EARS & HEARING
How Come I’m Snoring?
Forty-five percent of normal adults snore at least occasionally and 25 percent are habitual snorers. Problem snoring is more frequent in males and overweight people and usually worsens with age. Snoring may be an indication of obstructed breathing and should not be taken lightly. An otolaryngologist can help you to determine where the anatomic source of your snoring may be, and offer solutions for this noisy and often embarrassing behavior.
The noisy sounds of snoring occur when there is an obstruction to the free flow of air through the passages at the back of the mouth and nose. This area is the collapsible part of the airway where the tongue and upper throat meet the soft palate and uvula. Snoring occurs when these structures strike each other and vibrate during breathing.
In children, snoring is most often associated with enlargement of the tonsils and adenoids. A chronically snoring child should be examined by an otolaryngologist, who may recommend a tonsillectomy and adenoidectomy to return the child to full health.
Poor muscle tone in the tongue and throat can lead to snoring. When muscles are too relaxed, the tongue falls backwards into the airway or the throat muscles virtually collapse. Some relaxation is natural during deep sleep, but may become a problem if exacerbated by alcohol or drugs that cause sleepiness. Other factors that can exacerbate this include enlargement of the tonsils, excessive soft palate tissue, long or fluttering uvula, nasal obstruction causing excess negative pressures in the throat, and weight gain resulting in increased fat relative to muscle in the soft tissues of the throat. Weight loss can improve snoring and OSA especially if it has contributed to the problem to begin with.
Snoring may bother others more than it bothers you but can be bad enough that it not only disturbs others but may lead to their constantly shaking or kicking you leading to your own disrupted sleep. Beyond the social issues and external sleep disruption, snoring can also interfere with your own sleep to a greater or lesser extent and is often associated with obstructive sleep apnea (OSA), a potentially very serious medical condition that can lead to risk of heart attack, stroke, car accidents, and long term breathing problems. When snoring is associated with sleep apnea, there are actual pauses in your breathing that can occur for more than 10 seconds sometimes more than 50 times an hour. These pauses can often be witnessed by somebody who observes your sleep. They may be worse if you sleep on your back. Because this results in drops in oxygen levels in addition to disruption in your sleep pattern, you probably don’t feel well rested, may have morning headaches, may affect your concentration, and ultimately your overall well being.
Snoring can be assessed by an ENT doctor who can examine all parts of your upper airway, evaluate your height, weight, and body mass index, and have you take a sleepiness screen to determine the likelihood of OSA. A polysomnogram or sleep study is the test that is ultimately performed to determine whether you have OSA and, if so, how severe it is.
Treatment of snoring and OSA are highly individualized. This depends on the diagnosis and level(s) of upper airway narrowing. In some cases, more than one area may be involved. Obstructive sleep apnea is most often treated with a device that opens the airway with a small amount of positive pressure. This pressure is delivered via a nasal mask worn during sleep. This treatment is called CPAP; it is currently the initial treatment of choice for patients with moderate to severe OSA.
Uvulopalatopharyngoplasty (UPPP) is surgery for treating snoring and mild obstructive sleep apnea. It removes excess soft palate tissue and opens the airway. In addition, the remaining tissue stiffens as it heals, thereby minimizing tissue vibration. The size of the air passage may be further enlarged when a tonsillectomy is added to the procedure.
Thermal ablation procedures reduce tissue bulk in the nasal turbinates, tongue base, and/or soft palate. These procedures are used for both snoring and OSA. Different methods of thermal ablation include bipolar cautery, laser, and radiofrequency. These procedures may be done in the operating room or during an office visit. Several treatments may be required.
Methods to increase the stiffness of the soft palate without removing tissue include injecting an irritating substance that causes stiffness in the injected area near the uvula. Another method is inserting stiffening rods (Pillar implants) into the soft palate.
Genioglossus and hyoid advancement is a surgical procedure for the treatment of sleep apnea. It prevents collapse of the lower throat and pulls the tongue muscles forward, thereby opening the obstructed airway.
A custom-fit oral appliance, which repositions the lower jaw forward, may also be considered for certain patients with snoring/ OSA. This should be fitted by an otolaryngologist, dentist, or oral surgeon with expertise in sleep dentistry.
Some things that should be considered, particularly in milder snoring, include adoption of a healthy and athletic lifestyle to develop good muscle tone and lose weight. Avoiding tranquilizers, sleeping pills, and antihistamines before bedtime may reduce sleep phases that are associated with snoring. In addition, alcohol and heavy meals or snacks should be limited for several hours before bedtime. Because snoring is highly positional, sleeping on your side rather than your back will often decrease the snoring; use a pillow designed to help you maintain this position. Some examples are available on www.sleep-apnea-guide.com.
The most common and effective nonsurgical treatment for sleep apnea is Continuous Positive Airway Pressure or CPAP which is applied through a nasal or facial mask while you sleep. The CPAP device does not breathe for you. Instead, it creates a flow of air pressure when you inhale that is strong enough to keep your airway passages open. Once your otolaryngologist determines that CPAP is the right treatment, you will need to wear the CPAP mask every night. CPAP is the most effective means of treating snoring and sleep apnea. It keeps airway passages open which prevents pauses in breathing and helps you to get better sleep. This, in turn, reduces daytime sleepiness, fatigue and other sleep apnea related health problems such as high blood pressure, heart disease, diabetes, and stroke.
While CPAP is considered the gold standard treatment for OSA, it needs to be used every night. Some patients complain of mask discomfort, nasal congestion, and nose and throat dryness when using CPAP. Others find the device to be too constrictive and cumbersome, particularly when traveling. Unfortunately, these complaints sometimes lead to inconsistent use or abandonment of the device altogether. Proper mask fitting and use of a humidifier can resolve these issues.