Balakrishnan, D (2008) A Comprehensive study of Clinical and Psychological Factors in Snoring and Obstructive Sleep Apnoea. Doctoral thesis, The Tamilnadu Dr. M.G.R. Medical University, Chennai.
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Abstract
INTRODUCTION: In recent decades, awareness of sleep apnoea syndromes has increased both in the public mind and among medical professionals. As a result, more patients demand treatment of sleep disorders. However, the health care delivery system is unable to meet this demand. The inadequacies mainly relate to lack of infra structure and lack of skilled manpower. When great advances have been made in the medical field, provision of such facilities may appear to be simple. But, we are hampered by lack of information regarding the size of the problem. We do not know the actual prevalence of sleep disordered breathing. Another significant inadequacy relates to the absence of a comprehensive algorithm for approaching a patient with suspect OSA. The skill sets required for this algorithm are spread widely amongst various specialists, namely pulmonologists, neurologists, critical care specialists, internal medicine specialists and otolaryngologists. Supporting staff in the pulmonary, sleep and imaging laboratories must be developed. The willingness of the health insurance to assume the reimbursement of expenses will play an important role in this development. This study is an effort in meeting the first of these inadequacies namely, defining the magnitude of the burden of this disease. AIMS OF THIS STUDY: 1. To study the prevalence of snoring and sleep apnoea in the general population. 2. Comparison of clinical and psychological profiles of children suffering from snoring and sleep apnoea with non-obstructed children. 3. Study of the changes in the above profiles, after therapeutic intervention i.e. adeno tonsillectomy. PLAN AND SCOPE OF THE STUDY: The entire study was done in two parts Part I. Study of the prevalence of snoring. Part II. Interventional study of children with adeno tonsillar enlargement, before and after surgical therapy. SUMMARY OF THE PREVALENCE STUDIES: Collection of data on the prevalence of snoring and other features of sleep disordered breathing was achieved by a series of surveys with wide ranging bases, namely Pedex survey, Street survey, Households survey, Adolescent Students survey and Adult industrial workers survey. PEDEX SURVEY: In this survey, the prevalence of snoring in the general community was ascertained by a questionnaire. BMI was calculated by taking height and weight. In this Pedex survey, with a sample size of 1075 persons of all ages and economic background, the total prevalence of snoring was 19.5 %. The percentage of snorers was found to be 24.4 % in males vs. 13 % of females (higher in the males). Among the age groups, with increasing age, the prevalence of snoring increased – children: 12 %, adults: 24 %. The prevalence of snoring in children and in adolescents was found to be independent of BMI. In contrast, the adult age group showed a significant increase in snoring with increasing BMI. The prevalence of snoring was found to increase positively with increasing affluence. Children with sore throat had a significant tendency to have snoring. In the general community, awareness of the condition exists. However, many persons (snorers and non snorers alike) are not interested in getting more information. STREET SURVEY: Trained personnel interviewed persons at busy streets consecutively, and and recorded the answers in a standard survey format. In the novel street survey with a sample size of 937 persons of all ages, gender and build, the over all prevalence of snoring was 21.1 % (males 11% and females 10.1%). In this sample, the self reported prevalence and the frequency of snoring showed no significant difference between the genders. This is at variance to the conventional belief that more males snored more frequently. However, it was seen that females tend to snore less loudly than males. The method of obtaining sample subjects from the streets is found by this study to yield less appropriate data. On analysing the prevalence of the self reported snoring, it was found that no one below the age of 30 years (male and female) reported snoring, even though they constituted 43.8 percent of the sample. This is in contradiction with similar surveys and our own surveys. This method of getting subjects from the streets is commonly adopted in opinion surveys and in election predictions. This method had even been employed to estimate the prevalence data for snoring itself. With the experience gained in this survey, we find that this method of obtaining the prevalence data is not yielding correct data. A relatively comfortable environment, where the patient has the time, inclination and willingness to think and answer (not one where the subject awaits the change of signals or for the arrival of the next bus) would be appropriate. HOUSEHOLDS SURVEY: All the inhabitants of an entire housing colony in Chennai, formed the sample. A total of 398 persons (222 males and 176 females) were included in this study. In addition to the questionnaire, each person had a clinical examination. The overall prevalence of snoring in this sample was found to be quite high at 43 percent (26.4% males and 16.6% females). Among the total of 114 children below the age of 12 years, 34% were snorers. Out of the male snorers, 18.5 % snored frequently. Oropharyngeal indicators like tonsil size and Mallampatti had significantly higher scores in this sample. STUDENTS SURVEY: One of the important problems engendered by snoring and sleep apnoea is learning impairment. Hence, this part of the survey had a focus on young adult students. 198 medical students and nursing students of both gender formed the sample. The medical history and details of snoring, if any, were recorded. The subjects underwent morphological and clinical examination. This sample comprised of the students with a mean age of 20.6 years. The over all prevalence of snoring was 7.6 per cent. It is noteworthy that even persons who had a BMI below the normal i.e. below 23 snored. BMI was found to be significantly associated with snoring in this sample. It should be noted that as many as 21% of the of this study sample comprising exclusively of young students complained of excessive daytime sleepiness when they were administered the Berlin questionnaire. The association of sleepiness with snoring was found to be significant statistically. In addition, waist hip ratio was higher in all snoreers. ADULT INDUSTRIAL WORKERS SURVEY: This part of the study focused on industrial workers, who have shift duties. All the employees on shift duty in a large industrial establishment formed the subjects of this study. The subjects had their heights and weights measured. Then, each one of them filled up a questionnaire. The questions pertained to the presence of snoring, its frequency and any precipitating factors, if present. 602 employees of all ages formed this sample. All were men. Six hundred and two employees of all ages formed this sample. All were men. Among all ages, the over all prevalence of snoring was 16.8%. The prevalence of snoring is seen to increase with age. In the age group, 19- 29 years, the prevalence was 7.7%. In the age group 45-59 years, the prevalence was 21.5%. The loudness is not associated with either on age groups or on BMI status. Among the snorers, 68.2 % snored occasionally and 31.8 % snored frequently. Among the snorers, the snoring status worsened with tiredness (100%), good food (92%) and with alcohol (62%). SUMMARY OF THE INTERVENTIONAL PART OF THE STUDY: A total of 197 children of ages 3 – 15 years, attending a specialist ENT clinic for recurrent throat infections and features of obstructed airway entered this study. Several of them had adenotonsillar enlargement. Based on their snoring pattern, they were stratified into frequent snorer group and occasional snorer groups. All the children were assessed with tests for behaviour and learning. The above variables among these three groups groups were different. AGE, GENDER, BMI AND SES : These did not have any significant association with snoring, in this sample. There was also no linear relationship between the mild snorer and the habitual snorer groups in this regard. UARS, APNOEA and EDS : In this sample population of children with adeno tonsillar enlargement, the relative frequencies of UARS, Apnoea and EDS are interesting. Struggling to breathe, chest caving in or see sawing (features of UARS), breathing pauses (a feature of apnoea), sleeping during school hours, napping at home, unrefreshed sleep and continuous tiredness (features of EDS) were significantly present only in snorers and were absent or less frequent in the non snorers. When the snoring frequency is factored in, there is a further significant difference – apnoea and EDS are more frequent in the frequent snorers. Hence, when a child comes with a history of snoring, care must be taken to identify this population of frequent snorers – because it is this population which is at a higher risk. TONSIL SIZE AND ADENOID SIZE: Tonsil size was found to be significantly associated with snoring; more so with frequent snoring. Adenoid size per se (alone) was found to be of no importance in this regard. However, children with adeno tonsillar enlargement were more likely to have impaired QOL scores if they had a history of frequent snoring. In these children with adeno tonsillar enlargement, the addition of historical questionnaire data, other than snoring frequency, did not improve predictions of snoring. PHARYNGEAL DIMENSIONS IN CHILDREN WITH SNORING: The tonsil sizes and Tsai pharyngeal grades are significantly higher in all snorers. Such significance is even higher in frequent snorers. The Mallampatti score is not significant, when the total group of all snorers is considered as a whole. But, it becomes significant when the frequent snorers are segregated and considered. Hence, in every snorer, examination of the oral cavity is important. Taking a history of the frequency is equally or perhaps more important, thereby alerting the clinician to bestow a little more attention to the oral cavity examination. ASSOCIATED DISEASES: Nasal allergy, sinusitis, secretory otitis media and CSOM have signigficant associations with snoring. But, GERD did not show any positive association with snoring in this study. All the snorers, regardless of whether they are frequent snorers or occasional snorers, have a higher presence of nasal allergy and secretory otitis media. Snorers, when taken up for statistical analysis as a whole, do not show any increased presence of sinusitis or CSOM. But when the frequent snores are segregated and analysed separately, the frequent snorers were found to have a significantly higher presence of sinusitis and CSOM. A snoring child has a high possibility of having nasal allergy and secretory otitis media. Hence, in the clinical examination of snoring children, a focused effort must be made to identify whether a child has nasal allergy (including wheezing). The ears must be specifically examined for secretory otitis and CSOM. In a frequently snoring child, this becomes more imperative. CEPHALOMETRIC IMAGING AND MEASUREMENTS: In this study, out of the seven cephalometric measurements taken up for analysis, namely, Retro palatal airway space, Retro glottal airway space, Hypo pharyngeal airway space, MP-H distance, position of hyoid (Rgn–H, H-C3, and C3-Rgn), AN ratio, Lower anterior face – total facial height ratio, the former six were not associated with snoring at all. Only the LFH/TFH ratio, indicating the long face syndrome (adenoid facies), was significantly associated with snoring and snoring frequency. All the others were not significantly associated. The digitization had been done in an academic institution by a very well experienced orthodontist. Even though the airway analysis was novel and hence, relatively unfamiliar to the orthodontic practitioners, the digitization techniques are extremely familiar to them. Even then, the initial ten films had been digitized twice by two different orthodontists and cross checked. With all these precautions, the cephalometry did not yield any positive association with snoring. BEHAVIOUR: In children with snoring (all the snorer groups taken together), the behaviour scores were not different from those of non snorers. But, when the frequent snorers were specifically studied separately, the behaviour scores were found to be worse than mild snorers. And, after surgery, these worse scores of frequent scores were found to improve significantly. GENERAL LEARNING; There was no difference in the over all academic performance, as measured by the school marks between the frequent and occasional snorer groups. This might mean that the tool used (the single marker of 50% marks in the last terminal examination) lacked precision (did not measure the academic performance correctly) or that the underlying impaired learning skills have been compensated to some extent by the strenuous efforts of the student, his teachers and parents. EFFECT OF THERAPEUTIC INTERVENTION: In this sample, almost all the parameters of the QOL OSA 18 tool improved well, with the sole exception of emotional domain, which showed a marginal worsening after surgery; however, this change was very minimal (0.16 increase in the mean domain score value) and was not at all significant. Overall, the QOL scores improved after the therapeutic intervention in the snoring children. A snoring child has a high possibility of having nasal allergy, secretory otitis media. Hence, in the clinical examination of snoring children must include a pointed effort to identify whether a child has nasal allergy (including wheezing). The ears must be specifically examined for secretory otitis and CSOM. look allergy associated feature of wheezing, attention must be made to identify all snorers pointed atten and the ears must be specifically examined in a snoring child. When the frequent snorers are specifically identified and the presence of nasal allergy is looked for, The tonsil sizes and Tsai pharyngeal grades are significantly higher in all snorers. Such significance is even higher in frequent snorers. The Mallampatti score is not significant, when the total group of all snorers is considered as a whole. But, it becomes significant when the frequent snorers are segregated and considered. Hence, in every snorer, examination of the oral cavity is important; Taking a history of the frequency is equally or perhaps more important, thereby alerting the clinician to bestow a little more attention to the oral cavity examination. However, on statistical analysis did not show any significance between relative frequencies between the snorers and non snorers. The adequacy of the sample size may be the issue. In this connection, further investigations like polysomnography, oesophageal pressure studies and MSLT would have yielded assertive diagnostic labels. However, those studies could not be suggested to the patients, because of reasons like (1) their invasive nature (2) necessity for overnight hospitalization (3) non availability (4) waiting time and consequent delay in treatment (5) expensiveness and (6) the ethical issue of not suggesting any extra investigation which may not have a bearing on management of the child.
| Item Type: | Thesis (Doctoral) |
|---|---|
| Uncontrolled Keywords: | Clinical, Psychological Factors, Snoring, Obstructive Sleep Apnoea, Comprehensive study. |
| Subjects: | Respiratory Medicine > Otolaryngology > Respiratory Medicine > Otolaryngology |
| Depositing User: | Devi S |
| Date Deposited: | 20 Jun 2017 06:43 |
| Last Modified: | 11 Sep 2022 04:09 |
| URI: | http://repository-tnmgrmu.ac.in/id/eprint/124 |
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