Snoring

Snoring, although in most cases a relatively trivial problem, may if gross have serious implications. Although snoring is commonly associated with obesity, aging, (where the pharyngeal tissues become more lax) along with late-night excess food and alcohol intake, there are anatomical factors in the upper respiratory tract that contribute to snoring. Nasal obstruction accentuates snoring but is not commonly the prime cause. Surgery therefore for airway problems to the nose may not be curative.

The anatomy of the soft palate and oropharynx however is a cause of snoring when the soft palate, uvula and fauces are long and lax. Large tonsils may also cause snoring. Surgery to reduce the size and mobility of the soft palate—uvulopalatoplasty—has become established world-wide. The uvula is excised along with shortening of the faucial pillars, either with excision, or laser techniques. (see Fig. 4.38a, b). Sleep studies are carried out preoperatively for assessment of the snoring. Apart from appraising the predominant site causing the snoring, whether the oropharynx, tongue base, or nose, sleep studies monitor the respiration rate, cardiac function with O2 and CO2 levels during sleep.

With gross snoring both in children (where upper respiratory tract obstruction from marked adenoids and tonsil hypertrophy may be relevant) and in adults, significant physiological upset may ensure. With sleep apnea respiration is sufficiently disturbed by snoring to cause cardiac arrhythmia and maybe cardiac enlargement, along with periods of oxygen deficit.

In these instances treatment for snoring either by surgery or by oxygen administration at night is necessary along with other steps, for example, weight loss. Oxygen supplied at night prevents sleep apnea— continuous positive airway pressure (CPAP; Fig. 4.38c). A mask is firmly attached to the nose to supply oxygen; the patient's discomfort may limit the application of this treatment (see over).

Steps How Remove Snoring

Fig. 4.38 Snoring. a, b Uvuloplasty to remove the uvula and shorten the faucial pillars. c An oxygen mask may be worn at night to prevent sleep apnea.

Fig. 4.38 Snoring. a, b Uvuloplasty to remove the uvula and shorten the faucial pillars. c An oxygen mask may be worn at night to prevent sleep apnea.

Squamous Cell Carcinoma The Uvula

Fig. 4.39 Papillomas. These may occur on the uvula (a), fauces, and tonsil. The patient often notices these papillomas when looking at the throat, or they are found at medical examination. Symptoms are uncommon. They are usually pedunculated and are easily and painlessly removable in outpatients. They should be sent for histology to exclude a squamous carcinoma. If ignored, a papilloma may cause symptoms on account of size. This large papilloma (b) arises from the base of the right tonsil.

Papilloma Tonsil

Fig. 4.40 Tonsil size. There is no recognized "normal" size for a tonsil. It is, therefore, arguable as to whether tonsils can be described as "enlarged." The apparent size of the tonsil can be altered considerably when the tongue is protruded forcibly. This child, whose oropharynx looks normal when the tongue is slightly protruded (a), can make the tonsils meet in the mid-line with maximum protrusion of the tongue (b).

Fig. 4.40 Tonsil size. There is no recognized "normal" size for a tonsil. It is, therefore, arguable as to whether tonsils can be described as "enlarged." The apparent size of the tonsil can be altered considerably when the tongue is protruded forcibly. This child, whose oropharynx looks normal when the tongue is slightly protruded (a), can make the tonsils meet in the mid-line with maximum protrusion of the tongue (b).

Gagging Tongue Depressor
Fig. 4.41 a, b Tonsil size affected by tongue depressor. The tongue depressor also alters the apparent size of the tonsils. If the tongue is firmly depressed, the patient gags and the tonsils meet in the mid-line (b).
Tonsils Adenoids Lateral Radiograph

Fig. 4.43 Lateral radiograph of tonsils. The tonsils (arrow) and adenoids shown on lateral radiograph, and the soft-tissue shadow helps in assessing the degree of obstruction that the lymphoid tissue may be causing. The lingual tonsil is unusually large in Down's syndrome patients and contributes to their characteristic bulky tongue.

Fig. 4.42a, b Tonsils meeting in the mid-line. It is unusual for tonsils to meet in the mid-line or to overlap. Lymphoid tissue of this bulk, particularly during an acute tonsillitis, may cause respiratory obstruction and severe dysphagia. There is an increased awareness of the severity of upper respiratory tract obstruction from the bulk of tonsillar and adenoid lymphoid tissue.

In children, particularly at times of superimposed tonsillitis, the interference with breathing becomes alarming, and obstructive sleep apnea syndrome is nowwell-recog-nized as an important indication for surgery to remove the tonsils and adenoids. Cor pulmonale is seen in children with marked upper respiratory tract obstruction.

Fig. 4.43 Lateral radiograph of tonsils. The tonsils (arrow) and adenoids shown on lateral radiograph, and the soft-tissue shadow helps in assessing the degree of obstruction that the lymphoid tissue may be causing. The lingual tonsil is unusually large in Down's syndrome patients and contributes to their characteristic bulky tongue.

Fig. 4.44 Unilateral tonsil enlargement. A tonsil can be described as "large" when compared with the other tonsil. A conspicuously large tonsil in the absence of acute inflammation is an important finding suggesting either a chronic quinsy or a lymphosarcoma. A persistent and conspicuously large tonsil, therefore, should be removed for histology.

Fig. 4.45 A palate and tonsil carcinoma. This presents as an indurated ulcer rather than a diffuse enlargement, and causes referred ear pain. The biopsy is taken from the ulcer margin.

Keratosis Pharyngeus

Fig. 4.47 Tumors of the deep lobe of the parotid gland causing medical displacement of the tonsil are other more common parapharyngeal swellings, as are chemod-ectomas, neurofibromata, and enlargement of the parapharyngeal lymph nodes.

Fig. 4.46 Simulated tonsil enlargement. A tonsil may appear to be enlarged by medial displacement from a parapharyngeal swelling, and careful examination of the fauces ensures that the correct diagnosis is made. It is possible to biopsy a normal tonsil and realize later that medial displacement is simulating enlargement. In this case, the parapharyngeal mass is an internal carotid aneurysm. This initial diagnosis in Casualty was a quinsy—a dangerous error if followed by incision.

Fig. 4.47 Tumors of the deep lobe of the parotid gland causing medical displacement of the tonsil are other more common parapharyngeal swellings, as are chemod-ectomas, neurofibromata, and enlargement of the parapharyngeal lymph nodes.

Supratonsillar Recess

Fig. 4.48 Supratonsillar cleft. This recess near the superior pole of the tonsil, if large, tends to collect debris. A mass of yellow fetid material can be extruded from the tonsil with pressure; discomfort or halitosis are symptoms with which this condition may present. Tonsillectomy may be necessary. The surgeon, however, must beware of tonsillectomy for halitosis.

Although dental or gastric pathology may cause this symptom (as may a pharyngeal pouch), the symptom may be imagined by the patient, or by another person complaining about the halitosis.

Halitosis Fatty Yellow

Fig. 4.49 Keratosis pharyngeus. Yellow spicules due to hyperkeratinized areas of epithelium are sometimes extensive over the tonsil and lingual tonsil (a). It is usually a chance finding, and it is important in diagnosis to probe the tonsil (b) to be certain that these yellow areas are not exudate. No treatment is required for this condition unless it is associated with tonsillitis.

Fig. 4.49 Keratosis pharyngeus. Yellow spicules due to hyperkeratinized areas of epithelium are sometimes extensive over the tonsil and lingual tonsil (a). It is usually a chance finding, and it is important in diagnosis to probe the tonsil (b) to be certain that these yellow areas are not exudate. No treatment is required for this condition unless it is associated with tonsillitis.

Tonsil Crypt Infection
Fig. 4.50 Tonsillar exudate. Exudate from tonsillar crypts may appear indistinguishable from keratosis pharyngeus, and hence palpation with a probe is necessary.

Fig. 4.51 Retention cysts. These are common on the tonsil and appear as sessile yellow swellings (a). If small they can be ignored, and although symptoms are uncommon, a concern by the patient or a sensation of a lump in the throat may call for surgical removal. Retention cysts are also seen following tonsillectomy in the region of the fauces (b).

Natural Ways To Stop Snoring

Natural Ways To Stop Snoring

Is Snoring Ruining Your Life? Find A Cure For It Today! It's loud, it's disturbing and it's embarrassing during a sleep over. Snoring effects everyone around you and if you are one of the millions of people around the world who suffer from snoring, then you know how negatively it can affect your relationships. People who don't snore don't understand how bad it really is to snore. Going to bed every night knowing that as soon as you coast off into sleep you'll be emitting an annoying and loud sound that'll disturb everyone around you.

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