Snoring
Summary/Definition
Snoring is the phenomenon where sound is produced as air passes through partially obstructed airways during sleep, causing vibrations. It is a common sleep issue, with approximately 45% of the adult population known to snore occasionally and about 25% snoring habitually. During sleep, the muscles of the upper airway become relaxed, narrowing part of the airway. When a person attempts to inhale, the narrowed upper airway vibrates, producing the sound known as snoring. If the airway is partially blocked, snoring sounds occur; if it is completely blocked, it can lead to sleep apnea, where breathing repeatedly stops during sleep. Snoring not only affects the individual’s health but also negatively impacts interpersonal relationships, causing sleep deprivation and anxiety for the bed partner. Beyond simple discomfort, snoring may be associated with serious health issues such as sleep apnea.
The causes of snoring include airway obstruction due to various anatomical problems such as enlarged tonsils or adenoids, a large tongue and soft palate, a low palate arch, a short and thick neck, or a small jaw. Accurate diagnosis of the underlying cause is necessary for treatment, which may include lifestyle changes such as quitting smoking, reducing alcohol consumption, and losing weight.
Symptoms
Snoring is more common in men and tends to increase with age. In women, it often increases after menopause. In children, snoring becomes more prevalent after the age of 2 to 8, when the tonsils and adenoids develop, and it tends to increase further during adolescence with weight gain. Obese individuals are three times more likely to snore compared to those with normal weight, and smokers are three times more likely to have obstructive sleep apnea than non-smokers. Additionally, alcohol consumption, sedatives, and sleeping pills can worsen snoring and sleep apnea.
Snorers often experience obstructive sleep apnea syndrome, where the airway becomes completely blocked during sleep, leading to pauses in breathing. This condition causes hypoxia (low oxygen levels) and hypercapnia (elevated carbon dioxide levels), leading to frequent awakenings during the night. As a result, individuals are unable to achieve restful sleep, which can lead to excessive daytime sleepiness, fatigue, concentration problems, morning headaches, personality changes, and psychological issues. In severe cases, there is an increased risk of accidents while operating machinery, a higher likelihood of traffic accidents due to drowsy driving, and a greater risk of erectile dysfunction. Excessive daytime sleepiness is reported in 87% of snorers. In children, insomnia may lead to irritability, colds, morning headaches, reduced appetite, lack of concentration, and increased incidence of bedwetting. Adolescents commonly report excessive daytime sleepiness.
Diagnostics
Patients are often unaware of their snoring or sleep apnea, so they usually visit a hospital based on the recommendation of their bed partner. To confirm the presence of snoring and sleep apnea, it is important to undergo a polysomnography test. Testing is recommended for individuals who are male, obese, consume excessive alcohol, smoke, have symptoms of nasal congestion, or experience excessive daytime sleepiness. However, if there are no risk factors or if apnea has not been observed, it is likely just simple snoring, and testing may not be necessary.
Polysomnography is an overnight test that monitors electromyography, electroencephalography, and electrocardiography to assess the degree of apnea during sleep. Apnea is defined as a pause in breathing lasting 10 seconds or longer, while hypopnea refers to a 30-50% reduction in airflow lasting 10 seconds or longer, along with a 3-4% decrease in oxygen saturation. Obstructive sleep apnea syndrome is diagnosed when apnea or hypopnea occurs five or more times per hour, accompanied by excessive daytime sleepiness. If these events occur 30 or more times per hour, it is classified as severe obstructive sleep apnea.
Treatment and course of the disease
The treatment of snoring and obstructive sleep apnea syndrome depends on the presence of sleep apnea and the level of discomfort experienced by the bed partner. Treatment options are divided into non-surgical and surgical approaches.
1. Non-Surgical Treatment:
- Improvement of Sleep Position and Lifestyle Habits: Snoring and sleep apnea tend to worsen when lying on the back, so sleeping on the side and elevating the head can be beneficial. Avoiding alcohol and sedatives is recommended, as these can exacerbate the condition. Smoking should be avoided as it causes inflammation and swelling of the upper airway, making quitting smoking necessary.
- Weight Loss: For obese patients, losing more than 10% of their body weight can lead to significant improvement in symptoms and also increases the success rate of surgical treatments.
- Oral and Nasal Devices: Oral devices, which help to widen the airway during sleep, are suitable for younger patients with a lower body mass index (BMI) and those without a thick neck circumference. Nasal devices are used for patients who snore due to nasal congestion.
2. Surgical Treatment:
- Uvulopalatopharyngoplasty: This surgery involves removing the uvula, soft palate, and tonsils under general anesthesia while expanding the pharyngeal area. It reduces snoring and decreases the frequency of sleep apnea episodes.
- Laser-Assisted Uvulopalatoplasty: A localized anesthetic procedure that uses a laser to remove the soft palate and uvula. It is effective for simple snoring or mild sleep apnea.
- Radiofrequency Ablation: This procedure generates less heat than a laser and causes less discomfort, but it requires multiple sessions.
- Palatal Sclerotherapy: This involves making incisions in the soft palate mucosa to create scars, which help reduce snoring through fibrosis.
- Palatal Implant: Implants are inserted into the soft palate to prevent vibrations and airway obstruction.
- Mandibular Advancement: This procedure is used for patients with facial abnormalities of the palate or a retruded mandible.
