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Snoring - causes, remedies, surgery

 
Snoring is the sound made by air passing through narrowed airways, that causes parts of the throat or nose to vibrate.  Surgical treatment and non-surgical remedies and therapies focus on reducing or removing airway obstructions.
 
Approximately 50% of all adults will snore occasionally and approximately 25% of all adults will be habitual snorers.  Snoring is most common in men and the severity of the snoring tends to worsen with age.

General information

When we breathe, air travels into the mouth and/or nostrils, down the throat and into the lungs via the windpipe (trachea). On the way, the air passes several structures including the tongue, soft palate, uvula (the small appendage visible at the back of the throat) and the tonsils.

Normally the muscles in the throat are firm but when we sleep they relax. In some people they relax to such a degree that the structures they support collapse and partially block the airway. As air is inhaled and exhaled during sleep these structures can vibrate, producing distinctive snoring sounds.

Snoring can be disruptive – both for the snorer and anyone within earshot.  This means that they are not getting the quality, restorative sleep they require, leading to daytime sleepiness. Also, heavy snorers are at greater risk of developing high blood pressure at a younger age than people who don't snore.

The most exaggerated and potentially dangerous form of snoring is obstructive sleep apnoea (OSA). This is when snoring is interrupted by frequent episodes of totally obstructed breathing, semi wakening, and a resumption of breathing. The effect is to reduce the quality and benefits of a good night’s sleep and has the potential to cause high blood pressure and heart rhythm abnormalities. If OSA is suspected, a doctor should be consulted.

Causes

There are many factors that make a person more likely to snore. These include:

  • Poor muscle tone in the tongue and throat - this can occur during stages of deep sleep. Alcohol and medications such as sleeping tablets can also cause the muscles to excessively relax
  • Nasal obstruction - this may be caused by conditions such as a cold or sinusitis, or by allergic conditions such as hay fever.  Nasal obstruction may also be due to nasal polyps or a structural abnormality in the nasal passages
  • Abnormalities of the soft palate - the area of soft tissue that is attached to the back of the roof of the mouth (known as the hard palate). The soft palate may be swollen, floppy or excessively long
  • Being overweight - excessive weight can also make the throat bulkier and can exert extra pressure on the breathing passages.

Diagnosis

The experiences of the snorer's partner or members of their household can confirm that snoring occurs and will frequently be the reason why treatment is being sought.

If snoring is problematic or OSA is suspected, a doctor should be consulted. A referral to an ear, nose and throat (ENT) specialist (otolaryngologist) may be recommended for tests and treatment. The specialist will take a full medical history and will examine the nasal passages, mouth and throat to see if the cause for the snoring can be identified. Tests may include:

Nasendoscopy - where a small telescope is inserted into the nasal passages allowing them to be viewed on a television monitor. This can be performed in the specialist's office. The test may also be performed in an operating theatre under a light general anaesthetic in order for the specialist to assess what happens to the structures in the nasal passages and throat when the person is asleep. This is called 'sleep nasendoscopy'.

Sleep studies - an overnight assessment in a special sleep laboratory where the person is precisely monitored to assess the extent of their snoring and how it affects their sleep. This test is primarily used to diagnose OSA.  

Non surgical treatment / remedies

Treatment for snoring differs from treatment for OSA. It is therefore important to ensure that the person does not also have OSA before treatment for snoring is undertaken.

The type of treatment or lifestyle change recommended will depend on the cause of the snoring. Treatment can be either non-surgical or surgical but surgery is usually not recommended until non-surgical treatments have been tried and have proven unsuccessful.

Lifestyle factors:

  • Maintain a healthy body weight (lose weight if overweight)
  • Exercise regularly
  • Reduce alcohol intake and avoid alcohol close to bedtime
  • Avoid taking sleeping tablets
  • Sleep on the side rather than the back
  • Don’t smoke.

Devices (available at most pharmacies):

  • Nasal strips - worn across the bridge of the nose, can help to open the nasal passages
  • Mouth guards (mandibular splints) - help to hold the jaw forward, thus preventing the tongue and other structures obstructing the airway
  • Collars - also help to keep the jaw forward and open the airway.
Medications:
Sprays to unblock congested nasal passages may be helpful. These should be used in careful consultation with a doctor as some sprays should not be used on a long-term basis.

Alternative treatments:
Some people find alternative therapies such as acupuncture, homeopathy and herbal remedies helpful in reducing snoring. 

Surgery options

There are several different types of surgery that are used to attempt to reduce or eliminate snoring:

Injection Snoreplasty - This may be recommended when snoring is caused by floppiness of the soft palate. It involves injecting a sclerosing (scarring) liquid into the soft palate. Over a period of about eight weeks, scarring develops in the soft palate and it becomes stiffer and less floppy.

Tonsillectomy and adenoidectomy - If enlarged tonsils and adenoids are identified as being the cause of the airway obstruction, then surgery to remove them may be recommended.

Septoplasty and trimming of nasal turbinates - This surgery may be recommended if structural abnormalities in the nasal passages have been identified. It is usually performed using endoscopic (keyhole) surgical techniques as a day-stay case under a mild general anaesthetic. The surgery straightens the septum (the cartilage partition that divides the nostrils) and reduces the size of small structures within the nasal passages called turbinates. Soft tissue obstructions such as polyps can also be removed during this surgery.

Uvulopalatopharyngoplasty (UPPP) - This surgery removes the uvula and part of the soft palate in order to widen the airway and to prevent these structures vibrating during breathing. The tonsils may also be removed during this surgery. The surgery is performed in an operating theatre under a general anaesthetic. A stay in hospital of one to two days is usually required.

Laser assisted uvulopalatoplasty (LAUP) - This surgery uses a laser to remove the uvula and part of the soft palate. It has the advantage of being able to be performed as a day-stay case procedure under a local anaesthetic. It usually requires a series of procedures to be performed, several weeks apart, before final results are achieved.

Somnoplasty/Palatal stiffening - This surgical technique uses a laser or cauterizer to create small burn areas on the soft palate. As the burnt areas heal, the tissue shrinks, therefore increasing the size of the airway. This procedure takes approximately 30 minutes and can be performed in an outpatient setting using a local anaesthetic.

Pillar procedure - This is a minimally invasive operation involving the insertion of palatal implants.  Once in place, the implants add structural support to the soft palate and their presence stimulates tissue scarring that results in increased structural integrity of the soft palate.  The procedure can be performed in an outpatient setting.

Further information and support

For further information and support about snoring, or about Obstructive Sleep Apnoea (OSA), consult a doctor or contact:
Sleep Apnoea Association of NZ Inc.
PO Box 88
Hamilton 3240
Phone:  021 344 253
Email: saanz.secretary@gmail.com
Website: www.sleepapnoeanz.org.nz  

References

Ford-Martin, P. A. (2006) Snoring. The Gale Encyclopaedia of Medicine, Third Edition. Jacqueline L. Longe, Editor. Farmington Hills, MI. Thompson Gale.
Kramer, B. M., & Adornato, B. T (2005) Snoring and sleep apnea. The StayWell Company. San Bruno.
Lindman, J.P. Surgical Approach to Snorting and Sleep Apnea (2011). Medscape Reference: Drugs, ?Diseases & Procedures. WebMD LLC. http://emedicine.medscape.com/article/868770-overview

Last Reviewed – 26 April 2013 
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