of the muscles in the region, airflow, chest and abdomen movements and changes in PO2 and PCO2.
Oximetry during sleep, is a useful, easy, simple and inexpensive that allows studies in young children and yet we can see the saturation index at the desired time.
The endonasal fibroscopy is a very important method to observe these patients. Unchanged anatomical structures can be observed and documented in detail all the way from the nostril to the nasopharynx and hypopharynx to the glottis. It looks really good size from posterior uvula and the distance that separates it from the pharynx. We note also the glossopharyngeal space, ie the separation between the base of the tongue and the pharyngeal wall.
Contrast radiography of soft palate deglusión (palatografía), allows us to document the adequacy velopalatal and over the veil below the "knee" velo-pharyngeal.
CT and MRI can measure the air spaces at the cavum, rhino, and oropharynx and can be supplied by the fiberscope.
Clinical examination O.R.L. guides us on the cause or causes of snoring, and pathology shows aggregate damages the table: septal deviation, turbinate hypertrophy, especially at the tails, the hypertrophy of tonsils and adenoids, and the size and spacing of the pillars .
By depressing the tongue and pronounce the "a" long, you can see the height of the soft palate and uvula size.

Classification of snoring

Following Chouard were categorized in:
Latent, or simple snoring. when the only symptom is noisy breathing.
Minor, when daytime symptoms: morning headaches, sleepiness, irresistible sleep, etc..
Severa, and we face a sleep apnea syndrome (SAS), plus daytime conditions and in some cases popliglobulia and hypertension.
Grave, or Pickwickian syndrome symptoms are noted above but with real aggravated cardiac symptoms.

Consequences of snoring

In cases of latent or simple snoring, there are no severe organic disorders. Only the annoying noisy breathing.
In severe cases, there is a significant obstruction to airflow, decreased alveolar ventilation during sleep with elevated pressure and hypoxemia. This leads to hypercapnia with acidosis. In the extension of these tables is pulmonary hypertension and heart rhythm disturbances.
In more advanced cases are waking hallucinations because the patient's struggle to overcome sleep. Boxes also appear depression, anxiety, and changes of character.
Lugaresi showed that 55% of stroke, occurs in snoring patients .-
In between there so all possible combinations.

Snoring in children

The child symptomatology is similar to that of adults, which is added: enuresis, decreased school performance, sonanbulismo and obesity with excessive appetite. The apnea may be accompanied by cyanosis.
There is a relationship between infant snoring and table of sudden infant death.
Many cases of infant snoring, are associated with large tonsillar hypertrophy in these cases, Professor Joan Coma and Aragon advised tonsillectomy, regardless of patient age.

Treatment

1) DOCTOR. Always start by normalizing the patient's weight. Remove the alcohol at dinner, relaxants and sedatives.
There are mechanical methods that include keeping the tongue forward so as not to obstruct the passage of air and encourage positive pressure breathing with a nasal mask. This method is effective, but complicated and resisted by patients.

2) SURGICAL. Surgical treatment should aim to address both the cause of the snoring problem, as contributing factors that also deserve a surgical solution .-
In this paper we will describe only limit to our surgical technique for treatment of uvular hypertrophy and radio equipment velopalatal .-

Radiofrequency Roncopalatoplastía

Anatomy of the soft palate
It is necessary to first do a quick review of the anatomy of the soft palate and uvula in order to place better in the world to surgery.
The soft palate is a partition musculomembranous of an inch thick, which extends behind the vault, hence the name portion of soft palate or soft palate.
The front edge is attached to the vault. The posterior border, scalloped and floating, falling at rest at the base of the tongue. In the anterior lateral edge is attached to the solid sphenomaxillary while behind intimately joins the side walls of the pharynx. The lower edge, above and below the tongue, form the isthmus of fauces.
The soft palate is mobile and contractile and configures a true oral-nasal sphincter.

EXTERNAL CONFORMATION
It has two faces and four edges. An anterior face or mouth; smooth, concave and pink. The other, posterior nasal or convex, more rugged and more pink.
Of the four edges, the most important thing to remember is the bottom. In the be examined: the uvula, the pillars of the soft palate and tonsillar fossa.
The uvula is a lower extension of the soft palate and may reach 10 to 25 mm.
The pillars of the veil are born at the base of the uvula and finish on the tongue and pharynx. They are shaped like a dome and are two before and two after.
Tonsillar fossa. The anterior and posterior pillars, which are based on the soft palate are separated from each other when they reach the base of the tongue. Intercept each other a deep depression, so-called triangular fossa amygdalin. Houses the tonsils.

ANATOMICAL CONSTITUTION
They are: The aponeurosis of the veil, the veil muscles, mucosa and glands .-
Aponeurosis of the veil. Tendon is a broad leaf, very strong, which is behind the bony vault. Only occupies the anterior third of the veil and has an anteroposterior extension Exed not the 15 mm. The aponeurosis is a key in the statics and mechanics of the soft palate, since it sets the veil muscles .-
Thick veil. There are ten, five on each side.
1) external peristafilino, 2) internal peristafilino, 3) palatostafilino, 4) glosostafilino, 5) faringostafilino.

1) Peristafilino content. It extends from the base of the skull to the soft palate.
2) internal Peristafilino. As above, born at the base of the skull, very close to each other, are directed toward the eye leaving a veil between them, by the penetration of the eustachian tube.
Both take insertions in this body and go on to the veil forming a cinch charge of raising .-
3) Palatostafilino.Nace behind the posterior nasal spine and is directed backward and downward to finish in the top of the uvula. When they contract raises the uvula, the curved back and shorten the soft palate in the direction of its length.
4) Glosostafilino. It arises from the base of the tongue by two bundles expanded its fibers end in the veil. The two form a sphincter glosostafilinos previous preamigdalino, which narrows the isthmus of the throat. The two pillars are approaching like two curtains, the base of the tongue is raised, while the veil down. So it is closed the isthmus of fauces.
5) Faringostafilino. It extends from the pharynx to the palate. Muscle is a long, vertical path, whose middle part is condensed in a muscle bundle that occupies the posterior pillar of the veil and whose two ends are expanded in range, the higher the veil and the lower pharynx. Its main role is to strengthen the isthmus faringonasal, bringing together the posterior pillars of the veil. He is responsible for that is isolated at the bottom of the pharynx from the upper or nasotubárica.
In addition to the function described, this muscle elevates the pharynx and larynx during swallowing. You also share in the expansion of the tube.
Mucosa of soft palate. There are two layers mucosae, superior and inferior or nasal or oral.
It consists of a columnar epithelium with cilia. Beneath this lining is a layer of submucosal tissue.
Glands of the soft palate. The glands are distributed in two layers, an upper with more glands in the periphery than in the middle, and lower most abundantly in the salivary glands like.

Vessels and nerves
The arteries of the soft palate is derived from three sources: susperior palatine branch of the internal maxillary, the lower palatal branch of the facial and inferior pharyngeal branch of the external carotid.
The nerves are sensory and motor. The former are supplied by the three palatine nerves, sphenopalatine nerve branches, in turn born of the maxilla. The trigeminal is thus the sensory nerve of the soft palate.
Motor nerves are branches of the posterior palatine nerve.

Surgical technique

Our technique is based on the Kamami uvulopalatoplasty.
Professor Victor Yves Kamami of France, has the highest case mix of the world in this surgery for snoring.
Uses for CO2 laser technique, we use the 150 LIGHT RADIOFREQUENCY, which acts by cutting and coagulating.
The operation is done under local anesthesia and in sitting position. It works on the mucosa, fascia and muscles that form the palate, and with special care on the muscles palatostafilinos, glosostafilinos and faringostafilinos, that constitute the uvula and the anterior and posterior pillars, respectively.
The greatest care should be taken in the subsequent work on the pillars, which must be sectioned enough to achieve the desired result, but not too much, to not cause a shortage velopalatal.
The results are surprising and sometimes spectacular. A dialogue with patients operated on, is the best testimony to the results obtained with this operation .-

Minimum pre-testing

a) Questioning complete.
b) X-rays: Mento-Naso, cavun, palatografía.
c) nasal fiberscope, see glossopharyngeal space.

In cases of S.A.S add

d) oximetry and / or
e) Polysomnography .-

Operation Determined

a) Explain to the patient:
-Objetivos7
-Technical
-Rates of cure and improvement
Times pre-and post-operative
-Pain

b) Deliver the leaf PREPARATION
"Do not take A.A.S. 10 days before
"Do not go to the operation fasting
Applying corticosteroid deposit-12 pm. preoperatively

Inpatient on the day of the operation

a) Premedication:
Atropine -1 Phenergan + 1 + 1 cc of morphine I. Muscular an hour before the operation.
b) Ten minutes before the operation, a glass of sugar water + 40 drops Reliverán.

c) Instrumental minimum:
LIGHT-Team 150 with complete accessories.
-Tongue blades angled metal.
Clamp-making uvula.
-Suction equipment

Patient in the OR

a) comfortable sitting position, with headrest and armrests.
b) Spray with Spray Xylocaina, pharynx, uvula, soft palate.
c) Check with the LIGHT 150 a reference point for a 15 mm below the junction of the hard palate with the soft. (PD) (PB).
d) Hacking the soft palate Xylocaina with a solution of 2% with epinephrine from the uvula to both sides.
e) Clamp and hold the uvula from the distal end. Sections, as calculated in the previous examination, more or less near the proximal end. Using the thin electrode (Micro-Needle MA 100), using the cut MEDIUM (50%) to a power of 5 to 6 in intensity.
f) Make lateral incisions to form the neo-uvula, sectioning of the posterior pillar (faringostafilino fibers.) must be respected in these incisions, the limit of 10 mm from the PD-PB .- (p. 15) .-
g) Making the neo-uvula.

Post-operative recovery

1) Antibiotics for 7 days
2) Analg, only if necessary
3) antifungals, only if the patient is a smoker
4) Bucher from 5% cold water with hydrogen peroxide.
5) FOR 7 DAYS DELETE:
-A.A.S. -Condiments
-Alcohol-Cheese
-Snuff-Mustards
6) Diet, common with the aforementioned limitations.

High normal

At 2 to 3 hours.


Ques is the radio?

RADIO WAVES: It's an electro-magnetic oscillation causing molecular agitation in tissues by their natural constitution have a lot of water and salts.
For this property are capable of conducting electric currents. The ability to conduct current in a conductor is proportional to the amount of free electrons it possesses.
In tissues, the conductive capacity is directly proportional to the amount of water and salts that made it. For this conformation, the tissues are "electrolytes", ie liquids with decoupled atoms, which allows the movement of electrons with some freedom.

CUT BY RADIO WAVES,
During the cutting process generates an intense electric field around the electrode a few thousandths charge of transmitting energy.
The vaporization of water and salts resulting from the rise of temperature in the field, serves as the vehicle (electrical conductor) to the current. When the relationship between forward speed and power is used correctly, the tejdo fails to make direct contact with metal. NO touch and SHORT, like a needle on the approach to hot butter.
It is important that the heat generated coagulant in the process of cutting with hemostasis, is controlled and greater penetration into adjacent tissues, as they result from electromagnetic fields (similar to the physiatry team or microwave oven) instead of being by direct contact with the heating element or spark as in conventional electrocautery.
This explains the phenomenon observed when you cut coagulated with RADIOFREQUENCY units, obtaining a much greater ability to control minor bleeding with tissue necrosis. In any case there is fire, smoke that can disturb the work in the surgical field. The post-operative is almost painless.

CUTS RATES BY RADIO WAVES WITH TEAM LIGHT 150 ".
Working in RADIOFREQUENCY, you can cut and coagulate tissue with varying degrees of damage adjacent, as waveforms, power, characteristics of the unit in use, etc. .. The cut with hemostasis is achieved when the radio wave is discontinuous (modulated or interrupted). One way of imagining it is to assimilate to power cycle the device 10,000 times per second. The intended effect is to apply radio frequency (cut) and then switch off, allowing a decrease of temperature in the tissues (hemostasis), to turn it back on. These cycles vary quickly and the effect is audible. If one pays attention there is a difference in sound between "pure cut" and cut with clotting.