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Thread: Snoring

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    Exclamation Snoring

    What is snoring?

    Snoring, like all other sounds, is caused by vibrations that cause particles in the air to form sound waves. For example, when we speak, our vocal cords vibrate to form our voice. When our stomachs growl (borborygmus), our stomach and intestines vibrate as air and food move through them. While we are asleep, turbulent air flow can cause the tissues of the nose and throat to vibrate and give rise to snoring. Essentially, snoring is a sound resulting from turbulent airflow that causes tissues to vibrate during sleep.

    What causes snoring?

    While we are breathing, air flows in and out in a steady stream from our nose or mouth to our lungs. There are relatively few sounds when we are sitting and breathing quietly. When we exercise, the air moves more quickly and produces some sounds as we breathe. When we are asleep, the area at the back of the throat sometimes narrows. The same amount of air passing through this smaller opening can cause the tissues surrounding the opening to vibrate, which in turn can cause the sounds of snoring. Different people who snore may have various reasons for the narrowing of the area at the back of the throat. The narrowing can be in the nose, mouth, or throat.

    Any person can snore. Frequently, people who do not regularly snore will report snoring after a viral illness, after drinking alcohol, or when taking some medications. Studies estimate that 45 % of men and 30% of women snore on a regular basis. People who snore can have any body type. We frequently think of a large man with a thick neck as a snorer. However, a thin woman with a small neck can snore just as loudly. In general, as people get older and as they gain weight, snoring will worsen.

    Normal breathing


    For breathing at rest, it is ideal to breathe through the nose. The nose acts as a humidifier, heater, and filter for the incoming air. When we breathe through our mouth, these modifications to the air entering our lungs do not occur. Our lungs are still able to use the cold, dry, dirty air, but you may have noticed that breathing really cold, dry, or dirty air can be uncomfortable. Therefore, our bodies naturally want to breathe through the nose if possible.

    The nose is made up of two parallel passages, one on each side. They are separated by the septum, which is a relatively flat wall of cartilage, bone, and lining tissue called the nasal mucosa. On the lateral side of each passage, there are three nasal turbinates, which are long, cylindrical-shaped structures that lie roughly parallel to the floor of the nose. The turbinates contain many small blood vessels that function to regulate airflow. If the blood vessels in the turbinates increase in size, the turbinate as a whole swells, and the flow of air decreases. If the vessels narrow, the turbinates become smaller and airflow increases. Everyone has a natural nasal cycle that generally will shift the side that is doing most of the breathing about every eight hours. For example, if the right nasal turbinates are swollen, most of the air enters the left nasal passage. After about eight hours, the right nasal turbinates will become smaller, and the left nasal turbinates will swell, shifting the majority of breathing to the right nasal passage. You may notice this cycle when you have a cold or if you have a chronically stuffy nose. The turbinates may also swell from allergic reactions or external stimuli, such as cold air or dirt.

    Mouth breathing and snoring

    As discussed above, we naturally want to breathe through our noses. Some people cannot breathe through their noses because of obstruction of the nasal passages. This can be caused by a deviation of the septum, allergies, sinus infections, swelling of the turbinates, or large adenoids. In adults, the most common causes of obstruction are septal deviations from a broken nose or tissue swelling from allergies. In children, enlarged adenoids are often the cause of the obstruction. People with nasal airway obstruction who must breathe through their mouths are therefore sometimes called “mouth breathers.” Many mouth breathers snore, because the flow of air through the mouth causes greater vibration of tissues.

    The soft palate and snoring

    The soft palate is a muscular extension of the bony roof of the mouth (hard palate). It separates the back of the mouth (oropharynx) from the nasal passages (nasopharynx). It is shaped like a sheet attached at three sides and hanging freely in the back of the mouth. This is important when breathing and swallowing. During nasal breathing, the palate moves forward and “opens” the nasal airway for air. During swallowing, the palate moves backward and “closes” the nasal passages, thereby directing the food and liquid down the esophagus instead of into the back of the nose. The uvula is the middle extension of the palate. It assists with the function of the soft palate and also is used in some languages (Hebrew and Farsi) to produce the guttural fricative sounds (like in the Hebrew word “L'chaim”). English words do not use the guttural fricative sounds. The palate and uvula often are the structures that vibrate during snoring and surgical treatments for snoring alter these structures and prevent guttural fricative sounds. Therefore, if you speak a language that uses guttural fricative sounds, make sure you do not have a surgical procedure to improve snoring.

    The narrowed airway and snoring

    The tonsils are designed to detect and fight infections. They are located at the back of the mouth on each side of the throat (oropharynx). Like other infection-fighting tissue, the tonsils swell while they are fighting bacteria and viruses. Often, the tonsils do not return to their starting size after the infection is gone. They can remain enlarged (hypertrophied) and can narrow the airway, vibrate, and cause snoring.

    The soft palate, as described above, is the flap of tissue that hangs down in the back of the mouth. If it is too long or floppy, it can vibrate and cause snoring. The uvula is suspended from the center of the palate. An abnormally long or thick uvula also can contribute to snoring.

    The base of the tongue is the part of the tongue that is the farthest back in the mouth. The tongue is a large muscle that is important for directing food while chewing and swallowing. It also is important for shaping words while we are speaking. It is attached to the inner part of the jaw bone (mandible) in the front and to the hyoid bone underneath. The tongue must be free to move in all directions to function properly. Therefore, it is not attached very tightly at the tip or top of the tongue. If the back of the tongue is large or if the tongue is able to slip backwards, it can narrow the space through which air flows in the pharynx, which can lead to vibrations and snoring.

    Stage of sleep and snoring

    Snoring can occur during all or only some stages of sleep. Snoring is most common in rapid eye movement (REM) sleep, because of the loss of muscle tone characteristic of this stage of sleep. As discussed in the article on sleep stages, during REM sleep, the brain sends the signal to all the muscles of the body (except the breathing muscles) to relax. Unfortunately, the tongue, palate, and throat can collapse when their muscles relax. This can cause the airway to narrow and worsen snoring.

    Sleeping position and snoring

    When we are asleep, we are usually (though not always) lying down. Gravity acts to pull on all the tissues of the body, but the tissues of the pharynx are relatively soft and floppy. Therefore, when we lie on our backs, gravity pulls the palate, tonsils, and tongue backwards. This often narrows the airway enough to cause turbulence in airflow, tissue vibration and snoring. Frequently, if the snorer is gently reminded (with an elbow to the ribs) to roll onto his or her side, the tissues are no longer pulled backwards and the snoring lessens.

    Medications and alcohol and snoring


    The root cause of snoring is vibration of the tissues while breathing. Some medications as well as alcohol can lead to enhanced relaxation during sleep. As the muscles of the palate, tongue, neck, and pharynx relax more, the airway collapses more. This leads to a smaller airway and greater tissue vibration. Some medications encourage a deeper level of sleep, which also can worsen snoring.

    Why is snoring a problem?

    Snoring sometimes can be the only sign of a more serious problem. People who snore should be checked to rule out other problems such as sleep apnea, other sleeping problems, or other sleep related breathing problems . If the snorer sleeps and breathes normally, then snoring is only a problem for the snorer's bed partner or family members. In fact, snoring often disrupts the sleep of family members and partners more than it affects the snorer. Frequently, partners of snorers report leaving the bedroom (or making the snorer leave the bedroom) many nights per week. Snoring may not be a medical problem, but it can become a significant social problem for the snorer and sleep problem for the bed partner.

    Signs and symptoms snoring may be a medical problem

    Determining if snoring is a medical problem

    People who sleep (or lie awake not sleeping) near a snorer often report signs that may indicate a more serious problem. Witnessed apnea (stopping breathing) or gasping can suggest a breathing problem like sleep apnea (see below) or heart problems. Leg kicking or other jerking movements can indicate a problem such as periodic limb movements or restless leg syndrome.

    If someone's sleep is disrupted because of snoring, the person may also notice other symptoms. Frequently, people complain of difficulty waking up in the morning or a feeling of insufficient sleep. They may take daytime naps or fall asleep during meetings. If sleep disruption is severe, people have fallen asleep while driving or performing their daily work.

    Daytime sleepiness can be estimated with a sleepiness inventory, and a sleep study can be performed if a sleeping problem is suspected. There are two general types of sleep studies. A home (unattended) sleep study can measure some basic parameters of sleep and breathing. Often, it will include pulse oximetry (a measurement of the concentration of oxygen in the bloodstream), a record of movement, snoring, and apneic events. A home study can prove that there are no sleeping problems or suggest that there may be a problem.

    If a home sleep study suggests a problem, a full sleep study (polysomnography) often is performed in a clinic. (For a complete description of sleep studies, see below).

    If a sleepiness inventory and sleep study suggest there are no sleeping or breathing disorders, a person is diagnosed with primary snoring. Treatment options then can be discussed.

    Epworth Sleepiness Scale


    The Epworth Sleepiness Scale is a self-report test that establishes the severity of sleepiness. A person rates the likelihood of falling asleep during specific activities. Using the scale from 0-3 below, rank your risk of dozing in the chart below. (You can also print this out and take it to your doctor visit.)



    After ranking each category, the total score is calculated. The range is 0-24, with the higher the score the more sleepiness.

    Scoring:

    * 0-9 = Average daytime sleepiness
    * 10-15 = Excessive daytime sleepiness
    * 16-24 = Moderate to severe daytime sleepiness

    Breaking it down further, excessive daytime sleepiness is greater than 10. Primary snorers usually have a score less than 10, and individuals with moderate to severe sleep apnea usually have a score greater than 16. (One woman filled out the sleepiness scale and had a low score. Sitting in the physician's office, however, she was falling asleep while waiting. The physician asked her why her score was so low. She replied, “I don't ever read books, watch TV, or ride in a car, so the likelihood that I would fall asleep doing those things is very low.” )

    Tests for objectively measuring sleepiness

    For someone who reports being sleepy during the day, it is sometimes helpful to measure how sleepy they are. Also, after treatment of sleep problems, we sometimes want to measure improvement in daytime sleepiness. Sleepiness can be measured with a Multiple Sleep Latency Test (MSLT). Basically, the MSLT measures how fast someone falls asleep during the day. It must be done after an overnight sleep study (polysomnography) has documented adequate opportunity for sleep the night before. The test is composed of 4 to 5 “naps” that last 20 minutes each and are spaced two hours apart. The person is instructed to “try to fall asleep.” The average time to fall asleep is calculated for all four or five tests. A normal time would be greater than ten minutes needed to fall asleep. Excessive sleepiness is defined as falling asleep in less than five minutes.

    The Maintenance of Wakefulness Test (MWT) also measures daytime sleepiness. The person taking this test is instructed to “try to stay awake.” This is repeated for four 40 minute sessions, two hours apart. Not falling asleep in all four tests is the strongest objective measure of the absence of daytime sleepiness.

    Some businesses use these tests to ensure that their employees are not excessively sleepy while at work. Specifically, airline pilots and truck drivers who experience sleepiness need to have a test to ensure public safety and productivity at work. Unfortunately, there is no test that will guarantee that someone will not fall asleep at their job or while driving.

    What are the treatments for snoring?

    Goals of treatment for snoring

    The problem of snoring usually is a problem for the bed partner or roommate. Therefore, successful treatment should include the goal of achieving a successful night's sleep for the other person. This makes treatment of snoring a difficult challenge. For example, someone may have a successful treatment if their snoring decreases from a jackhammer level to that of a passing truck. If their bed partner is happy, then the snoring problem is “cured.” However, another person whose snoring decreases from a mild sound to the level of heavy breathing may still have an unhappy bed partner. It is wise to look at the “success” reports for various treatments with a critical eye. If the number of nights that a bed partner has to leave the room decreases from seven nights per week to one night per week, is that success? Some would say that it is. However, the bed partner (or snorer) still has to leave the room one night per week. Be sure to know what your expectations for a “cure” are before considering any treatments.

    Non-surgical treatments for snoring

    The main categories of non-surgical treatment of snoring are:

    * behavioral changes,
    * dental devices,
    * nasal devices, and
    * other products.

    Behavioral changes

    Behavioral changes are the easiest to identify, but some of the hardest to accomplish. For example, if a person gains ten pounds, his snoring may become a problem. It is easy to tell a person to lose the ten pounds, but it is difficult to accomplish. Behavioral changes include weight loss, changing sleeping positions, avoiding alcohol, and changing medications. Losing weight usually will improve snoring. Snoring usually is worse when lying flat on your back, as discussed previously. To help this problem, a pocket can be sewn into the back of the snorer's pajama tops. A tennis or golf ball in the pocket will “encourage” the snorer to roll over to sleep on his/her side. Alcohol or sedative medications make snoring worse, and therefore should be avoided.

    Dental devices

    As previously discussed, snoring is exacerbated by normal airflow through a narrowed area in the throat. Part of the narrowing is caused by the tongue and palate falling back during sleep. Some dental devices have been developed that hold the jaw forward. Since the tongue is attached in the front to the jaw, the tongue also is held forward when these devices are used. Some devices are designed to hold the palate up and forward. All dental devices are best made by a dentist to ensure a correct fit without causing problems. These devices improve snoring in 70 to 90% of cases. There are some drawbacks to dental devices, however. They must be worn every night in order to work, they can cause or exacerbate temporomandibular joint (TMJ) problems, and they can be moderately expensive.

    Nasal devices and medications

    For people with narrow nasal passages, snoring can be alleviated with nasal devices or medications. Breath-rite strips open the anterior nasal valve (front part of the nose). If this is the main or only area of narrowing, snoring may improve with use of these strips, but this is frequently not the case. I have encountered other nasal devices that hold open the front nasal passageway, but they are generally not ideal or completely successful. If nasal mucosal swelling from allergies or irritation is causing the problem, nasal sprays may help. Nasal saline irrigation spray is a way to clean and moisturize the nasal lining since environmental irritants that stay in the nose (dust, pollen, and smoke) continue to irritate as long as they are present. The nasal lining also swells when it is cold and dry. Nasal saline helps to wash away irritants and moisturizes the mucosa without side effects. Other nasal sprays that may be used to improve nasal breathing include nasal steroid sprays. They are very helpful for swelling due to minor allergies or irritation. Steroid sprays decrease inflammation in the nasal passages. Very little of the steroid is absorbed into the body from the nose so there are few side effects with these sprays. Medicated sprays also can be used to improve snoring that results from nasal congestion.

    Other products


    Finally, there are many over-the-counter “miracle” anti-snoring devices and medications. Snoring is very common (occurring in about 33% of the population), so there are many people ready to buy products to stop their partner from snoring. Because of this, there are many companies ready to sell products, including lubricating sprays, pillows, head straps, and medications. Some of these products may in fact decrease snoring and they may be worth the $19.99 special TV offer. However, do not be surprised if you or your partner's snoring is not much better after you have tried the latest “miracle cure.”


    Surgical treatments for snoring

    Surgery to treat snoring is designed to reduce obstruction or narrowing in the anatomic area that is causing the snoring. Frequently, there is more than one involved area, so surgery on only one of the narrow areas may decrease snoring but not eliminate it entirely. Surgical treatment of snoring is generally focused on the nasal passages, palate and uvula, and tongue. Most of the surgical procedures are performed in a doctor's office. Most insurance companies do not cover procedures or medications to treat snoring, so make sure to check with your insurance provider and ask the cost of a procedure before you schedule it.

    Nasal surgery for snoring


    Nasal surgery to treat snoring is generally focused on improving a narrow nasal passage. In the doctor's office, radio-frequency energy can be used to shrink the turbinates by creating scar tissue in them, resulting in a more open nasal passage. The procedure takes about 15 minutes. Most of that time is spent numbing the nasal tissue with topical and injectable medications. The procedure is performed with a wand that is placed into the tissues. Radio-frequency energy then is released into the tissues for about ten seconds. Several applications are done on each side of the nose for maximal effect. The procedure is successful when scar tissue forms. Therefore, it takes about three months to see the full effect of the procedure. As the scar tissue softens over time, however, the swelling and narrowing may recur. The procedure then can be repeated as needed in the office.

    Several other anatomic problems can cause or worsen snoring. The nasal septum is the “wall” in the center of the nose that separates the right and left nasal passages. After trauma (including during birth), the septum can be deviated to one side or may curve to both sides (one side by the front of the septum and the other by the back of the septum). The septum deviation can be corrected by removing the crooked cartilage. This surgery usually is performed in the operating room under general anesthesia. After surgery, if the nasal obstruction is improved, the snoring often improves.

    Nasal polyps are mucosal “growths” in the nose that are usually caused by allergies. As they continue to enlarge over time, they can cause nasal obstruction. If the polyps are large enough, they will require surgery to remove them. This surgery was previously performed in the doctor's office. However, it is currently more usual to perform to perform the surgery in the operating room under general anesthesia. Removing the polyps reduces nasal obstruction, which may also improve snoring.

    Oral surgery for snoring

    Snoring can also be caused by a long, floppy palate and uvula. There are several procedures that involve the uvula and palate. Some procedures remove the tissue whereas others try to stiffen the tissues.

    Uvulectomy
    is the removal of the uvula. This can easily be performed under local anesthesia in the doctor's office. A person usually does not miss having the uvula. However, there is a period of one to two weeks of discomfort in the throat after the procedure. Some people require strong pain medications for several days, whereas others need only acetaminophen (Tylenol) or an over-the-counter equivalent. Most people describe the pain as similar to a bad viral sore throat that is worst when swallowing. The main risks of uvulectomy are pain, bleeding, and altered speech (if you speak a language with guttural fricatives like Hebrew or Farsi).

    Laser Assisted uvulopalatoplasty (LAUP) involves trimming the palate with a laser. It can be performed in the doctor's office under local anesthesia. Small cuts are made in the palate on each side of the uvula with a laser. Several procedures are usually needed for a maximal effect. The scarring caused by the procedure stiffens the palate, decreasing the ability of the palate to vibrate and pulls the palate sideways to tighten it. This procedure results in mild to moderate pain for one to two weeks that is generally controlled with oral pain medications.

    Snoring due to a long, floppy palate can be treated with office procedures that stiffen the palate. Like a sail on a sail boat, the air moving around the palate can cause vibrations of the tissue. For a sailboat sail, battens are placed to stiffen the sail and decrease vibration. Similarly, a stiffer palate vibrates less. The palate can be stiffened by creating scar tissue (as discussed previously) or with implants.

    Radio-frequency ablation of the palate can be performed under local anesthesia in the doctor's office. Usually, three tunnels in the tissue are made with a radiofrequency wand. The radiofrequency energy is applied for approximately ten seconds with the wand in the palate muscle tissue. The tissue heals as scar tissue, and the palate becomes stiffer and vibrates less. Generally, scar tissue in the palate continues to form for up to three months. Up to 77% of people report reduced snoring after this procedure, however, as the tissue continues to heal over time, the palate may soften and re-obstruct. One study demonstrated a 29% relapse in snoring after one year.

    Palate implants
    are now being used to treat snoring. They are made from Dacron, which is a non-reactive material that has been used for many years for heart valve surgery and hernia repair. Dacron also encourages the normal tissue to grow into it. Small Dacron implants are placed into the palate under local anesthesia. The implants stiffen the palate like scar tissue after radiofrequency treatments. The implants stay in the tissue, so recurrence of snoring should be reduced. There is a small increased risk of infection after insertion of foreign material in the palate tissue. If this occurs, the implant should be removed and replaced with another implant. Although this sounds like a negative consequence, infection actually leads to scarring, which helps decrease the vibrations of the palate. The implant procedure results in less tissue inflammation and therefore the procedure does not hurt as much or for as long as following radio-frequency treatments.

    Success of Surgery


    Surgeries are generally successful in reducing snoring. The success of a procedure depends on the problem area causing the snoring. For example, someone with nasal congestion will not have much improvement with a palate procedure and vice versa. The other factor that makes success hard to measure is the definition of success. As discussed earlier, the goal of surgery is a successful night's sleep for those around the snorer.

    Palate implant surgery has been reported to decrease snoring. On a loudness scale of 1-100, the average decrease is from 79 to 48 at three months. Is a snoring level of 48 a success? For some people it may be, but for others it may not. Similarly, palate implant surgery was recommended by 89% of snorers, but only 69% of their partners. Palatal implant surgery, like other surgeries, is very successful if the patients are carefully selected. Only people with snoring due to palate problems will improve with palate surgery, and only the snorer's partner will determine if the improvement in snoring is a “success.”

    Snoring At a Glance

    * Snoring is caused by vibrating tissues within the airways of the nose and throat.
    * The vibrations that cause snoring are caused by turbulent airflow through narrowed airways.
    * Snoring is affected by the stage of sleep, sleeping position, and the use of medications and alcohol.
    * Snoring is a problem for family members and sleeping partners of the snorer.
    * Snoring also may be a sign of a medical problem.
    * Treatments for snoring are nonsurgical and surgical.
    Last edited by PreDator; 12-06-2007 at 07:50 PM.

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