Ventilation disorders during sleep are extremely common. In general, sleep-disordered breathing problems are attributed to narrowing of the upper aerodigestive tract during sleep due to changes in position, muscle tone, and soft tissue hypertrophy or laxity. The most common sites of obstruction are the oropharynx and the base of the tongue. The spectrum of the problem ranges from simple snoring without cessation of airflow to Obstructive Sleep Apnea (OSA) with long periods of apnea and life-threatening physiologic sequelae. In contrast to OSA, snoring is almost exclusively a social problem, and despite its prevalence and association with OSA, there is comparatively little known about the management of this problem.
Snoring is the hoarse or harsh sound that occurs when air flows past relaxed tissues in your throat, causing the tissues to vibrate as you breathe.
Snoring is often associated with a sleep disorder called obstructive sleep apnea (OSA). Not all snorers have OSA, but if snoring is accompanied by any of the following symptoms, it may be an indication to see a doctor for further evaluation for OSA:
- Witnessed breathing pauses during sleep
- Excessive daytime sleepiness
- Difficulty concentrating
- Morning headaches
- Sore throat upon awakening
- Restless sleep
- Gasping or choking at night
- High blood pressure
- Chest pain at night
- Your snoring is so loud it’s disrupting your partner’s sleep
- In children, poor attention span, behavioral issues or poor performance in school
OSA often is characterized by loud snoring followed by periods of silence when breathing stops or nearly stops. Eventually, this reduction or pause in breathing may signal you to wake up, and you may awaken with a loud snort or gasping sound.
You may sleep lightly due to disrupted sleep. This pattern of breathing pauses may be repeated many times during the night.
People with obstructive sleep apnea usually experience periods when breathing slows or stops at least five times during every hour of sleep.
Symptoms of OSA (including snoring, excessive daytime somnolence, daytime headaches, and weight gain) may be present in as many as 30% of patients without demonstrable apnea or hypopnea on formal testing. Clinical examination should include examination of the nasal cavity, nasopharynx, oropharynx, and larynx to help exclude other causes of dynamic airway obstruction. In many cases of isolated snoring, the palate and uvula appear enlarged and elongated with excessive mucosa hanging below the muscular portion of the soft palate.
Sleep examination with polysomnography is strongly advised in the evaluation of a patient with complaints of snoring. Radiographic imaging of the head or neck is generally not necessary
Expeditious and inexpensive management solutions of snoring are sought, often with little or no benefit. Diet modification and physical exercise can lead to improvement in snoring through the weight loss and improvement in pharyngeal tone that accompanies overall physical conditioning. Position change during sleep can be effective, and time-honored treatments, such as taping or sewing a tennis ball to the back of a shirt worn during sleep, may satisfactorily eliminate symptoms by ensuring recumbency on one side. Although numerous pharmacologic therapies have been endorsed, none demonstrate any significant utility when scrutinized.
Anatomic management of snoring can be challenging. As with OSA, snoring can come from a number of sites in the upper aerodigestive tract. While medical or surgical correction of nasal obstruction may help alleviate snoring problems, most interventions aim to improve airflow through the nasopharynx and oropharynx. Nonsurgical options include mandibular advancement appliances designed to pull the base of the tongue forward and continuous positive airway pressure via face or nasal mask. Compliance with both of these treatment options is problematic because snorers without OSA do not notice the physiologic benefits of these devices noted by patients with sleep apnea.
Surgical correction of snoring is most commonly directed at the soft palate. Historical approaches involved resection of redundant mucosa and the uvula similar to uvulopalatopharyngoplasty that is used for OSA. Regardless of how limited the procedure or what technique was used, postoperative pain, the expense of general anesthesia, and high recurrence rates limit the utility of these procedures. Office-based approaches are more widely used because of these limitations. Most of these procedures aim to stiffen the palate to prevent vibration rather than remove it.
A series of procedures, including injection snoreplasty, radiofrequency thermal fibrosis, and an implantable palatal device, have been used with variable success and patient tolerance. The techniques can be technically challenging. Persistent symptoms may occur following initial treatment necessitating costly (and sometimes painful) repeat procedures. The durability of these procedures in alleviating symptoms is also poorly understood, and late failures can lead to patient and clinician frustration.