Snoring

What is it?


Snoring is the sound produced by upper airway tissues vibrating during inspiration, when asleep. Studies report that it affects nearly half the population. Males are affected almost twice as often as are females.

Snoring may be an isolated finding, but may indicate

  • a specific sleep-related breathing disorder;

  • obstructive sleep apnoea; or

  • upper airways resistance syndrome.

Snoring in a child is ALWAYS abnormal, and is often an indication for removal of enlarged adenoids.

Causes and contributory factors


Throat anatomy
Anything narrowing the upper airways, like enlarged tonsils/adenoids or an elongated uvula will cause partial obstruction, and these floppy tissues vibrate during inspiration. Obesity results in fat being deposited in tissues around the throat, which also causes narrowing, and is a leading cause of snoring.

Nose
A deviated nasal septum or chronic nasal congestion has the same effect

Alcohol
Excess alcohol acts as a muscle relaxant, causing floppy tissues in the throat.

Smoking
Studies show that smokers who snore far outnumber non-smokers. It is thought that nightly nicotine withdrawal somehow contributes to snoring.

Sleep apnoea
This specific syndrome produces enough airway obstruction to completely prevent breathing for a while. Periods of increasingly loud snoring (as the airway becomes increasingly obstructed) are followed by up to 10 seconds of total obstruction when breathing stops completely. When oxygen levels drop too low, and carbon dioxide levels reach dangerously high levels, brain activity causes the person to wake up, which forces the airway open with a loud gasp. This cycle is repeated several times during the night.

Sleep position
Lying on one’s back significantly increases the likelihood of snoring

Diagnosis


This is very simple: the sleep partner is usually the one to complain and describe the problem. The patient may complain of constant tiredness and excess daytime sleepiness. A child who snores must be referred to a paediatrician or ear, nose & throat (ENT) specialist.

Tests


A general history and examination are standard, but with special attention to weight, smoking/alcohol habits, other airway problems and the use of any medications inducing muscle relaxation.
If specific ENT pathology is suspected, referral to an ENT specialist is advised. Sleep-related disorders can be investigated at dedicated Sleep Centres.

Complications


Persistent snoring causes enough sleep disturbance to lead to day-time sleepiness, which has many risks, including higher motor accident rates. There is also an increased risk of developing high blood pressure and stroke.

Treatment


The basic aim of treatment is to maintain an open airway, by combining patient-controlled factors, plus conservative treatment or surgical means.

Patient factors include:

  • weight loss;

  • stopping smoking;

  • avoiding alcohol and sedatives, especially in the evenings;

  • treating nasal congestion; and

  • learning to sleep on one's side, rather than on one's back.

Conservative treatment involves using a special apparatus, such as a customised dental mouthpiece for keeping the tongue and palate in position; or a CPAP mask. This is a mask worn over the nose during sleep. A small pump feeds pressurised air into the mask, forcing the airways open. It is successful, but very few patients can tolerate the discomfort.

Surgery is reserved for resistant cases, and called uvulopalatopharyngoplasty. This operation removes all excess tissues from the soft palate and tonsillar areas, and may be done by traditional means (under general anaesthesia, using a scalpel) or under local anaesthesia using a laser scalpel. The procedure is painful and has many complications, including narrowing of the pharynx, and nasal reflux.

Outcome


With patient co-operation, much success can be obtained using non-surgical methods alone. Surgery does not cure the majority of snorers, and should only be used when specific problems can be identified and corrected, such as an abnormally large uvula in a non-smoker of normal weight.

(Dr AG Hall)

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