Postgraduate Medicine
ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
The ABZzzzs of snoring Alexander K. C. Leung MBBS, FRCPC & Wm. Lane M. Robson MD, FRCPC To cite this article: Alexander K. C. Leung MBBS, FRCPC & Wm. Lane M. Robson MD, FRCPC (1992) The ABZzzzs of snoring, Postgraduate Medicine, 92:3, 217-222, DOI: 10.1080/00325481.1992.11701451 To link to this article: http://dx.doi.org/10.1080/00325481.1992.11701451
Published online: 17 May 2016.
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Date: 03 July 2016, At: 11:42
-@CME credit article
The ABZzzzs of snoring
Alexander K. C. Leung, MBBS, FRCPC Wm. Lane M. Robson, MD, FRCPC
Downloaded by [Monash University Library] at 11:42 03 July 2016
Preview "Laugh and the world laughs with you; snore, and you sleep alone." There is some truth to this play on the words of American poet Ella Wheeler Wilcox. Snoring can be very annoying and may lead to ridicule and personal problems. But it may also be a symptom of an underlying medical disorder. Drs Leung and Robson discuss the causes of snoring as well as complications, evaluation, and management.
Snoring is a predominantly inspiratory sound that occurs during sleep. It is produced by vibrations of the soft parts of the oropharyngeal airway, notably the soft palate and the posterior faucial pillars of the tonsils. 1-3 Snoring implies partial blockage of the nasopharyngeal airway. Habitual snoring may be a nuisance, but it also may be a symptom of significant medical problems. 1-3 Although snoring is common, it has received little attention in the medical literature.
Incidence Lugaresi and colleagu~.4 found that 1,085 (19%) of 5,713 persons in an unselected population were habitual snorers (subjects who reported snoring every or almost every night). The incidence of snoring in children is not known. Up to 45% of adults snore occasionally, and 25% are habitual snorers.' The incidence
of snoring increases in men after age 20 and in women after age 40. 6 By 60 years of age, 50% of men and 40% of women are habitual snorers. The incidence thereafter remains stable or slowly diminishes after age 65. 3 Snoring is three times more common in obese persons than in thin persons.'·7
Causes Snoring results when narrowing of the nasopharyngeal airway is aggravated by the effects of sleep. 3 The sound of snoring originates in the collapsible part of the oropharyngeal airway, from the epiglottis to the choanae/ Negative intrathoracic pressure develops during inspiration. 3This negative pressure acts on the base of the tongue, the soft palate, and the pharyngeal walls and may result in collapse of the oropharyngeal airway. 8 Normally, the muscles of the oropharyngeal ring
VOL 92/NO 3/SEPTEMBER 1, 1992/POSTGRADUATE MEDICINE • SNORING
(genioglossus, geniohyoid, sternohyoid, and sternothyroid) exert counterpressure, which prevents collapse of the oropharyngeal airway. 8 Snoring is more common in persons who sleep in the supine position, because the tongue falls backward in this position.3 Some persons snore only or predominantly when in the supine position. The following factors, alone or in combination, may contribute to snoring. ANATOMIC NARROWING OF TilE NASOPHARYNGFAL AIRWAY-
Space-occupying masses that impinge on the nasopharyngeal airway may cause snoring. 7 Hypertrophy of the nasopharyngeal tissue, specifically the adenoids and tonsils, is the most common cause of chronic airway obstruction and snoring in children. 7·9•10 Other anatomic causes of narrowing of the nasopharyngeal airway, such as choanal atresia, choanal polyp, nasal septal deviation, nasopharyngeal cyst, macroglossia, retrognathia, and micrognathia, are less common. 9•10 In one study; Bradley and associates 11 found that snorers have a smaller pharyngeal crosssectional area than nonsnorers. Obesity may predispose persons to snoring because the lumen of continued
217
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By 60 years of age, 50% of men and 40% of women are habitual snorers.
the upper airway is narrowed by excessive adipose tissue.u Excessive length of the soft palate and uvula narrows the nasopharyngeal airway and may lead to snoring.7.12 NASAL AIRFLOW RFSfRICilON-
Patients with an upper respiratory infection or allergic rhinitis are prone to snoring because the associated restriction of nasal airflow accentuates negative intrathoracic pressure during inspiration.7.12.IJ Smoking, whether active or passive, has been linked to an increased incidence of snoring. 13 Smoking causes mucosal edema and inflammation and results in narrowing of the nasopharyngeal airway. INADEQUATE OROPHARYNGFAL MUSCLE lONE-The
oropharyngeal muscles, especially the genioglossus muscle, force the tongue forward during inspira-
Alexander K. C. Leung, MBBS, FRCPC Wm. Lane M. Robson, MD, FRCPC Dr Leung is clinical associate professor of pediatrics, University of Calgary, and pediatric consultant, Alberta Children's Hospital and Foothills Provincial Hospital, Calgary, Alberta, Canada. Dr Robson is clinical associate professor of pediatrics, University of Calgary, and pediatric consultant, Alberta Children's Hospital.
218
tion and play a major role in the normal maintenance of a patent oropharyngeal airway, particularly during sleep in the supine position. 14 Direct cineradiographic observations of the upper airway in snoring patients have shown inspiratory narrowing of the pharyngeal airway during sleep. 8 Hypotonia of the oropharyngeal muscles may occur in some persons during normal sleep and in others in association with sleep deprivation, general anesthesia, neurologic lesions, or ingestion of alcohol or of drugs such as hypnotics, tranquilizers, or antihistamines.6'7'11'14 GENETIC FACIDRS-A genetic predisposition to snoring has been reported. 1 However, it is not known whether this predisposition is related to a familial tendency to narrowing of the nasopharyngeal airway, obesity, or hypotonia of the oropharyngeal muscles.
Complications In the majority of patients who snore, snoring is a benign finding. However, habitual or heavy snoring may be an indication of alveolar hypoventilation, which may lead to pulmonary or systemic hypertension. ~' Extreme snoring and obstructive sleep ap1
16
nea syndrome coexist in some patients; both disorders are caused by narrowing of the airway. Symptoms of obstructive sleep apnea syndrome develop because of sleep deprivation, significant asphyxia, and cardiovascular impairment.17 Patients with obstructive sleep apnea do not get adequate ventilation during sleep and may wake up periodically. The resulting sleep deprivation may lead to daytime sleepiness, lethargy, tiredness, personality changes, or morning headache. Complications of snoring in children include failure to thrive, poor school performance, and behavioral problems such as hyperactivity or antisocial behavior.w Chronic hypoventilation is associated with hypoxemia and may result in pulmonary hypertension and an increased cardiac workload; these effects may lead to systemic hypertension or cardiac arrhythmias. 7 Chronic hypoventilation may progress to classic pickwickian syndrome, which is characterized by obesity, daytime hypersomnolence, hypoxia, and hypercapnia. 18 Common consequences of pickwickian syndrome include secondary polycythemia, cor pulmonale, and heart failure. 18 Obstructive sleep apnea is a possible cause of
SNORING • VOL 92/NO 3/SEPTEMBER 1, 1992/POSTGRADUATE MEDICINE
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Obese persons may be predisposed to snoring because the lumen of the upper airway is narrowed by excessive adipose tissue.
sudden infant death syndrome. 14 In adults, a link between habitual snoring and an increased risk of angina pectoris and cerebral infarction has been reported.3'15'19 Habitual snoring can be a distressing social problem. The loudness of heavy snoring has been measured as high as 69 dB. 1 Habitual snoring is a recognized cause of marital problems. Snorers may be subjected to teasing and ridicule.
Evaluation Clinical evaluation of snoring begins with a detailed sleep history, including the patient's sleeping habits, the degree of sleep disturbance, and the resultant effect on daytime activities. Nocturnal symptoms include frequent awakenings, restless sleep, diaphoresis, respiratory pauses or apneic episodes, nightmares, and night terrors. Snorers do not usually hear their own noise. The activity is typically first noted by a family member. Most snorers, except those with obstructive sleep apnea syndrome, have no other symptoms. Diaphoresis may result from the hypercapnia and secondary vasodilatation that occur with obstructive sleep apnea. 10 Symptoms of obstructive
sleep apnea, such as excessive daytime sleepiness, fatigability, morning headache, or behavioral problems, may be noted. The patient's history may offer clues about the cause of snoring. Sneezing or an itchy nose suggests allergic rhinitis. Nasal discharge, cough, and fever suggest an upper respiratory tract infection. Snoring following ingestion of drugs or alcohol suggests that these may be the offending agents. On physical examination, the nasopharyngeal airway should be inspected with particular attention to potential sites of airway obstruction. The nose should be checked for evidence of allergic rhinitis (edematous mucosa, clear mucoid nasal discharge, horiwntal crease on the dorsum of the nose), polyps, and septal deviation. Examination of the throat may reveal an edematous uvula with an elongated palate, tonsillar enlargement, redundant lateral pharyngeal mucosa, or a shallow oropharyngeal space.6 The presence of macroglossia, micrognathia, and retrognathia should be noted. Mouth breathing accompanied by a hyponasal speech quality suggests a nasopharyngeal obstruction such as may occur with adenoid hypertrophy. 10
VOL 92/NO 3/SEPTEMBEA 1, 1992/POSTGRADUATE MEDICINE • IINORIIIQ
In children, direct or indirect visualization of the adenoid tissue may be possible.9 Examination of the cranial nerves may provide clues about the presence of neuromuscular abnormalities, which could cause reduced oropharyngeal muscle tone or deficits in the coordination of swallowing and breathing. Cardiovascular problems should be considered; the presence of high blood pressure or a loud and closely split second heart sound suggests pulmonary hypertension. Radiographic evaluation should include a lateral radiograph of the nasopharynx when adenoid hypertrophy is suspected. A lateral sofr-tissue radiograph of the neck may be helpful in assessing the position of the posterior pan of the tongue in relation to the oropharynx. A chest radiograph should be considered if pulmonary hypertension or cor pulmonale is suspected. Cephalometric studies may be indicated in patients with craniofacial syndromes or facial dysmorphism. 10 A sleep study (polysomnography) is indicated when obstructive sleep apnea is suspected.
Management The underlying cause of snoring should be treated whenever possicontinued
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Persons who snore should avoid use of sedatives and alcohol, which may reduce oropharyngeal muscle tone.
ble. Nasal allergy or upper respiratory tract infection should be treated if present. Snoring in obese patients may subside with weight loss. Persons who snore should avoid use of sedatives and alcohol, which may reduce oropharyngeal muscle tone. They should sleep in the prone position or on their side, which may help. to ameliorate or abolish snonng. In children whose snoring is caused by enlarged adenoids, adenoidectomy often brings prompt and dramatic relief and improvement in sleep and in daytime energy. Tonsillectomy should be considered along with adenoidectomy if the tonsils are enlarged. At present, there is no indication for pharmacologic management of snoring. The effectiveness of drugs in treatment of obstructive sleep apnea is disappointing. Protripryline hydrochloride (Vivactil), a tricyclic antidepressant, stimulates oropharyngeal muscles and decreases rapid eye movement sleep, during which the oropharyngeal muscle tone is decreased to a greater extent. However, the anticholinergic side effects of protripryline tend to limit its use. 20 Continuous positive nasal air-
way pressure, by supplying positive pressure over the upper airway and thereby abolishing negative pressure during inspiration, is effective in eliminating snoring as well as sleep apnea.'·3 The application of such pressure, however, is uncomfortable and often is not tolerated by patients. Uvulopalatopharyngoplasry may be considered for adults who are habitual or heavy snorers, especially those with obstructive sleep apnea syndrome. The procedure involves resection of the uvula, the distal portion of the soft palate, the anterior tonsillar pillars, and the redundant lateral pharyngeal wall mucosa. 2•5·6 The procedure widens the nasopharyngeal and oropharyngeal aperture to allow unobstructed movement of air through the pharynx. Experience with this procedure in children is very limited.
Summary Snorers sleep through their obnoxiously loud breathing, but other members of their household often do not. Their bed partner and family members may grow so tired of the noise that they insist the offender seek medical attention. Physio-
logic problems such as obesity, narrowing of the airway, or inadequate oropharyngeal muscle tone often can be identified as the cause of snoring. Whenever possible, the underlying disorder should be treated. PCJ\11
-@
Earn credit on this article. See CME Quiz.
Michelle Drew and Kathy CampbellBrown provided secretarial assistance. Sulakhan Chopra provided research assistance. Address for correspondence: Alexander K. C. Leung, MBBS, FRCPC, Alberta Children's Hospital, 1820 Richmond Rd SW, Calgary, Alberta, Canada T2T 5C7.
References 1. Kolkmvuo M, Partinc:n M, Kaprio J. Snoring and disease. Ann Clin Res 1985; 17(5): 247-51 2. Heiner M, Jobbins D. Snoring and sleep apnoea. Aust Fam Physician 1987;16(5):582..{) 3. Lugarcs.i E, Ciripoua F, Montqna P. Snoring: pathogenic, clinical, and therapeutic aspects. In: Kryger MH, Roth T, Dement WC, eds. Principles and practice of sleep medicine. Philaddphia: WB Saunders, 1989:494-500 4. Lupres.i E, Ciripoua F, Coc:agna G, et aL Some epidemiological data on snoring and cardiocirculatory disturbances. Sleep 1980; 3(3/4):221-4
continued
220
SNORING • VOL 92/NO 3/SEPTEMBEA 1, 1992/POSTGRADUATE MEDICINE
BRIEF SUMMARY
Beconase® (beclomethasone dipropionate, USP) Inhalation Aerosol For Nasal Inhalation Only Beconase AQ® (beclomethasone diproplonate, monohydrate)
basis.
~~:~~u~:::J·,~·~~::,;,d SHAKE WELL For Intranasal Use Only BEFORE USE. The following IS a brief summary only. Before prescnb~ng, see complete prescnbing information 10 Beconase® lnhalat1on Aerosol and Beconase AQ® Nasal Spray product labeling. CONTRAINOICATIONS: Hypersensitivity to any of the ingredients of either preparation contraindicates rts use. WARNINGS: The replacement of a systemic.corticosteroid with Beconase® Inhalation Aerosol or Beconase AQ® Nasal Spray can be accompanied by signs of ~drenal insuffi~tency.
tra~~r:~~dar;~~~"o~~~~~~~a~~~i~n ~~;~tc,f~~n~~g~~~~eu~~ t~~~~ddg;a~~of~rsgrsdta~~~~~~n~sl~~~~;Tnc,~~~~~~J~~~; ~~o have
associated asthma or other clinical conditions where too rapid a decrease in systemic corticosteroids may cause a severe exacerbation ofthetrsymptoms. Studies have shown that the combmed administration of altemate·day prednisone systemic treatment and orally inhaled 1
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in patients already on alternate·day prednisone regimens for any disease. If recommended doses of intranasal beclomethasone are exceeded or if individuals are particularly sensitive or predisposed by virtue of recent systemic steroid therapy, symptoms of hypercorticism may occur, including very rare cases of menstrual irregularities. acneiform lesions, and cushingoid features_. If such changes occur. Beconase lnhalatton Aerosol and Beconase AO Nasal Spray should be discontinued slowly consistent with accepted procedures for discontinuing oral steroid therapy. PRECAUTIONS: General: During withdrawal from oral steroids. some patients may experience symptoms of withdrawal, e.g., joint and/or muscular pain, lassitude, and depression. In chmcal studies with beclomethasone dipropionate administered intranasally, the development of localized infections of the
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~~~;o~~~t~h~~~a~~~~~p~a~d~r;c~~ti~~~~~~~ffr~~~~~~~it~a~~Ko~~:~~~~~~;t~~~fX~~~~or~~e~~~~n~s~~Q~~~~ g~~:ent with
Beclomethasone diprop1onate is absorbed mto the Circulation. Use of excesstve doses of Beconase Inhalation Aerosol or Beconase AQ Nasal Spray may suppress HPA function. Beconase Inhalation Aerosol and Beconase AQ Nasal Spray should be used wnh caution. if at all, in patients with active or qutescent tuberculous Infections of the respiratory tract: untreated fungal, bacterial, or systemtc vtral infect1ons; or ocular herpes simplex. For either preparation to be effective in the treatment of nasal polyps, the aerosol or spr~y must be able to enter the nose. Therefore, treatment of nasal polyps with these preparations should be considered adjunctive therapy to surgical removal and/or the use of other medications that wit\ permit effective penetration of these preparations into the nose. Nasal polyps may recur afteranyformoftreatment. or ~sn~;~hs~~~~~~~·~;im~~~~m:~~~~~~T~~6~~~sgs~T~~~!~~!~h ~1~~~~:;; o~oJco~s~~conase AO Nasal Spray over several months Because of the inhibitory e~ct of corticosteroids on wound healing, patients. who have experienced recent nasal septum ulcers, nasal surgery, or trauma should not ~sea nasal corticosteroid until healmg has oc_curred.
1
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Th!~~~~e~~a~~~~et~~~ ~~~~~~:~~~J~~~~u;;~e~~~;;;~~~:~~~dA~~~;gi !~~ ~~~~~~~~n;Qe~~~~~~~;;~~6~~e bdeoi~~ided. BeCO!JBSB lnhalalfon Aeros~J: Rare mstances of nasal septum perforation have been spontaneously reported.
co~i~;;~~~~di~s of mcreased mtraocular pressure have been reported following the intranasal application of aerosolized
Beconase AQ Nasal Spray: Rarely, 1mmediate hypersensitivity reactions may occur after the intranasal administration of beclomethasone
fol~~~~~~~e ri~~~~i~!~~~~~f~a~~~e~;na~r~~~~~:~pi~~la~1~r~i~~~Af~~~~~'fri:;~ ~~~~o;ri~~e~~e~~~~ervheBJfnb~fn~6ift~l~fsd with Beconase AO Nasal Spray, vigilance should be maintained.
I ation 1or stopping Beconase AO Nasal sl;~ly should receive the this medication. It is not a disclosure of all possible a~verse or intended effe_cts. Patients should use the~e prep~rations at regular intervals since their effectiveness depends on the1r reQUiar use. The pat1ent should take the. medicatton as directed. It is not acutely effective, and the prescribed dosage should not be mcreased. Instead, nasal vasoconstnctors or oral antihistamines may be needed until the effects of Beconase Inhalation Aerosol or Beconase AO Nasal Spray are fully manifested. One to 2 weeks may pass before full relief is 0
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~~~~lni~~taii~~ Po~~eu r~~n~ t~;~~~P~;~;f~f~lf~!~ ~n~l~W~~:tt~fn ~~T~~~~m~r~~~~;~t~~e ~atl~~;~~u~d ~e~~ei~dn~o~~w
carefully the patient's Instructions section of the package msert
;~~~~~~ t~:~~~a~~:r:,er~:~:feJ~P~~'':v~:n~~eF~~~Zin~g;:Ce~~ti~i~t~f~[a~~~~~~s~~~~the;vk;,nb? b~:~k~e~o~:~~tion and 8
82
of fertility, as evidenced by inhtbition of the estrous cycle in dogs, was observed following treatment by the oral route. No mhtbition of the estrous cycle in dogs was seen foltowmg treatment with beclomethasone diprop1onate by the inhalation route. lmpatr~en_t
:r;r~~ron;It~ ~:~a~:f~~~o~~e:~e~~g~~~~fc ~~,~~~~~c~~f ~~~; ~o~;~~~d~:~eb~:e~e~~r~~~~~edorii~sb:~~~~xr~:fe~~~ o times the human dose. In these studtes, beclomet~asone was found to produce fetal resorption, cleft palate, aQnathia, microstomia, absence of tongue, delayed ossification, and agenesis of the thymus. No teratogenic or embryoc1dal effects have
0
~~~3os~~e~ t~ee ~~~~~e;o~:~~~;!h:r~ ~ci ~W;g~~ie~~dw;;ll~g~~~}:~e~~~~!~hi~~;~~n~ni~~~~~~hie~~~~~h~~~~~r orally at d1prop10nate should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Nonleralogenlc Effects: Hypoadrenalism may occur in infants born of mothers receiving corticosteroids during pregnancy. Such infants should be carefully observed Nursing Mothers: II is n~t known whether beclomethasone diproptonate IS excreted in human milk. Because other corticosteroids are excreted in human milk, caution should be exercised when Beconase Inhalation Aerosol or Beconase AQ Nasal Spray is administered to a nursing woman. Pediatric Use: Safety and effectiveness 10 children below 6 years of age have not been established. A~VERSE REACTIONS: In general, side effects in clinical studies with both preparations have been primarily associated with 1rntation of the nasal mucous membranes Rare cases of immed1a~e and delayed hypersens~1vrty reactiOns, including urticaria, angioedema, rash, and bronchospasm. have been reported followmg the oral and mtranasal inhalation and administration of beclomethasone. Beconase® Inhalation Aero~ol: Adverse reactions. reported in controlled clinical trials and long·term open studies in patients treated with Beconase InhalatiOn Aerosol are descnbed below. SensatiOns of irritatiOn and burning !n the nose (11 per 100 patients) following the use of Beconase Inhalation Aerosol have ~een repo~ed. Also, ~ccas10nal sneeztng attacks (10 per 100 adult patients) have occurred imme~iately following the use of _the 10 tLaoncaa~~e~~~~:~~ti~~~~ ~f~~t~~~aaldb~h~~~ex ~i~C~~d~d~h~~~~n~~~~~6~u~:~ ~;~~; (;~;~~~~~Uq18~s1. 0 patients) Trans1ent episodes of epistaxis have been reported in 2 per 100 patients. Rare cases of ulceration of the nasal mucosa and instances of nasal septum perforation have been spontaneously reported (see PRECAUTIONS). Rare mstances of mcreased Intraocular pressure have been reported following the intranasal application of aerosollzed corticosteroids (see PRECAUTIONS). Systemic corti~ostermd side effects were not reported dunng controlled clinica! trials. If ~ecommended doses are exceeded, however, or if indiViduals are particularly se~sttive, symptoms of hypercort_icism. 1.e , Cushtng's syndrome, could occur. Beconase AQ® Nasal Spray: Adverse reacttons reported 10 controlled climcal tnals and open studies in pattents treated w1th Beconase AO Nasal Spray are described below.
0
pa~i~~s ~~~re~~7n~~~~:~~b~~~~tg~~~~~i~~e~~~gui~a~k~e(~~~u~t~~) ~~c~~~~~ui~~:clla~~~~ro~~~~nege~~:Po~~~~ ~~~fy~~n ~~i~~ts 0
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expene.ncmg these symptoms. none had to. d1scontmue tr~atment. The _1ncrdence of _tran~ient rrritation and sneezing was approxtmatel~ the same 1n the group of patients who rece1ved placebo 1n these studtes, tmplymg that these complaints may be related to vehicle components of the formulation. Fewer than 5 per 100 ~at1ents reported headache, nausea, or lighthe~dedness follow!ng the use of Beconase AQ Nasal Spray Fewer than 3 per _1 00 patients report~d nasal stuffiness. nosebl_eeds, rhmorrhea, or teanng eyes. Extremely r_are tnstances of wheezmg, nasal septum perforation, and Increased tntraocular pressure have been reported following the Intranasal administration of aerosolized corticosteroids (see PRECAUTIONS). OVERDOSAGE: Information concerning possible overdosage and lis treatment appears in the full prescribing information
d/1t!Jl§,!fanburys
5. Rice DH, Persky M. Snoring: clinical implications and treaunenr. Otolaryngol Head Neck Surg 1986;95(1):28-30 6. Rice D. Snoring. Otolaryngol Clin North Am 1986;19(1):135-40 7. Fairbanks DN. Snoring: not funny-not hopeless. Am Fam Physician 1986;33(2):205-11 8. Wong HB. The problem of the snoring child and obstructive apnea syndrome. JSingapore Paediau Soc 1988;30(1&2):1-6 9. Mandel EM, Reynolds CF. Sleep disorders associated with upper airway obstruction in children. Ped.iau Clin NorthAm 1981;28(4): 897-903 10. Maddem BR. Snoring and obsuuctive sleep apnea syndrome. In: Bluestone CD, Stool SE, Scheetz MD, eds. Pediatric otolaryngology. Philadelphia: WB Saunders, 1990:927-34 11. Bradley TD, Brown IG, Grossman RF, et al. Pharyngeal size in snorers, nonsnorers, and patients with obsuuctive sleep apnea. N Eng! J Med 1986;315(21):1327-31 12. Fairbanks DN. Snoring: surgical vs nonsurgical management. Laryngoscope 1984; 94(9):1188-92 13. Corbo GM, Fuciarelli F, Foresi A, et al. Snoring in children: association with respiratory symptoms and passive smoking. Br Med J 1989;299: 1491-4 14. Torino GM, Goldring RM. Sleeping and breathing. (Editorial) N Eng! J Med 1978; 299(18):1009-11 15. Waller PC, Bhopal RS. Is snoring a cause of vascular disease? Lancet 1989;1(8630):143-6 16. Mauer Kw, Staats BA, Olsen KD. Upper airway obstruction and disordered nocturnal breathing in children. Mayo Clin Proc 1983; 58(5&6):349-53 17. Butt W, Robertson C, Phdan P. Snoring in children: is it pathological? Med J Aust 1985; 143(8):335-6 18. Block AJ. Is snoring a risk factor? (Editorial) Chest 1981;80(5):525-6 19. Pattinen M, Palomaki H. Snoring and cerebral infarction. Lancet 1985;2(8468):1325-6 20. Snoring and sleepiness. (Editorial) Lancet 1985;2(8461):925-6
Research Triangle Park. NC 27700
R~lerences:
1. Beswtc~ KBJ. Kenyon GS, Ch~rry JR. A comparative _study of beclomethasone dipropionate aqueous nasal spray wtth terfenadtne ~ablets 1n seasonal aller9ic rhtMis. CurrMed Res qpm. 198~;9(8):560·567. 2. Salomonsson P. Gottbe~g L, Hetlborn H, Norrlmd K, Pegelow K-0. Efftcacy of an oral antihistamme. astem1zole. as compared to a nasal steroid spray 1n hay fever. "!fergy. 1988;43:214-~18. 3. Tarlo SM. Cockcroft OW, Dolov1ch J, Harweave FE. Bec!omethasone d1prop1onate aerosol m pe~enmal rhmit1s. J Affergy C!m lmmunol. Mar_ch 1977;5~:232-236. 4. Holopamen E. Malmberg H, Binder E. Long·term follow·up of mtra·nasal beclomethasone treatment: a cltnical and histologic study. Acta Otolaryngo/ Suppl (Stockh). 1982;386:270·273
81·719 February 1991
BSE431
Printed in USA
October 1991
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ISSN: 0032-5481 (Print) 1941-9260 (Online) Journal homepage: http://www.tandfonline.com/loi/ipgm20
The ABZzzzs of snoring Alexander K. C. Leung MBBS, FRCPC & Wm. Lane M. Robson MD, FRCPC To cite this article: Alexander K. C. Leung MBBS, FRCPC & Wm. Lane M. Robson MD, FRCPC (1992) The ABZzzzs of snoring, Postgraduate Medicine, 92:3, 217-222, DOI: 10.1080/00325481.1992.11701451 To link to this article: http://dx.doi.org/10.1080/00325481.1992.11701451
Published online: 17 May 2016.
Submit your article to this journal
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipgm20 Download by: [Monash University Library]
Date: 03 July 2016, At: 11:42
-@CME credit article
The ABZzzzs of snoring
Alexander K. C. Leung, MBBS, FRCPC Wm. Lane M. Robson, MD, FRCPC
Downloaded by [Monash University Library] at 11:42 03 July 2016
Preview "Laugh and the world laughs with you; snore, and you sleep alone." There is some truth to this play on the words of American poet Ella Wheeler Wilcox. Snoring can be very annoying and may lead to ridicule and personal problems. But it may also be a symptom of an underlying medical disorder. Drs Leung and Robson discuss the causes of snoring as well as complications, evaluation, and management.
Snoring is a predominantly inspiratory sound that occurs during sleep. It is produced by vibrations of the soft parts of the oropharyngeal airway, notably the soft palate and the posterior faucial pillars of the tonsils. 1-3 Snoring implies partial blockage of the nasopharyngeal airway. Habitual snoring may be a nuisance, but it also may be a symptom of significant medical problems. 1-3 Although snoring is common, it has received little attention in the medical literature.
Incidence Lugaresi and colleagu~.4 found that 1,085 (19%) of 5,713 persons in an unselected population were habitual snorers (subjects who reported snoring every or almost every night). The incidence of snoring in children is not known. Up to 45% of adults snore occasionally, and 25% are habitual snorers.' The incidence
of snoring increases in men after age 20 and in women after age 40. 6 By 60 years of age, 50% of men and 40% of women are habitual snorers. The incidence thereafter remains stable or slowly diminishes after age 65. 3 Snoring is three times more common in obese persons than in thin persons.'·7
Causes Snoring results when narrowing of the nasopharyngeal airway is aggravated by the effects of sleep. 3 The sound of snoring originates in the collapsible part of the oropharyngeal airway, from the epiglottis to the choanae/ Negative intrathoracic pressure develops during inspiration. 3This negative pressure acts on the base of the tongue, the soft palate, and the pharyngeal walls and may result in collapse of the oropharyngeal airway. 8 Normally, the muscles of the oropharyngeal ring
VOL 92/NO 3/SEPTEMBER 1, 1992/POSTGRADUATE MEDICINE • SNORING
(genioglossus, geniohyoid, sternohyoid, and sternothyroid) exert counterpressure, which prevents collapse of the oropharyngeal airway. 8 Snoring is more common in persons who sleep in the supine position, because the tongue falls backward in this position.3 Some persons snore only or predominantly when in the supine position. The following factors, alone or in combination, may contribute to snoring. ANATOMIC NARROWING OF TilE NASOPHARYNGFAL AIRWAY-
Space-occupying masses that impinge on the nasopharyngeal airway may cause snoring. 7 Hypertrophy of the nasopharyngeal tissue, specifically the adenoids and tonsils, is the most common cause of chronic airway obstruction and snoring in children. 7·9•10 Other anatomic causes of narrowing of the nasopharyngeal airway, such as choanal atresia, choanal polyp, nasal septal deviation, nasopharyngeal cyst, macroglossia, retrognathia, and micrognathia, are less common. 9•10 In one study; Bradley and associates 11 found that snorers have a smaller pharyngeal crosssectional area than nonsnorers. Obesity may predispose persons to snoring because the lumen of continued
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By 60 years of age, 50% of men and 40% of women are habitual snorers.
the upper airway is narrowed by excessive adipose tissue.u Excessive length of the soft palate and uvula narrows the nasopharyngeal airway and may lead to snoring.7.12 NASAL AIRFLOW RFSfRICilON-
Patients with an upper respiratory infection or allergic rhinitis are prone to snoring because the associated restriction of nasal airflow accentuates negative intrathoracic pressure during inspiration.7.12.IJ Smoking, whether active or passive, has been linked to an increased incidence of snoring. 13 Smoking causes mucosal edema and inflammation and results in narrowing of the nasopharyngeal airway. INADEQUATE OROPHARYNGFAL MUSCLE lONE-The
oropharyngeal muscles, especially the genioglossus muscle, force the tongue forward during inspira-
Alexander K. C. Leung, MBBS, FRCPC Wm. Lane M. Robson, MD, FRCPC Dr Leung is clinical associate professor of pediatrics, University of Calgary, and pediatric consultant, Alberta Children's Hospital and Foothills Provincial Hospital, Calgary, Alberta, Canada. Dr Robson is clinical associate professor of pediatrics, University of Calgary, and pediatric consultant, Alberta Children's Hospital.
218
tion and play a major role in the normal maintenance of a patent oropharyngeal airway, particularly during sleep in the supine position. 14 Direct cineradiographic observations of the upper airway in snoring patients have shown inspiratory narrowing of the pharyngeal airway during sleep. 8 Hypotonia of the oropharyngeal muscles may occur in some persons during normal sleep and in others in association with sleep deprivation, general anesthesia, neurologic lesions, or ingestion of alcohol or of drugs such as hypnotics, tranquilizers, or antihistamines.6'7'11'14 GENETIC FACIDRS-A genetic predisposition to snoring has been reported. 1 However, it is not known whether this predisposition is related to a familial tendency to narrowing of the nasopharyngeal airway, obesity, or hypotonia of the oropharyngeal muscles.
Complications In the majority of patients who snore, snoring is a benign finding. However, habitual or heavy snoring may be an indication of alveolar hypoventilation, which may lead to pulmonary or systemic hypertension. ~' Extreme snoring and obstructive sleep ap1
16
nea syndrome coexist in some patients; both disorders are caused by narrowing of the airway. Symptoms of obstructive sleep apnea syndrome develop because of sleep deprivation, significant asphyxia, and cardiovascular impairment.17 Patients with obstructive sleep apnea do not get adequate ventilation during sleep and may wake up periodically. The resulting sleep deprivation may lead to daytime sleepiness, lethargy, tiredness, personality changes, or morning headache. Complications of snoring in children include failure to thrive, poor school performance, and behavioral problems such as hyperactivity or antisocial behavior.w Chronic hypoventilation is associated with hypoxemia and may result in pulmonary hypertension and an increased cardiac workload; these effects may lead to systemic hypertension or cardiac arrhythmias. 7 Chronic hypoventilation may progress to classic pickwickian syndrome, which is characterized by obesity, daytime hypersomnolence, hypoxia, and hypercapnia. 18 Common consequences of pickwickian syndrome include secondary polycythemia, cor pulmonale, and heart failure. 18 Obstructive sleep apnea is a possible cause of
SNORING • VOL 92/NO 3/SEPTEMBER 1, 1992/POSTGRADUATE MEDICINE
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Obese persons may be predisposed to snoring because the lumen of the upper airway is narrowed by excessive adipose tissue.
sudden infant death syndrome. 14 In adults, a link between habitual snoring and an increased risk of angina pectoris and cerebral infarction has been reported.3'15'19 Habitual snoring can be a distressing social problem. The loudness of heavy snoring has been measured as high as 69 dB. 1 Habitual snoring is a recognized cause of marital problems. Snorers may be subjected to teasing and ridicule.
Evaluation Clinical evaluation of snoring begins with a detailed sleep history, including the patient's sleeping habits, the degree of sleep disturbance, and the resultant effect on daytime activities. Nocturnal symptoms include frequent awakenings, restless sleep, diaphoresis, respiratory pauses or apneic episodes, nightmares, and night terrors. Snorers do not usually hear their own noise. The activity is typically first noted by a family member. Most snorers, except those with obstructive sleep apnea syndrome, have no other symptoms. Diaphoresis may result from the hypercapnia and secondary vasodilatation that occur with obstructive sleep apnea. 10 Symptoms of obstructive
sleep apnea, such as excessive daytime sleepiness, fatigability, morning headache, or behavioral problems, may be noted. The patient's history may offer clues about the cause of snoring. Sneezing or an itchy nose suggests allergic rhinitis. Nasal discharge, cough, and fever suggest an upper respiratory tract infection. Snoring following ingestion of drugs or alcohol suggests that these may be the offending agents. On physical examination, the nasopharyngeal airway should be inspected with particular attention to potential sites of airway obstruction. The nose should be checked for evidence of allergic rhinitis (edematous mucosa, clear mucoid nasal discharge, horiwntal crease on the dorsum of the nose), polyps, and septal deviation. Examination of the throat may reveal an edematous uvula with an elongated palate, tonsillar enlargement, redundant lateral pharyngeal mucosa, or a shallow oropharyngeal space.6 The presence of macroglossia, micrognathia, and retrognathia should be noted. Mouth breathing accompanied by a hyponasal speech quality suggests a nasopharyngeal obstruction such as may occur with adenoid hypertrophy. 10
VOL 92/NO 3/SEPTEMBEA 1, 1992/POSTGRADUATE MEDICINE • IINORIIIQ
In children, direct or indirect visualization of the adenoid tissue may be possible.9 Examination of the cranial nerves may provide clues about the presence of neuromuscular abnormalities, which could cause reduced oropharyngeal muscle tone or deficits in the coordination of swallowing and breathing. Cardiovascular problems should be considered; the presence of high blood pressure or a loud and closely split second heart sound suggests pulmonary hypertension. Radiographic evaluation should include a lateral radiograph of the nasopharynx when adenoid hypertrophy is suspected. A lateral sofr-tissue radiograph of the neck may be helpful in assessing the position of the posterior pan of the tongue in relation to the oropharynx. A chest radiograph should be considered if pulmonary hypertension or cor pulmonale is suspected. Cephalometric studies may be indicated in patients with craniofacial syndromes or facial dysmorphism. 10 A sleep study (polysomnography) is indicated when obstructive sleep apnea is suspected.
Management The underlying cause of snoring should be treated whenever possicontinued
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Persons who snore should avoid use of sedatives and alcohol, which may reduce oropharyngeal muscle tone.
ble. Nasal allergy or upper respiratory tract infection should be treated if present. Snoring in obese patients may subside with weight loss. Persons who snore should avoid use of sedatives and alcohol, which may reduce oropharyngeal muscle tone. They should sleep in the prone position or on their side, which may help. to ameliorate or abolish snonng. In children whose snoring is caused by enlarged adenoids, adenoidectomy often brings prompt and dramatic relief and improvement in sleep and in daytime energy. Tonsillectomy should be considered along with adenoidectomy if the tonsils are enlarged. At present, there is no indication for pharmacologic management of snoring. The effectiveness of drugs in treatment of obstructive sleep apnea is disappointing. Protripryline hydrochloride (Vivactil), a tricyclic antidepressant, stimulates oropharyngeal muscles and decreases rapid eye movement sleep, during which the oropharyngeal muscle tone is decreased to a greater extent. However, the anticholinergic side effects of protripryline tend to limit its use. 20 Continuous positive nasal air-
way pressure, by supplying positive pressure over the upper airway and thereby abolishing negative pressure during inspiration, is effective in eliminating snoring as well as sleep apnea.'·3 The application of such pressure, however, is uncomfortable and often is not tolerated by patients. Uvulopalatopharyngoplasry may be considered for adults who are habitual or heavy snorers, especially those with obstructive sleep apnea syndrome. The procedure involves resection of the uvula, the distal portion of the soft palate, the anterior tonsillar pillars, and the redundant lateral pharyngeal wall mucosa. 2•5·6 The procedure widens the nasopharyngeal and oropharyngeal aperture to allow unobstructed movement of air through the pharynx. Experience with this procedure in children is very limited.
Summary Snorers sleep through their obnoxiously loud breathing, but other members of their household often do not. Their bed partner and family members may grow so tired of the noise that they insist the offender seek medical attention. Physio-
logic problems such as obesity, narrowing of the airway, or inadequate oropharyngeal muscle tone often can be identified as the cause of snoring. Whenever possible, the underlying disorder should be treated. PCJ\11
-@
Earn credit on this article. See CME Quiz.
Michelle Drew and Kathy CampbellBrown provided secretarial assistance. Sulakhan Chopra provided research assistance. Address for correspondence: Alexander K. C. Leung, MBBS, FRCPC, Alberta Children's Hospital, 1820 Richmond Rd SW, Calgary, Alberta, Canada T2T 5C7.
References 1. Kolkmvuo M, Partinc:n M, Kaprio J. Snoring and disease. Ann Clin Res 1985; 17(5): 247-51 2. Heiner M, Jobbins D. Snoring and sleep apnoea. Aust Fam Physician 1987;16(5):582..{) 3. Lugarcs.i E, Ciripoua F, Montqna P. Snoring: pathogenic, clinical, and therapeutic aspects. In: Kryger MH, Roth T, Dement WC, eds. Principles and practice of sleep medicine. Philaddphia: WB Saunders, 1989:494-500 4. Lupres.i E, Ciripoua F, Coc:agna G, et aL Some epidemiological data on snoring and cardiocirculatory disturbances. Sleep 1980; 3(3/4):221-4
continued
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SNORING • VOL 92/NO 3/SEPTEMBEA 1, 1992/POSTGRADUATE MEDICINE
BRIEF SUMMARY
Beconase® (beclomethasone dipropionate, USP) Inhalation Aerosol For Nasal Inhalation Only Beconase AQ® (beclomethasone diproplonate, monohydrate)
basis.
~~:~~u~:::J·,~·~~::,;,d SHAKE WELL For Intranasal Use Only BEFORE USE. The following IS a brief summary only. Before prescnb~ng, see complete prescnbing information 10 Beconase® lnhalat1on Aerosol and Beconase AQ® Nasal Spray product labeling. CONTRAINOICATIONS: Hypersensitivity to any of the ingredients of either preparation contraindicates rts use. WARNINGS: The replacement of a systemic.corticosteroid with Beconase® Inhalation Aerosol or Beconase AQ® Nasal Spray can be accompanied by signs of ~drenal insuffi~tency.
tra~~r:~~dar;~~~"o~~~~~~~a~~~i~n ~~;~tc,f~~n~~g~~~~eu~~ t~~~~ddg;a~~of~rsgrsdta~~~~~~n~sl~~~~;Tnc,~~~~~~J~~~; ~~o have
associated asthma or other clinical conditions where too rapid a decrease in systemic corticosteroids may cause a severe exacerbation ofthetrsymptoms. Studies have shown that the combmed administration of altemate·day prednisone systemic treatment and orally inhaled 1
~f~ i~~;~;:~r;ni~_cf~!~!fo~~~ ~~~~~~~~ ~fh~rft?~a~~~;~~~~a~~ag~~~:~1~P~Js~~~;r~~s~~~af~~tta;~~u%~eaJ~:da~Tt~i6a~~i6~
in patients already on alternate·day prednisone regimens for any disease. If recommended doses of intranasal beclomethasone are exceeded or if individuals are particularly sensitive or predisposed by virtue of recent systemic steroid therapy, symptoms of hypercorticism may occur, including very rare cases of menstrual irregularities. acneiform lesions, and cushingoid features_. If such changes occur. Beconase lnhalatton Aerosol and Beconase AO Nasal Spray should be discontinued slowly consistent with accepted procedures for discontinuing oral steroid therapy. PRECAUTIONS: General: During withdrawal from oral steroids. some patients may experience symptoms of withdrawal, e.g., joint and/or muscular pain, lassitude, and depression. In chmcal studies with beclomethasone dipropionate administered intranasally, the development of localized infections of the
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~~~;o~~~t~h~~~a~~~~~p~a~d~r;c~~ti~~~~~~~ffr~~~~~~~it~a~~Ko~~:~~~~~~;t~~~fX~~~~or~~e~~~~n~s~~Q~~~~ g~~:ent with
Beclomethasone diprop1onate is absorbed mto the Circulation. Use of excesstve doses of Beconase Inhalation Aerosol or Beconase AQ Nasal Spray may suppress HPA function. Beconase Inhalation Aerosol and Beconase AQ Nasal Spray should be used wnh caution. if at all, in patients with active or qutescent tuberculous Infections of the respiratory tract: untreated fungal, bacterial, or systemtc vtral infect1ons; or ocular herpes simplex. For either preparation to be effective in the treatment of nasal polyps, the aerosol or spr~y must be able to enter the nose. Therefore, treatment of nasal polyps with these preparations should be considered adjunctive therapy to surgical removal and/or the use of other medications that wit\ permit effective penetration of these preparations into the nose. Nasal polyps may recur afteranyformoftreatment. or ~sn~;~hs~~~~~~~·~;im~~~~m:~~~~~~T~~6~~~sgs~T~~~!~~!~h ~1~~~~:;; o~oJco~s~~conase AO Nasal Spray over several months Because of the inhibitory e~ct of corticosteroids on wound healing, patients. who have experienced recent nasal septum ulcers, nasal surgery, or trauma should not ~sea nasal corticosteroid until healmg has oc_curred.
1
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Th!~~~~e~~a~~~~et~~~ ~~~~~~:~~~J~~~~u;;~e~~~;;;~~~:~~~dA~~~;gi !~~ ~~~~~~~~n;Qe~~~~~~~;;~~6~~e bdeoi~~ided. BeCO!JBSB lnhalalfon Aeros~J: Rare mstances of nasal septum perforation have been spontaneously reported.
co~i~;;~~~~di~s of mcreased mtraocular pressure have been reported following the intranasal application of aerosolized
Beconase AQ Nasal Spray: Rarely, 1mmediate hypersensitivity reactions may occur after the intranasal administration of beclomethasone
fol~~~~~~~e ri~~~~i~!~~~~~f~a~~~e~;na~r~~~~~:~pi~~la~1~r~i~~~Af~~~~~'fri:;~ ~~~~o;ri~~e~~e~~~~ervheBJfnb~fn~6ift~l~fsd with Beconase AO Nasal Spray, vigilance should be maintained.
I ation 1or stopping Beconase AO Nasal sl;~ly should receive the this medication. It is not a disclosure of all possible a~verse or intended effe_cts. Patients should use the~e prep~rations at regular intervals since their effectiveness depends on the1r reQUiar use. The pat1ent should take the. medicatton as directed. It is not acutely effective, and the prescribed dosage should not be mcreased. Instead, nasal vasoconstnctors or oral antihistamines may be needed until the effects of Beconase Inhalation Aerosol or Beconase AO Nasal Spray are fully manifested. One to 2 weeks may pass before full relief is 0
1
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~~~~lni~~taii~~ Po~~eu r~~n~ t~;~~~P~;~;f~f~lf~!~ ~n~l~W~~:tt~fn ~~T~~~~m~r~~~~;~t~~e ~atl~~;~~u~d ~e~~ei~dn~o~~w
carefully the patient's Instructions section of the package msert
;~~~~~~ t~:~~~a~~:r:,er~:~:feJ~P~~'':v~:n~~eF~~~Zin~g;:Ce~~ti~i~t~f~[a~~~~~~s~~~~the;vk;,nb? b~:~k~e~o~:~~tion and 8
82
of fertility, as evidenced by inhtbition of the estrous cycle in dogs, was observed following treatment by the oral route. No mhtbition of the estrous cycle in dogs was seen foltowmg treatment with beclomethasone diprop1onate by the inhalation route. lmpatr~en_t
:r;r~~ron;It~ ~:~a~:f~~~o~~e:~e~~g~~~~fc ~~,~~~~~c~~f ~~~; ~o~;~~~d~:~eb~:e~e~~r~~~~~edorii~sb:~~~~xr~:fe~~~ o times the human dose. In these studtes, beclomet~asone was found to produce fetal resorption, cleft palate, aQnathia, microstomia, absence of tongue, delayed ossification, and agenesis of the thymus. No teratogenic or embryoc1dal effects have
0
~~~3os~~e~ t~ee ~~~~~e;o~:~~~;!h:r~ ~ci ~W;g~~ie~~dw;;ll~g~~~}:~e~~~~!~hi~~;~~n~ni~~~~~~hie~~~~~h~~~~~r orally at d1prop10nate should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Nonleralogenlc Effects: Hypoadrenalism may occur in infants born of mothers receiving corticosteroids during pregnancy. Such infants should be carefully observed Nursing Mothers: II is n~t known whether beclomethasone diproptonate IS excreted in human milk. Because other corticosteroids are excreted in human milk, caution should be exercised when Beconase Inhalation Aerosol or Beconase AQ Nasal Spray is administered to a nursing woman. Pediatric Use: Safety and effectiveness 10 children below 6 years of age have not been established. A~VERSE REACTIONS: In general, side effects in clinical studies with both preparations have been primarily associated with 1rntation of the nasal mucous membranes Rare cases of immed1a~e and delayed hypersens~1vrty reactiOns, including urticaria, angioedema, rash, and bronchospasm. have been reported followmg the oral and mtranasal inhalation and administration of beclomethasone. Beconase® Inhalation Aero~ol: Adverse reactions. reported in controlled clinical trials and long·term open studies in patients treated with Beconase InhalatiOn Aerosol are descnbed below. SensatiOns of irritatiOn and burning !n the nose (11 per 100 patients) following the use of Beconase Inhalation Aerosol have ~een repo~ed. Also, ~ccas10nal sneeztng attacks (10 per 100 adult patients) have occurred imme~iately following the use of _the 10 tLaoncaa~~e~~~~:~~ti~~~~ ~f~~t~~~aaldb~h~~~ex ~i~C~~d~d~h~~~~n~~~~~6~u~:~ ~;~~; (;~;~~~~~Uq18~s1. 0 patients) Trans1ent episodes of epistaxis have been reported in 2 per 100 patients. Rare cases of ulceration of the nasal mucosa and instances of nasal septum perforation have been spontaneously reported (see PRECAUTIONS). Rare mstances of mcreased Intraocular pressure have been reported following the intranasal application of aerosollzed corticosteroids (see PRECAUTIONS). Systemic corti~ostermd side effects were not reported dunng controlled clinica! trials. If ~ecommended doses are exceeded, however, or if indiViduals are particularly se~sttive, symptoms of hypercort_icism. 1.e , Cushtng's syndrome, could occur. Beconase AQ® Nasal Spray: Adverse reacttons reported 10 controlled climcal tnals and open studies in pattents treated w1th Beconase AO Nasal Spray are described below.
0
pa~i~~s ~~~re~~7n~~~~:~~b~~~~tg~~~~~i~~e~~~gui~a~k~e(~~~u~t~~) ~~c~~~~~ui~~:clla~~~~ro~~~~nege~~:Po~~~~ ~~~fy~~n ~~i~~ts 0
0
2
expene.ncmg these symptoms. none had to. d1scontmue tr~atment. The _1ncrdence of _tran~ient rrritation and sneezing was approxtmatel~ the same 1n the group of patients who rece1ved placebo 1n these studtes, tmplymg that these complaints may be related to vehicle components of the formulation. Fewer than 5 per 100 ~at1ents reported headache, nausea, or lighthe~dedness follow!ng the use of Beconase AQ Nasal Spray Fewer than 3 per _1 00 patients report~d nasal stuffiness. nosebl_eeds, rhmorrhea, or teanng eyes. Extremely r_are tnstances of wheezmg, nasal septum perforation, and Increased tntraocular pressure have been reported following the Intranasal administration of aerosolized corticosteroids (see PRECAUTIONS). OVERDOSAGE: Information concerning possible overdosage and lis treatment appears in the full prescribing information
d/1t!Jl§,!fanburys
5. Rice DH, Persky M. Snoring: clinical implications and treaunenr. Otolaryngol Head Neck Surg 1986;95(1):28-30 6. Rice D. Snoring. Otolaryngol Clin North Am 1986;19(1):135-40 7. Fairbanks DN. Snoring: not funny-not hopeless. Am Fam Physician 1986;33(2):205-11 8. Wong HB. The problem of the snoring child and obstructive apnea syndrome. JSingapore Paediau Soc 1988;30(1&2):1-6 9. Mandel EM, Reynolds CF. Sleep disorders associated with upper airway obstruction in children. Ped.iau Clin NorthAm 1981;28(4): 897-903 10. Maddem BR. Snoring and obsuuctive sleep apnea syndrome. In: Bluestone CD, Stool SE, Scheetz MD, eds. Pediatric otolaryngology. Philadelphia: WB Saunders, 1990:927-34 11. Bradley TD, Brown IG, Grossman RF, et al. Pharyngeal size in snorers, nonsnorers, and patients with obsuuctive sleep apnea. N Eng! J Med 1986;315(21):1327-31 12. Fairbanks DN. Snoring: surgical vs nonsurgical management. Laryngoscope 1984; 94(9):1188-92 13. Corbo GM, Fuciarelli F, Foresi A, et al. Snoring in children: association with respiratory symptoms and passive smoking. Br Med J 1989;299: 1491-4 14. Torino GM, Goldring RM. Sleeping and breathing. (Editorial) N Eng! J Med 1978; 299(18):1009-11 15. Waller PC, Bhopal RS. Is snoring a cause of vascular disease? Lancet 1989;1(8630):143-6 16. Mauer Kw, Staats BA, Olsen KD. Upper airway obstruction and disordered nocturnal breathing in children. Mayo Clin Proc 1983; 58(5&6):349-53 17. Butt W, Robertson C, Phdan P. Snoring in children: is it pathological? Med J Aust 1985; 143(8):335-6 18. Block AJ. Is snoring a risk factor? (Editorial) Chest 1981;80(5):525-6 19. Pattinen M, Palomaki H. Snoring and cerebral infarction. Lancet 1985;2(8468):1325-6 20. Snoring and sleepiness. (Editorial) Lancet 1985;2(8461):925-6
Research Triangle Park. NC 27700
R~lerences:
1. Beswtc~ KBJ. Kenyon GS, Ch~rry JR. A comparative _study of beclomethasone dipropionate aqueous nasal spray wtth terfenadtne ~ablets 1n seasonal aller9ic rhtMis. CurrMed Res qpm. 198~;9(8):560·567. 2. Salomonsson P. Gottbe~g L, Hetlborn H, Norrlmd K, Pegelow K-0. Efftcacy of an oral antihistamme. astem1zole. as compared to a nasal steroid spray 1n hay fever. "!fergy. 1988;43:214-~18. 3. Tarlo SM. Cockcroft OW, Dolov1ch J, Harweave FE. Bec!omethasone d1prop1onate aerosol m pe~enmal rhmit1s. J Affergy C!m lmmunol. Mar_ch 1977;5~:232-236. 4. Holopamen E. Malmberg H, Binder E. Long·term follow·up of mtra·nasal beclomethasone treatment: a cltnical and histologic study. Acta Otolaryngo/ Suppl (Stockh). 1982;386:270·273
81·719 February 1991
BSE431
Printed in USA
October 1991
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