Snoring

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Snoring
Specialty Otorhinolaryngology, sleep medicine

Snoring is the vibration of respiratory structures and the resulting sound due to obstructed air movement during breathing while sleeping. The sound may be soft or loud and unpleasant. Snoring during sleep may be a sign, or first alarm, of obstructive sleep apnea (OSA). Research suggests that snoring is one of the factors of sleep deprivation.

Contents

Video of a pig snoring

Causes

Snoring is the result of the relaxation of the uvula and soft palate. [1] These tissues can relax enough to partially block the airway, resulting in irregular airflow and vibrations. [2] Snoring can be attributed to one or more of the following:

Possible consequences

Snoring is known to cause sleep deprivation to snorers and those around them, as well as daytime drowsiness, irritability, lack of focus and decreased libido. [6] It has also been suggested that it can cause significant psychological and social damage to those affected. [7] A 2008 study shows a positive correlation between loud snoring and the risk of heart attack (about +34% chance) and stroke (about +67% chance). [8] A 2021 meta-analysis reports up to a 46% increased risk of stroke. [9]

Though snoring is often considered a minor condition, snorers can sometimes experience severe impairment of lifestyle. The between-subjects trial by Armstrong et al. discovered a statistically significant improvement in marital relations after snoring was surgically corrected. This was confirmed by evidence from Gall et al., [10] Cartwright and Knight [11] and Fitzpatrick et al. [12]

Studies have associated loud snoring with the development of carotid artery atherosclerosis. [13] Amatoury et al. [14] demonstrated that snoring vibrations are transmitted to the carotid artery, identifying a possible mechanism for snoring-associated carotid artery damage and atherosclerotic plaque development. These researchers also found amplification of the snoring energy within the carotid lumen at certain frequencies, adding to this scenario. Vibration of the carotid artery with snoring also lends itself as a potential mechanism for atherosclerotic plaque rupture and consequently ischemic stroke. [14] Researchers also hypothesize that loud snoring could create turbulence in carotid artery blood flow. [15] Generally speaking, increased turbulence irritates blood cells and has previously been implicated as a cause of atherosclerosis. While there is plausibility and initial evidence to support snoring as an independent source of carotid artery/cardiovascular disease, additional research is required to further clarify this hypothesis. [16]

Treatment

So far, there is no certain treatment that can completely stop snoring. Almost all treatments for snoring revolve around lessening the breathing discomfort by clearing the blockage in the air passage. Medications are usually not helpful in treating snoring symptoms, though they can help control some of the underlying causes such as nasal congestion and allergic reactions. Doctors, therefore, often recommend lifestyle changes as a first-line treatment to stop snoring. [17] This is the reason snorers are advised to lose weight (to stop fat from pressing on the throat), stop smoking (smoking weakens and clogs the throat), avoid alcohol and sedative medications before bedtime (they relax the throat and tongue muscles, which in turn narrow the airways) [18] and sleep on their side (to prevent the tongue from blocking the throat).

A number of other treatment options are also used to stop snoring. These range from over-the-counter aids such as nasal sprays, nasal strips or nose clips, lubricating sprays, oral appliances and "anti-snore" clothing and pillows, to unusual activities such as playing the didgeridoo. [19] [ unreliable medical source ] Many over-the-counter snoring treatments, such as stop-snoring rings or wrist-worn electrical stimulation bands, have no scientific evidence to support their claims.

Tongue exercises

Myofunctional therapy, which incorporates oropharyngeal and tongue exercises, reduces snoring in adults based on both subjective questionnaires and objective sleep studies. Snoring intensity was reduced by 51%. [20]

Orthopedic pillows

Orthopedic pillows are the least intrusive option for reducing snoring. These pillows are designed to support the head and neck in a way that ensures the jaw stays open and slightly forward. This helps keep the airways unrestricted as possible and in turn leads to a small reduction in snoring.

Dental appliances

One style of mandibular advancement splint Avance mandibular.jpg
One style of mandibular advancement splint

Specially made dental appliances called mandibular advancement splints, which advance the lower jaw slightly and thereby pull the tongue forward, are a common mode of treatment for snoring. Such appliances have been proven to be effective in reducing snoring and sleep apnea in cases where the apnea is mild to moderate. [21] Mandibular advancement splints are often tolerated much better than CPAP machines. [22]

Positive airway pressure

A continuous positive airway pressure (CPAP) machine is often used to control sleep apnea and the snoring associated with it. It is a relatively safe medical treatment. To keep the airway open, a device pumps a controlled stream of air through a flexible hose to a mask worn over the nose, mouth, or both. [23] A CPAP is usually applied through a CPAP mask which is placed over the nose and/or mouth. The air pressure required to keep the airway open is delivered through this and it is attached to a CPAP machine which is like an air compressor.

The air that CPAP delivers is generally "normal air"—not concentrated oxygen. The machine utilizes the air pressure as an "air splint" to keep the airway open. In obstructive sleep apnea, the airway at the rear of the throat is prone to closure.

Surgery

Surgery is also available as a method of correcting social snoring. Some procedures, such as uvulopalatopharyngoplasty, attempt to widen the airway by removing tissues in the back of the throat, including the uvula and pharynx. These surgeries are quite invasive, however, and there are risks of adverse side effects. The most dangerous risk is that enough scar tissue could form within the throat as a result of the incisions to make the airway more narrow than it was prior to surgery, diminishing the airspace in the velopharynx. Scarring is an individual trait, so it is difficult for a surgeon to predict how much a person might be predisposed to scarring. Currently, the American Medical Association does not approve of the use of lasers to perform operations on the pharynx or uvula.

Radiofrequency ablation (RFA) is a relatively new surgical treatment for snoring. This treatment applies radiofrequency energy and heat (between 77 °C and 85 °C) to the soft tissue at the back of the throat, such as the soft palate and uvula, causing scarring of the tissue beneath the skin. After healing, this results in stiffening of the treated area. The procedure takes less than one hour, is usually performed on an outpatient basis, and usually requires several treatment sessions. Radiofrequency ablation is frequently effective in reducing the severity of snoring, but often does not eliminate it. [24] [ unreliable medical source ]

Bipolar radiofrequency ablation, a technique used for coblation tonsillectomy, is also used for the treatment of snoring.

Pillar procedure

The pillar procedure is a minimally invasive treatment for snoring and obstructive sleep apnea. In the United States, this procedure was FDA indicated in 2004. During this procedure, three to six+ Dacron (the material used in permanent sutures) strips are inserted into the soft palate, using a modified syringe and local anesthetic. While the procedure was initially approved for the insertion of three "pillars" into the soft palate, it was found that there was a significant dosage response to more pillars, with appropriate candidates.[ citation needed ] As a result of this outpatient operation, which typically lasts no more than 30 minutes, the soft palate is more rigid, possibly reducing instances of sleep apnea and snoring. This procedure addresses one of the most common causes of snoring and sleep apnea—vibration or collapse of the soft palate (the soft part of the roof of the mouth). If there are other factors contributing to snoring or sleep apnea, such as conditions of the nasal airway or an enlarged tongue, it will likely need to be combined with other treatments to be more effective. [25]

Epidemiology

Statistics on snoring are often contradictory, but at least 30% of adults and perhaps as many as 50% of people in some demographics snore. [26] One survey of 5,713 American residents identified habitual snoring in 24% of men and 13.8% of women, rising to 60% of men and 40% of women aged 60 to 65 years; this suggests an increased susceptibility to snoring with age. [27]

An observational study in the UK Biobank estimated that ~37% of 408,317 participants were habitual snorers, and confirmed positive associations with larger body-mass index, lower socio-economic status and more frequent smoking and alcohol consumption. [3]

Related Research Articles

<span class="mw-page-title-main">Sleep apnea</span> Disorder involving pauses in breathing during sleep

Sleep apnea is a sleep-related breathing disorder in which repetitive pauses in breathing, periods of shallow breathing, or collapse of the upper airway during sleep results in poor ventilation and sleep disruption. Each pause in breathing can last for a few seconds to a few minutes and occurs many times a night. A choking or snorting sound may occur as breathing resumes. Common symptoms include daytime sleepiness, snoring, and non restorative sleep despite adequate sleep time. Because the disorder disrupts normal sleep, those affected may experience sleepiness or feel tired during the day. It is often a chronic condition.

<span class="mw-page-title-main">Uvula</span> Fleshy appendage that hangs from the back of the palate

The uvula, also known as the palatine uvula, is a conic projection from the back edge of the middle of the soft palate, composed of connective tissue containing a number of racemose glands, and some muscular fibers. It also contains many serous glands, which produce thin saliva. It is only found in humans.

<span class="mw-page-title-main">Obesity hypoventilation syndrome</span> Condition in which severely overweight people fail to breathe rapidly or deeply enough

Obesity hypoventilation syndrome (OHS) is a condition in which severely overweight people fail to breathe rapidly or deeply enough, resulting in low oxygen levels and high blood carbon dioxide (CO2) levels. The syndrome is often associated with obstructive sleep apnea (OSA), which causes periods of absent or reduced breathing in sleep, resulting in many partial awakenings during the night and sleepiness during the day. The disease puts strain on the heart, which may lead to heart failure and leg swelling.

<span class="mw-page-title-main">Positive airway pressure</span> Mechanical ventilation in which airway pressure is always above atmospheric pressure

Positive airway pressure (PAP) is a mode of respiratory ventilation used in the treatment of sleep apnea. PAP ventilation is also commonly used for those who are critically ill in hospital with respiratory failure, in newborn infants (neonates), and for the prevention and treatment of atelectasis in patients with difficulty taking deep breaths. In these patients, PAP ventilation can prevent the need for tracheal intubation, or allow earlier extubation. Sometimes patients with neuromuscular diseases use this variety of ventilation as well. CPAP is an acronym for "continuous positive airway pressure", which was developed by Dr. George Gregory and colleagues in the neonatal intensive care unit at the University of California, San Francisco. A variation of the PAP system was developed by Professor Colin Sullivan at Royal Prince Alfred Hospital in Sydney, Australia, in 1981.

Upper airway resistance syndrome (UARS) is a sleep disorder characterized by the narrowing of the airway that can cause disruptions to sleep. The symptoms include unrefreshing sleep, fatigue, sleepiness, chronic insomnia, and difficulty concentrating. UARS can be diagnosed by polysomnograms capable of detecting Respiratory Effort-related Arousals. It can be treated with lifestyle changes, functional orthodontics, surgery, mandibular repositioning devices or CPAP therapy. UARS is considered a variant of sleep apnea, although some scientists and doctors believe it to be a distinct disorder.

<span class="mw-page-title-main">Mandibular advancement splint</span>

A mandibi splint or mandibi advancement splint is a prescription custom-made medical device worn in the mouth used to treat sleep-related breathing disorders including: obstructive sleep apnea (OSA), snoring, and TMJ disorders. These devices are also known as mandibular advancement devices, sleep apnea oral appliances, oral airway dilators, and sleep apnea mouth guards.

<span class="mw-page-title-main">Obstructive sleep apnea</span> Sleeping and breathing disorder

Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder and is characterized by recurrent episodes of complete or partial obstruction of the upper airway leading to reduced or absent breathing during sleep. These episodes are termed "apneas" with complete or near-complete cessation of breathing, or "hypopneas" when the reduction in breathing is partial. In either case, a fall in blood oxygen saturation, a disruption in sleep, or both, may result. A high frequency of apneas or hypopneas during sleep may interfere with the quality of sleep, which – in combination with disturbances in blood oxygenation – is thought to contribute to negative consequences to health and quality of life. The terms obstructive sleep apnea syndrome (OSAS) or obstructive sleep apnea–hypopnea syndrome (OSAHS) may be used to refer to OSA when it is associated with symptoms during the daytime.

<span class="mw-page-title-main">Uvulopalatopharyngoplasty</span> Surgical procedure

Uvulopalatopharyngoplasty is a surgical procedure or sleep surgery used to remove tissue and/or remodel tissue in the throat. This could be because of sleep issues. Tissues which may typically be removed include:

Hypopnea is overly shallow breathing or an abnormally low respiratory rate. Hypopnea is defined by some to be less severe than apnea, while other researchers have discovered hypopnea to have a "similar if not indistinguishable impact" on the negative outcomes of sleep breathing disorders. In sleep clinics, obstructive sleep apnea syndrome or obstructive sleep apnea–hypopnea syndrome is normally diagnosed based on the frequent presence of apneas and/or hypopneas rather than differentiating between the two phenomena. Hypopnea is typically defined by a decreased amount of air movement into the lungs and can cause oxygen levels in the blood to drop. It commonly is due to partial obstruction of the upper airway.

Somnoplasty is a trademark by Somnus Medical Technologies used for its radiofrequency ablation medical devices cleared by the Food and Drug Administration (FDA) to treat habitual snoring, chronic nasal obstruction, and obstructive sleep apnea (OSA) to shrink the tissues that are causing obstruction. Somnoplasty is typically an outpatient procedure that takes 30–45 minutes.

When we sleep, our breathing changes due to normal biological processes that affect both our respiratory and muscular systems.

<span class="mw-page-title-main">Continuous positive airway pressure</span> Form of ventilator which applies mild air pressure continuously to keep airways open

Continuous positive airway pressure (CPAP) is a form of positive airway pressure (PAP) ventilation in which a constant level of pressure greater than atmospheric pressure is continuously applied to the upper respiratory tract of a person. The application of positive pressure may be intended to prevent upper airway collapse, as occurs in obstructive sleep apnea, or to reduce the work of breathing in conditions such as acute decompensated heart failure. CPAP therapy is highly effective for managing obstructive sleep apnea. Compliance and acceptance of use of CPAP therapy can be a limiting factor, with 8% of people stopping use after the first night and 50% within the first year.

<span class="mw-page-title-main">Catathrenia</span> Sleep-related breathing disorder

Catathrenia or nocturnal groaning is a sleep-related breathing disorder, consisting of end-inspiratory apnea and expiratory groaning during sleep. It describes a rare condition characterized by monotonous, irregular groans while sleeping. Catathrenia begins with a deep inspiration. The person with catathrenia holds her or his breath against a closed glottis, similar to the Valsalva maneuver. Expiration can be slow and accompanied by sound caused by vibration of the vocal cords or a simple rapid exhalation. Despite a slower breathing rate, no oxygen desaturation usually occurs. The moaning sound is usually not noticed by the person producing the sound, but it can be extremely disturbing to sleep partners. It appears more often during expiration REM sleep than in NREM sleep.

Uvulopalatoplasty is a surgical procedure performed with the aim of reducing or eliminating snoring. It is an out-patient procedure, in which a laser is used to remove parts or all of the uvula at the rear of the mouth. The surgery usually requires three to five visits, with each lasting less than 30 minutes. It is performed with the patient awake under local anesthesia, and normal functions can be resumed after the operation. An LAUP procedure typically costs between two and three thousand American dollars. The principal side effect is a severe sore throat which can last from 7 – 10 days. Speaking is not usually affected. Typically a CO2 type laser is used.

<span class="mw-page-title-main">Hypernasal speech</span> Medical condition

Hypernasal speech is a disorder that causes abnormal resonance in a human's voice due to increased airflow through the nose during speech. It is caused by an open nasal cavity resulting from an incomplete closure of the soft palate and/or velopharyngeal sphincter. In normal speech, nasality is referred to as nasalization and is a linguistic category that can apply to vowels or consonants in a specific language. The primary underlying physical variable determining the degree of nasality in normal speech is the opening and closing of a velopharyngeal passage way between the oral vocal tract and the nasal vocal tract. In the normal vocal tract anatomy, this opening is controlled by lowering and raising the velum or soft palate, to open or close, respectively, the velopharyngeal passageway.

Nasal expiratory positive airway pressure is a treatment for obstructive sleep apnea (OSA) and snoring.

A sleep-related breathing disorder is a sleep disorder in which abnormalities in breathing occur during sleep that may or may not be present while awake. According to the International Classification of Sleep Disorders, sleep-related breathing disorders are classified as follows:

Sleep surgery is a surgery performed to treat sleep disordered breathing. Sleep disordered breathing is a spectrum of disorders that includes snoring, upper airway resistance syndrome, and obstructive sleep apnea. These surgeries are performed by surgeons trained in otolaryngology, oral maxillofacial surgery, and craniofacial surgery.

TransOral Robotic Surgery (TORS) is a modern surgical technique used to treat tumors of the mouth and throat via direct access through the mouth. TransOral Robotic Sleep Apnea (TORSA) surgery utilizes the same approach to open the upper airway of patients with obstructive sleep apnea. In TORS and TORSA procedures, the surgeon uses a surgical robot to view and access structures in the oral cavity (mouth) and pharynx (back of the throat) without any incisions through the neck, chin or lip (these incisions are necessary in traditional, non-robotic approaches). Current TORS techniques include radical tonsillectomy, resection of palate and base of skull tumors, hemiglossectomy and resection of tumors above and involving the larynx. The TORSA technique is used for uvulopalatopharyngoplasty, hemiglossectomy, and other airway procedures.

An elongated soft palate is a congenital hereditary disorder that negatively affect dogs and cats' breathing and eating. A soft palate is considered elongated when it extends past the top of the epiglottis and/or past the middle of the tonsillar crypts. The soft palate is made up of muscle and connective tissue located in the posterior portion on the roof of the mouth. The soft palate creates a barrier between the mouth and nose. This continuation between the cavities makes it possible to chew and breathe at the same time. The soft palate only blocks the nasal cavity while swallowing. At rest the soft palate should only stretch caudally from the hard palate to the tip of the epiglottis leaving an opening between the nasal and oral cavities. When the soft palate is elongated, it partially blocks the throat thereby creating breathing and feeding-related issues. The elongation and other accompanying symptoms occur in breeds characterized with “smooshed faces” such as pugs, bulldogs, and Persian cats. This condition is a congenital, meaning it is present when the animal is born. The “smooshed” characteristics is the result of a genetic mutation. The animal’s genetic code causes the bones in their skull to grow to a smaller size. Because the bones are smaller, muscles and other tissues that surround the bones of the skull are out of proportion. These animals are often referred to as brachycephalic, derived from the Greek words for “short” and “head”. An elongated soft palate is a symptom of Brachycephalic Obstructive Airway Syndrome (BOAS) and is common in brachycephalic dog breeds and has been reported in brachycephalic cat breeds as well. Some of the other BOAS related symptoms include stenotic nares, everted laryngeal saccules, and laryngeal collapse.

References

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