One hundred fifty-five unselected obstructive sleep apneic patients seen in succession had cephalometric roentgenograms and polygraphic recordings performed. These patients were compared to a group of 41 subjects who had consulted orthodontists for malocclusion and had no clinical indication of sleep apnea. The cephalometric landmarks were also compared to those published as normative data in the literature. The limits of "normalcy" were conservatively defined as mean +/- 2 standard deviations. Only two obstructive sleep apneic patients had normal cephalometric landmarks and 150 of the 155 patients had at least two significantly different landmarks from the normative data in the literature. The common findings were a retroposition of the mandible, a different cranial base flexure with a nasion-sella-basion angle more acute than expected, and a displacement of the hyoid bone to a lower position than expected. These combined changes reduced the space occupied by soft tissues anchored on the skull and mandible, and the length of the soft palate was increased.

Sleep disorders occur in 74-98%

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Complaints of insomnia were inquired about in a questionnaire survey of 6 268 persons (2 801 men, 3 467 women, mean age 50.5 years, range 45-57 years) in 40 different occupational groups. Among bus drivers 18.9 % complained of having rather or very much difficulty falling asleep. Among female cleaners, male teachers, male directors, and male physicians the respective percentages were 18.8, 18.0, 3.7, and 4.9. Disturbed nocturnal sleep was complained of the most often by male laborers (28.1 % waking up at least three times a night), female cleaners (26.6 %) and female hospital aides (26.4 %). Disturbed nocturnal sleep was rare among male physicians (1.6 %), male directors (7.4 %), female head nurses (8.9 To), and female social workers (9.4 %). Complaints of waking up too early in the morning were the most common among female laborers (13.2 % often or always), male construction workers (9.1 %), and female cleaners (8.4 To). They were rare among male physicians (1.6 %), male directors (1.8 Yo), nurses in outpatient wards (1.2 Yo), and female bathers (2.0 '70). Sleeping pills were used the most frequently by male gardeners (7.1 % were frequent or habitual users), female social office workers (5.8 %), and male construction workers (5.4 %). Some aspects of work which could explain the differences are discussed.

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We studied two populations of patients who snored and had frequent nocturnal asthma attacks: ten overweight men presenting with typical obstructive sleep apnoea syndrome, and a group of five adolescents with regular snoring and an increase in negative inspiratory oesophageal pressure during stage II non-rapid eye movement (NREM) and rapid eye movement (REM) sleep. All subjects presented cranio-mandibular abnormalities at cephalometric evaluation, with a narrow space behind the base of the tongue. Both populations were treated with nasal continuous positive airway pressure (CPAP) during sleep. Snoring and partial or complete airway obstruction were eliminated, as were the nocturnal asthma attacks. Two adolescents treated with upper airway surgery after nasal CPAP showed no nocturnal asthma at short-term follow-up. Nasal CPAP had no effect on daytime asthma. One hypothesis is that a subgroup of asthmatic patients with small pharynxes may have enhanced vagal stimulation during sleep compared with other asthmatic patients. This enhancement would be related to the repetitive Muller manoeuvres noted with airway obstruction during sleep. Combined with the local effects of snoring, this extra vagal stimulation would be a precipitating factor in nocturnal asthma attacks.

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