Dr. Joachim T. Maurer
Interview of March 8, 2010 with Dr. Birgit Teichmann
You are going to speak about snoring and sleep apnoea at our NAR Seminar in April.
Snoring is the vibration of respiratory structures and the resulting sound, due to obstructed air movement during breathing. Sleep apnoea is a sleep disorder characterized by pauses in breathing during sleep and is mainly characterized by distinctive fatigue to micro sleep and a number of other symptoms and secondary diseases.
Are there statistics that show, how many people in Germany are snoring and how many suffer from sleep apnoea?
Snoring is age-dependent and about 10% of children are snoring but only 1-2% have sleep apnoea. It is also age-dependent in adults. There are studies from Europe as well as the United States and Asia that show that in the group of the adult working population, about 50% of men snore, 25% of those have pauses in breathing during sleep and only 4% additionally suffer from daytime sleepiness. When you look at younger men it becomes less, if you take older men it becomes more. The number of breathing pauses and snoring is less in women and an increase is expected during menopause. When hormones convert, it shifts adversely. There is an increase of male sex hormones and an decrease of female sex hormones and snoring and breathing pauses increase. Compared to males, females suffer about half as much, so 2% from sleep apnoea and about half of an increased number of breathing pauses while sleeping.
With that, you already answered another question, why men are more affected than women. So it is hormone related?
Yes, it is also hormone related. What you also have to look at under the gender aspect is the fat distribution. Fat distribution pattern in males is more in the upper part of the body, meaning the neck is more strong, the belly is bigger and there is not only fat in the abdominal wall but also on the inside of the belly between the intestines. When you store fat in the neck, the neck not only gets bigger on the outside but also the airway, which is a tube, is getting more narrow because fat lays around it. When you have fat in the belly you have to lift the belly more when you lay down and that is more exhausting, meaning that respiratory disorders are expected to be higher in men than women when they gain weight. Women have their typical female fat distribution pattern with flab on the hips and that has no influence on snoring.
Is snoring in kids connected to enlarged tonsils?
Of course snoring and breathing pauses depend on many things. There are functional reasons like the hormone situation. But also anatomical things like fat distribution in the throat or belly and enlarged tonsils. Everything that narrows the airway leads to an increase of the inclination of airway closure or vibration of the airway. This includes tonsils and polyps in children and in individual cases, benign and malignant tumours. Maybe a large cyst in the larynx can also narrows the airway. A large tongue can be the cause. There are growth hormone disorders that lead to a growth of the tongue. So there are different reasons that narrow the airway and they only have to be distinct enough to lead to an airway closure. We always have reflexes in the airway-reflex arcs- we feel how far open the air way is. While sleeping, this control changes and some control mechanisms that are active in the waking state, cease. So the more narrow the airway is, the easier it can collapse/ vibrate. In some cases we cannot find anything anatomically wrong. So in general we can say, the younger someone is, the more are anatomical components the reason- children with enlarged tonsils, defective position of the jaw, a large tongue. The older people get, the more we find predominantly functional components. That means, control of the airway, the coordination of the airway musculature and respiratory musculature is not functioning properly anymore: When does the diaphragm start moving and when does the airway musculature start to tighten so the airway stays open. So the older someone is, the less we find something unusual when you look into the mouth, into the nose, into the diaphragm but there are still breathing pauses that are mainly caused by neurological, functional disorders.
Is sleep not extremely disturbed by these breathing pauses?
Breathing pauses are interrupted, they don’t last forever. Why are they interrupted? Because we save ourselves from suffocating through a short waking- up reaction!
The question is, how sensitive is our respiratory center? There are people that can hold their breath for a minute, others maybe for 2, the next only 10 seconds or maybe only 8-9 seconds until the rescue reaction. In children we often see just the opposite: They have less breathing pauses but they breathe with great strain, trying to keep the airway open, gasping for air. Every parent knows this, when the child draws in, is breathing with all energy against the resistance that originates from the narrow airway, without it coming to a real breathing pause. Nevertheless, at one point it will come to an activation of the brain, the airway opens for s short time and the child is breathing a little irregular or a little deeper, you don’t hear any snoring anymore. And then the child starts snoring again and another breathing disturbance starts. All variations are possible and all will eventually lead to a sleep disorder. The only question is, how often it occurs and if those concerned really wake up. Not only the real waking up but also those small waking reactions of 3-10 seconds will chop the sleep to pieces. Being awake for 1-2 minutes, I usually remember that. When it is only for 5 seconds, nobody knows that they have been awake. But the brain still experiences a disruption in its recovery phase.
If I never enter this REM Sleep, if I don’t process daily experiences, can depression be a result of not processed daily experiences through sleep disorders?
Previously we thought that a sleep apnoea can cause depression because those concerned- if they have a severe disease- actually fall asleep during the day. One extreme example was a patient that fell asleep while I examined his nose with a speculum. But when someone sits at the computer at work and starts to get problems to handle his work and maybe some colleagues will make fun of him or he just cannot keep up, meaning others will get higher positions and he stays behind. Or he will be greeted in the morning with words like: Have you been drinking all night? Because his eyes are puffy, because he is tired. So that will get him down. Those people are often depressive because they realize that they are not efficient anymore. But it is not a depression in the proper meaning of the word because once the sleep apnoea has been treated, those symptoms usually disappear within days to weeks. What we know is, that depression is almost always linked to sleeping disorders and that those people often have problems sleeping through. Two things that commonly occur can also exist simultaneously. Meanwhile it is clear that depression is not a sequel to a sleeping apnoea.
Considering the importance of sleep, one could ask if not all people should be examined in a sleep laboratory, when you say that 50% of all men snore and partially have a sleep apnoea. But only a fraction will come to you, those who have enormous difficulties, have major daily problems.
We cannot examine 50% of men between the age of 40 to 50 in a sleep laboratory because of snoring. This would take an enormous amount of personnel, time, material, that is simply not realizable. So there are the so called graded procedures. If the symptoms, of a patient that is snoring, are not there, if someone has no secondary diseases that are typical for a sleep apnoea like high blood pressure, then he will not end up in a sleep laboratory. You will undertake a small examination with a device that controls breathing, oxygen in the blood, body posture, sleeping noises and you look if the chest and belly move consistent while breathing. This is feasible in an ambulant way, you measure at home in the bed of the patient and the next morning it will be analysed. For this we have extensive care throughout Germany. If you find any abnormalities there, you can still follow up with an examination at the sleep laboratory.
The accompanying symptoms that I have found, stress disorders as in ulcers, tinnitus, acute hearing loss, diabetes mellitus type 2, are very alarming. How often does it happen, that patients do not know about their sleep apnoea? And also in reverse, when I have tinnitus, hearing loss, do you examine if the cause is a sleep apnoea?
Not everything is true. Recent data about the increase of diabetes type 2 through sleep apnoea have been accumulated. At the end of a breathing pause, when we save ourselves, it is followed by a strong stress situation that goes along with release of cortisone and this influences the sugar metabolism. The sensitivity for insulin changes. With tinnitus we have indications- the inner ear is a very sensitive organ for oxygen deficiency- there are certain effects but which ones exactly, we do not know. With ulcers, to tell you the truth, I don’t see that a sleep apnoea is playing a role there.
You already mentioned high blood pressure. There is also sudden cardiac death, that will happen with high probability if the sleep apnoea is not treated.
The high blood pressure problem does not stop there, blood pressure damages the organs. To be exact, first the blood vessels, especially in the brain and the heart, as the most essential organ. Meanwhile, there are clear studies that show, that an over the years untreated sleep apnoea more and more increases the risk of a heart attack or a stroke. When you eliminate the breathing pauses while sleeping with an effective therapy such as a respiration therapy, the risk becomes just as high or low as people without breathing pauses.
Do you call sleep apnoea a disease? It is a syndrome, many symptoms come together. Is it called a disease or is it only something that hinders good sleep?
That’s a good question. Today we say it is a disease. It belongs to the group of sleep related respiratory disorders. And we don’t call it obstructive sleep apnoea syndrome anymore. According to the new classification of sleep disorders it is called obstructive sleep apnoea since 2005. Why? Because by now, we know much more about it: We know the process of breathing pauses during sleep, what the consequences are and we don’t have just one triggering cause. As I said earlier, we can differentiate according to age and anatomy between the modification of the airway and the functional change of the airway. Since both have to be right, we have different patterns of causes. In any case, we know fairly accurately what causes breathing pauses while sleeping and what can prevent them as well as the health effects. That’s why we don’t call it syndrome anymore.
I would not call it a disability because it is not something that is necessarily permanent. For example, if we remove extremely large tonsils, then the sleep apnoea disappears in 90% of all cases in children. When you have a child or adult that has a very small jawbone and displace it to the front and therefore dilate the airway, it disappears in 95-100% of all cases.
What can people do that “only” snore?
Basically all treatments used against the obstructive sleep apnoea also apply with snoring. Why? Because in both cases, the cause for the problem is the tight airway. With the obstructive sleep apnoea, the airway is so narrow that it closes, with snoring it is not so narrow, that’s why it only starts to vibrate. Of course there are treatments that are totally exaggerated in the case of harmless snoring because harmless snoring doesn’t hold a higher health risk. And vice versa, there are treatments that are not sufficiently effective with sleep apnoea. There are many different possibilities in the case of harmless snoring. One is to sleep in separate rooms. There is no need for medical treatment. The other is the avoidance to sleep on your back with a vest. Or the insertion of a brace in the mouth, that will displace the jawbone a little to the front and therefore dilate and tighten the throat. Finally you can treat the soft palate. In Switzerland they have a clasp that holds the uvular in the front, so it cannot vibrate so easily. Additionally, there are surgical possibilities in which the uvular is shaped, so it tends to snore less. And of course not to forget weight loss is not to be underestimated when it comes to snoring. Patients can sometimes clearly say that their snoring really started while the weight gain started. So with harmless snoring we try treatments, that are as little risky as possible for the patient.
Is the increase of snoring due to a change of the civilisation or why do people snore more nowadays?
Foremost it is because we are getting more corpulent. In children it is already a large problem because along with the weight gain comes the increase of breathing problems and everything connected to it. Then you have certain population groups like Asians, whose facial skull often show an unfavourable structure of the facial skull in regards to the airway width: they have a longer face which does not grow forward so much. In the end, us humans differ substantially from animals. In general, animals have a much higher larynx. The larynx is so high, e.g. with whales, that the epiglottis is behind the uvula- with newborns it is also like that. When the epiglottis is behind the uvula, you have a splinting of the airway from the nose over the uvula and the epiglottis directly into the inside of the larynx. With that we might be able to swallow while we still breathe but we cannot talk. Through evolution the larynx sank- after all a few centimetres- and developed a soft region in the area between palate and larynx in which there is no osseous- cartilaginous splinting of the airway. But we need this soft area to speak because it allows a much more extensive development of various sounds. Meaning that we “bought” our better ability to communicate, with an airway that can be unstable in an area and collapse while sleeping. However, those communication advantages were more useful in evolution than the risk to be stroked to death by your tribal neighbour because of your snoring.
Joachim T. Maurer was born in Speyer in 1964. After alternative service and foreign assignment in development service in Africa, he studied biology and medicine in Mainz and graduated with a dissertation in microbiology. He began his doctor in training as a ENT doctor an the University Medical Centre Mannheim in 1994 and committed himself right from the start, to the section of sleep medicine, which was founded by Prof. Dr. Karl Hörmann. In December of 1995 he was appointed director of the centre of sleep medicine, which shortly after, was accredited by the German Sleep Society, as the first sleep laboratory under an ENT leadership. Since 1998 he is senior physician and since 2006 assistant director of the University ENT clinic in Mannheim. He has the permission to teach in sleep medicine and also works as an examiner with the Medical Association as well as the sleep medicine society.
His scientific emphasis lies in the research of sleep medicine, especially sleep related breathing problems. In May of 2010 he received the Hoffmann and Heemann Award of the German Society of Otorhinolaryngology, Head and Neck Surgery for his works on diagnosis and therapy of sleep apnoea.