§ 呼吸通不了,竟然是舌根惹的禍!
打鼾與睡眠呼吸中止症的發生,肇因於上呼吸道塌陷阻塞,使得呼吸氣流受阻。在上呼吸道各部位中,又以舌根(tongue base)的影響最為關鍵。(註1-10)
舌根的體積與動態,決定上呼吸道的通暢度。當舌根太厚胖、舌根肌肉疲乏失去支撐力時,整個舌頭就容易往後墜,壓迫或堵塞上呼吸道。尤其當仰睡時,舌頭就更容易因為地心引力而貼近呼吸道,增加打鼾與睡眠呼吸中止發生的機率。根據研究,★高達70%睡眠呼吸中止症的患者,上呼吸道發生阻塞的部位,就在舌根(註11,12)。
§ 學者與醫師共識:睡眠呼吸中止,優先處理舌根問題!
由於舌根是導致打鼾與睡眠呼吸中止的關鍵部位,該如何防止舌根後墜、增加舌根肌肉收縮力、改變舌根的型態,是目前治療睡眠呼吸中止症的重點。根據研究,若處理舌根後墜問題,治療睡眠呼吸中止的成功率可高達75%~83%。(註13)
以手術來說,目前採用的方法包括:割除或燒灼舌根部分肌肉、頦舌肌前置、舌根懸吊等(註14,15),目的在透過縮小舌根肌肉、將舌根前拉或牽制,以維持上呼吸道通暢。然而,關於需要縮小多少舌根體積才能達到效果?目前尚未有一標準原則,再加上舌根神經複雜交錯,多對腦神經皆分佈於舌下,有誤傷神經的風險。在考量安全性的立場下,選擇非侵入性的口內裝置,於是成為患者首先考慮的治療方法。
 
 
 
 
§ 全都叫「牙套」,原理大不同:下顎前拉 V.S. 垂直壓舌
綜觀目前治療打鼾與睡眠呼吸中止的口內裝置,結構特色主要有三種:一是將下顎往前固定的「下顎前拉式」(Mandibular Advancement Devices, MAD)牙套;二是將舌頭拉住固定的「持舌器」(Tongue Retaining Device, TRD);三是從舌根部位壓住舌頭的「壓舌器」(Oral Pressure Therapy, OPT)。
目前90%以上的止鼾牙套,都屬第一種結構特色「下顎前拉式」牙套。
這款牙套的設計概念,認為舌根肌肉與下顎依附在一起,藉由下顎往前拉的動作,連帶讓舌根肌肉前移,以擴大口咽吞嚥部位呼吸道的空間。因此,配戴這款「下顎前拉式」牙套,樣貌會類似於「戽斗」一般,下顎的位置會前凸於上顎。根據臨床研究,此款牙套設計原理,雖然可以改變舌根位置,避免舌頭後墜,但長期配戴後,由於上下顎咬合位置不正,會產生顳顎關節疼痛、咬合變成開咬(Openbite, 戽斗)的副作用。
研究指出,這種強制將下顎前拉的動作,由於會導致患者咬合障礙,患者會因為咬合適應不良、顳顎關節不適的問題,暫停配戴治療。(註16, 17, 18, 19)
為了修正咬合不正的問題,但同時仍可達到防止舌根後墜的功能,口內裝置的設計因而轉向直接穩定舌頭位置:「持舌器」與「壓舌器」。
這兩款口內裝置的設計原理,都沒有將下顎往前拉,而是直接對舌頭施力:一是將舌頭往前固定住,另是將舌根往下壓住,藉此穩定舌根肌肉位置,提升舌根肌力,來維持口咽部呼吸道的通暢度。
有研究顯示,呼吸道擴張的空間,「持舌」比「下顎前拉」的效果更好。(註20, 21)此外,由於配戴時,上下顎是輕鬆垂直咬住,並未有咬合錯位的問題,因此適應上比「下顎前拉式」牙套舒服許多,也不會產生顳顎關節疼痛、咬合障礙的副作用。
根據近年臨床研究,「持舌器」具有改善睡眠呼吸中止、降低驚醒頻率、降低嗜睡問卷總分、提升血氧的成效!(註22, 23, 24)成功率與「下顎前拉式」牙套相近。(註25, 26)「壓舌器」對睡眠呼吸中止的改善率,也有高達73%與超過50%的顯著有效表現(註27, 28, 29, 30, 31)。
這些科學性數據可支持,就算沒有採用將下顎往前拉的設計,改採拉住或壓住舌根的結構特色,依舊可以達到降低睡眠呼吸中止指數與睡眠障礙指數的效果,並且降低配戴的副作用、提升安全性。
§ 壓住舌頭,是否真能改善睡眠呼吸中止?
在美國FDA公告已核准上市的止鼾器中,已經有兩款採用「壓住舌頭」的原理,分別為「Full Breath Solution」,以及「WINX」。
研究證明,採用「壓舌」原理的牙套,能成功維持呼吸道的通暢度,並大幅降低睡眠呼吸中止症的發生。
對配戴者來說,壓舌,是一個嶄新的選擇:終於,不用再忍受「下巴往前拉」的錯位感,可以用最自然的咬合方式,維持舌根的張力,防止舌根後墜阻擋呼吸道。

New Single-Arch Sleep Appliance Therapy | Dentistry Today

 

Full Breath Solution (斜凸的結構乃用來壓舌)

【上圖】無壓舌,舌頭無力往後倒,甚至壓迫到懸雍垂,導致呼吸道變得非常窄。

【下圖】壓舌後,懸雍垂位置正常無被壓迫,呼吸道空間變大。

 

【上圖】無壓舌,呼吸道空間窄。【下圖】壓舌後,呼吸道空間變大。

「Full Breath Solution」的研究論文
★ Singh GD, Keropian B, Pillar G., Effects of the full breath solution appliance for the treatment of obstructive sleep apnea: a preliminary study, Cranio. 2009 Apr;27(2):109-17.
★ Keropian B., New single-arch sleep appliance therapy, Dent Today. 2009 Oct;28(10):136, 138-9.

WINX

(紅色為舌頭,藍色為呼吸道)

【X光片上圖與A,C圖】無壓舌,舌頭無力往後倒,甚至壓迫到懸雍垂,導致呼吸道變得非常窄。【X光片下圖與B,D圖】壓舌後,懸雍垂位置正常無被壓迫,呼吸道空間變大。

 
「WINX」的研究論文
★ Girdhar A, Berry RB, Ryals S, Beck E, Wagner M. A young man running out of treatment options. J Clin Sleep Med 2015;11(10)1239–1242.
★ Schwab RJ, Kim C, Siegel L, Keenan BT, Black J, Farid-Moayer M, Podmore J, Vaska M., Examining the mechanism of action of a new device using oral pressure therapy for the treatment of obstructive sleep apnea, Sleep. 2014 Jul 1;37(7): 1237-47.
★ Farid-Moayer M, Siegel LC, Black J., Oral pressure therapy for treatment of obstructive sleep apnea: clinical feasibility, Nat Sci Sleep. 2013 May 14;5:53-9.
★ Ian M. Colrain, Jed Black, Lawrence C. Siegel, Richard K. Bogan, Philip M. Becker, Mehran Farid-Moayer, Rochelle Goldberg, D. Alan Lankford, Andrew N. Goldberg, Atul Malhotra, A multicenter evaluation of oral pressure therapy for the treatment of obstructive sleep apnea, Sleep Med. 2013 Sep; 14(9): 830–837.
 
§ § 長話短說之總結:
I. 舌根是管控呼吸道通暢度,最重要的肌肉。管好舌根,就能有效降低睡眠呼吸中止正的發生。
II. 穩定舌根的方法:靠手術切除肥厚,或是戴牙套壓住。
III. 傳統下顎前拉式牙套的限制:咬合錯位,就算把下顎往前拉,仰睡時舌頭還是沒有支撐力,會往後倒。
IV. 壓舌的好處:不用改變咬合位置,垂直抵壓舌根。如果壓舌能壓得深、持續壓,甚至可以強化舌根肌肉,讓舌頭變得更結實,直接鍛鍊舌根!
§ § 睡眠呼吸不中止的好方法:
★一定要鍛鍊舌頭:靠自己勤練習出力頂舌頭,或者靠用具持續性地壓舌。日間就要開始鍛鍊!晚上才開始練,都已經要睡了,就來不及了。
★一定要閉上嘴巴:人多半都用仰睡,如果睡覺時嘴巴鬆開,舌頭往後癱的機率就更高!睡覺時拿嬰兒用的膠帶,抿嘴貼住嘴巴,嘴巴周邊與口內的肌肉張力會提升,舌頭會比較穩,降低後癱的可能性。或者,可以考慮止鼾頭套,把下巴往上提拉、防止嘴巴鬆開。
 
★★本文乃林彥璋醫師與無恙團隊撰著,版權所有,引用請註明出處。
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註31. Ian M. Colrain, Jed Black, Lawrence C. Siegel, Richard K. Bogan, Philip M. Becker, Mehran Farid-Moayer, Rochelle Goldberg, D. Alan Lankford, Andrew N. Goldberg, Atul Malhotra, A multicenter evaluation of oral pressure therapy for the treatment of obstructive sleep apnea, Sleep Med. 2013 Sep; 14(9): 830–837.

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