Impact of Snoring
Snoring occurs when air flows in a choppy, turbulent fashion. This turbulence causes the tissues of the oral and nasal airway to vibrate and to create the unpleasant sound of snoring. Snoring is common and affects about 50% of adults; over 45 million American men and women across all age groups. It has been well-documented that snoring impacts personal relationships – in one study, 46% of respondents admitting that they sleep in separate bedrooms as a result of snoring. Respondents reported that snoring led to irritability (47%), arguments (36%), and had impacted their sexual relationships (17%). Some respondents stated that snoring had led to their divorce. Others noted that snoring had led to poor sleep (72%), and had impacted their ability to work effectively (38%). Fortunately, many of the ill effects of snoring seem to improve with treatment. One study of 10 married couples performed at the Mayo Clinic found that the bed-partner of the snoring patient gained an additional 74% to 87% of sleep per night after their partner’s snoring was corrected.
In addition to these lifestyle challenges, patients who snore have been shown to have increased rates of high blood pressure when compared to patients who do not snore. Some studies have documented a positive correlation between loud snoring and the risk of heart attack and stroke. Other studies have found that women who snore (with or without sleep apnea) have higher rates of diabetes mellitus. This is of particular concern, as diabetes is strongly related to cardiovascular disease and early death. Fortunately, there is some evidence that in diabetic patients with sleep apnea, diabetic parameters improve when patients’ sleep apnea is brought under control.
When snoring occurs in children, they should be observed for related symptoms of drowsiness, poor concentration, and congestion, to name a few. It has been suggested that snoring may even be associated with disruption of primary physiological activity in children, as one study found a direct relationship between primary snoring and elevated blood pressure in children. Other studies have found links between childhood snoring and diminished academic performance in primary school children. Suggestions have been made that children with routine, habitual snoring should be screened routinely for hypertension, and academic performance.
Anatomy of Snoring
As noted above, snoring occurs when the soft tissues of the upper airway vibrate due to turbulent airflow. This turbulence may occur at the level of the nose, mouth, or throat (Figure 1). In the nasal airway, a deviated septum (Figures 2 and 3), enlarged inferior turbinates (Figure 4), or nasal valve collapse may all lead to irregular and choppy airflow. Further back in the nasal airway, enlarged adenoids may also block the air entering the nose. When air flows in through the mouth, it may experience obstruction due to an enlarged tongue, a long soft palate or uvula, or enlarged tonsils. In some cases, the tongue, palate, uvula and tonsils are all normal in size, but are crowded and collapse in the oral airway as a result of a smaller than usual jaw (or mandible). Further down in the neck, excess soft tissue in patients with a “thick” neck may lead to blockage and turbulence.
Snoring and Sleep Apnea
Not all patients who snore have obstructive sleep apnea (OSA), but most patients with obstructive sleep apnea do snore. These 2 diagnoses – snoring, obstructive sleep apnea – both result from anatomical blockage at the same sites, so evaluation of snoring should include questions to see if OSA is also present.
Treatment for Snoring
It sometimes seems like there is a new “snoring solution” with a guarantee of a cure that appears on the radio, or in convenience stores on a weekly basis. These aggressively marketed anti-snoring “cures” rarely come with supporting scientific data, trials, or evidence to back up their bold claims. As noted above, snoring is a by-product of turbulent airflow and patients are well-served by a methodical, investigative approach to identify the source of obstruction.
As previously discussed, snoring significantly impacts a patient’s social and personal life, as well as medical health. Fortunately, effective treatments are available for snoring. A brief overview of some treatments follows, but treatment decisions should be addressed with your ear, nose and throat physician so that the treatment choice is appropriately tailored to your individual anatomy.
In many patients, snoring is associated with weight gain. Weight gain leads to increased soft tissue in the neck which relaxes at night and causes obstruction and turbulence. While weight loss often requires significant effort and discipline – usually involving both dietary modification and an exercise regimen – it is sometimes the most effective treatment for patients with new onset snoring. Weight gain is associated with multiple other health issues – high blood pressure, high cholesterol, diabetes, to name a few – and it may be beneficial to have a Primary Care doctor evaluate for these co-morbidities and to make suggestions for a weight loss regimen that will lead to long-term success.
In some cases, the turbulent airflow leading to snoring may be simply a result of swollen airway tissues from seasonal or inhalational allergies. Many physicians will prescribe a simple trial of allergy medications as a starting point for snoring treatment. These medications – oral antihistamines (ie-Claritin, Allegra, Zyrtec, Xyzal), nasal antihistamine sprays (ie-Azelastine, Olapatadine), nasal steroid sprays (ie-Fluticasone, Budesonide, etc) – may decongest patients enoigh for air to flow in a smooth, laminar fashion leading to a reduction in snoring. When this treatment is successful, further allergy evaluation is often recommended as a means to identify the offending allergen(s) and possibly lead to further treatment options such as allergy immunotherapy for long-term management.
When the nasal airway contributes to snoring, treatment options include straightening the deviated septum, shrinking the enlarged inferior turbinates, repairing the nasal valve collapse, or removing the enlarged adenoids. These procedures may be performed in the office or in the operating room depending on several factors, including the severity and location of the blockage.
When the oral airway is involved in snoring, treatments include a variety of procedures to address the tongue base, soft palate, tonsils, uvula, or smaller-than-usual mandible. An oral appliance may be recommended as a simple, non-invasive treatment to bring the jaw forward thereby preventing the tongue from falling back in the throat and blocking airflow. . An oral appliance is a plastic (or acrylic) device much like a mouth-guard [FIGURE 5]. By moving the lower jaw (mandible) forward, the appliance decreases the likelihood of the oral soft tissues collapsing and obstructing the airway. It is this obstruction that may contribute to snoring and OSA. While oral appliances are an effective solution for a variety of patients, many find it difficult to sleep through the night with the appliance in place.
Like all such interventional devices, oral appliances do have associated risks and complications. These complications should be discussed with the physician, dentist, or oral surgeon fitting your appliance, but can include TMJ (temporomandibular joint) pain, myofascial pain, dental/tooth pain, tongue pain, dry mouth, gum irritation, severe gagging, excessive salivation, occlusal/bite changes, and TM joint sounds.
Ablative procedures to remove tissues in the oral airway are typically avoided for the treatment of snoring alone, as these procedures can have a significant post-operative recovery period. In their place, several office-based procedures are available for treatment of the oral airway in patients who snore. The Pillar Procedure, for example, is performed under local anesthesia and takes around 20-30 minutes to perform in the office setting with most patients. By placing small implants into the soft-palate, tissue vibration diminishes leading to snoring reduction. Several studies have shown a significant decrease in snoring intensity with associated decreases in daytime sleepiness and significant improvements in lifestyle in patients who underwent the Pillar Procedure. Other studies have demonstrated patient and bed-partner satisfaction with the reduction in snoring after the Pillar Procedure at 80% or higher. RadioFrequency Ablation (RFA) is another office-based procedure designed to stiffen the soft palate and reduce tissue vibration and snoring. Like the Pillar Procedure, RFA of the soft-palate is typically performed as an office-based procedure using local anesthetic.
In some cases, ablative procedures may be considered for the treatment of snoring. These procedures, such as tonsillectomy, uvulectomy, uvulapalatopharyngoplasty (UPPP) are discussed in greater detail in the Sleep Apnea Surgery section of this site.
In summary, snoring is a common problem experienced by patients of all ages. Fortunately, many treatment options are available but should be approached in a methodical, data-driven fashion that focuses on treatment of the anatomical site most involved.
When we breathe (inhale and exhale) air flows in a smooth, laminar manner. Obstructions that occur along this pathway result in irregular, turbulent air movement. Air turbulence is often accompanied by loud vibrations of the upper airway structures – a sound we call snoring.
Snoring is commonly associated with abnormalities of the soft palate or uvula. An overly long or floppy soft palate may vibrate irregularly with airflow. Other sources may also contribute to snoring and, for this reason, careful and complete evaluation is imperative in order to direct effective treatment. Nasal sources (deviated septum, inferior turbinate hypertrophy, polyps, chronic and allergic nasal congestion), nasopharyngeal sources (enlarged adenoids and nasopharyngeal growths) oral sources (enlarged tongue base, small jaw, enlarged uvula or tonsils), and throat and neck sources (floppy neck soft tissues) may all contribute to snoring.
Snoring is widespread, and is believed to affect as many as 50% of adults including both men and women; over 45 million Americans. In one 2006 survey of over 2,000 British couples, 56% of respondents admitted that they snored (70% of men admitted to snoring; 40% of women admitted to snoring). 30% of the respondents stated that their bed partner snores. 48% of the respondents stated that snoring affected their personal relationships, with 46% of respondents admitting that they sleep in separate bedrooms as a result of snoring.
Drowsiness, irritability, and decreased libido may all be associated with snoring. It appears that snoring is independently associated with daytime somnolence, and not merely a proxy for sleep apnea.
People who snore have been shown to have increased rates of hypertension (elevated blood pressure) when compared to those who do not snore. Studies have also documented a positive correlation between loud snoring and the risk of heart attack and stroke. One 2008 study found that “objectively measured heavy snoring is an independent risk factor for early carotid atherosclerosis.and stroke.” Another study evaluated over 1500 patients who suffered acute myocardial infarcts (heart attaches), and found that “heavy snoring is associated with case fatality…in patients with a first acute myocardial infarction.”
In women aged 25-79 years old, one study found snoring with or without sleep apnea to be related to the presence of diabetes mellitus. This is of particular concern, as diabetes is strongly related to cardiovascular disease and early death. An earlier study supports these results, having found a two-fold higher risk of developing diabetes in women who snore compared to women who do not snore. Fortunately, there is some evidence that in diabetic patients with sleep apnea, diabetic parameters improve when patients’ sleep apnea is brought under control.
For women of child-bearing age, snoring and witnessed sleep apnea appear to be related to such complications during pregnancy as pre-eclampsia. One study found that women who snore during pregnancy have an increased incidence of pregnancy-induced hypertension, and that snoring may indicate a risk for growth retardation of the fetus. The presence of OSA seems to significantly increase in women who have gone through menopause, although this risk may decrease with hormone replacement therapy.
Raising a public safety issue, a 2009 study of 7905 subjects discovered that men suffering from excessive daytime sleepiness who habitually snore drive significantly more than others. Other studies have noted that snoring men have a greater than 3-fold higher risk of traffic accidents than those who do not snore!
Snoring may have a severe impact on inter-personal relationships. According to one study of 4900 couples, as many as 80% of snoring couples end up in separate bedrooms. Another study of women who sleep with men who snore found that these women were almost twice as likely as women who sleep with non-snorers to report problems with insomnia, daytime fatigue, daytime sleepiness, awakening unrefreshed from sleep, and morning headache. It is clear that snoring impacts both the patient who snores as well as his or her bed-partner.