Snoring and Obstructive Sleep Apnea (OSA)
What Causes Snoring?
Snoring is the sound produced when the soft tissues of the upper airway vibrate excessively during breathing. If the airway becomes narrowed due to obstruction, the velocity of the air increases and causes turbulence in that area. The vibration of snoring is due to this turbulent airflow.
Snorers frequently have multiple anatomic factors that contribute to their snoring problem. Obstructed nasal passages can cause snoring. Common problems that lead to nasal obstruction include a deviated septum, enlarged turbinates, nasal polyps, or sometimes just swelling due to allergies, sinus infections, or respiratory tract viruses. Nasal obstruction causes all or almost all of the inhaled air to be diverted through the mouth, usually contributing to snoring.
Air entering through the mouth enters the pharynx (throat) through the space bordered by the soft palate, the tonsils (if still present), the back of the throat and the tongue. This is frequently an area of significant airway narrowing. Contributing factors include large tonsils, a floppy or long soft palate or uvula, decreased muscle tone in the tongue and/or pharynx during deep sleep, a receding jaw, or a relatively large tongue can impair the flow of air through the mouth, and increase snoring.
Weight gain can cause or worsen snoring. Increased fat stores are deposited in many areas of the body including the tissues of the soft palate and throat, compromising the diameter of the airway.
What is Obstructive Sleep Apnea (OSA)?
Sometimes, snoring is an outward sign of a more significant problem, such as sleep apnea. When the blockage of the nose and/or throat becomes so severe that there is a significant reduction or intermittent cessation of breathing during sleep, it is known as obstructive sleep apnea (OSA). Individuals with OSA may stop breathing, gasp or snort in their sleep. Severe disruption of the normal sleep cycle severely reduces sleep efficiency causing OSA patients to usually wake up tired after a full night's sleep, and often leading to daytime sleepiness. Less frequently, OSA patients may experience morning headaches, memory or concentration problems, and restlessness.
Sleep apnea has both immediate and long-term effects. The immediate effects are more noticeable to the patient, and include all the symptoms of sleep deprivation as described above. The long-term effects, however, can be even more serious, leading to elevated blood pressure, congestive heart failure, pulmonary hypertension, and increased risk of cardiac arrhythmia and/or stroke. It is believed that many of these long-term effects can be prevented by effective treatment of OSA.
Differentiating Snoring from Sleep Apnea
While it is true that almost all obstructive sleep apnea patients snore, many patients who snore do not have obstructive sleep apnea. Heavy snorers, those who snore in any position or are disruptive to their partners, should seek a medical evaluation to ensure that sleep apnea is not a problem. As otolaryngologists, Dr. Bryan and Dr. Mettman will provide a thorough examination of the nose, mouth, throat, palate, and neck. An overnight sleep study (polysomnogram) may be recommended to record breathing, heart rate, oxygen levels and other physiologic functions during sleep. Analyzing the polysomnogram will determine whether sleep apnea is present and often provides information about the best treatment for you.
Treatment of Snoring and Sleep Apnea
Both non-surgical and surgical treatment options are available depending upon the degree and cause of an individual’s snoring and/or sleep apnea.
Non-Surgical Treatments and Procedures: For the light snorer, some lifestyle changes that may be effective include weight loss, the use of a specially designed oral appliance, eliminating alcohol, sedatives or a heavy meal before bedtime, sleeping on your side, and treating allergies or sinus problems. If snoring persists, or sleep apnea is diagnosed, many people need other alternatives.
Continuous Positive Airway Pressure (CPAP) is a non-surgical treatment that is considered the gold standard treatment of OSA. The CPAP machine uses a mask and continuous air pressure to effectively hold the airway open during sleep. Although CPAP is the most reliable treatment, not all patients are able to tolerate CPAP, or may have grown intolerant to CPAP, and desire other options.
Minimally invasive, non-surgical (office) procedures are available which are designed to treat snoring by reducing the vibration of the palate and uvula. Snoreplasty involves a series of injections, given over a period of a week or two, which increase the firmness of the soft palate and therefore decrease the movement and vibration of the palate. The Pillar Procedure™ involves inserting three to five small implants in the soft palate to gently stiffen the palate and stop the vibration. While these minimally invasive procedures are often very helpful for patients who snore but do not have sleep apnea, they are not usually appropriate for sleep apnea patients. Additionally, these procedures are not FDA approved for the treatment of sleep apnea, and therefore are almost never covered by insurance.
Surgical Treatments: The goal of surgery is to decrease the resistance to airflow in the nose and/or the throat. Surgical treatment can be useful in patients who do not tolerate, or do not respond to other less invasive treatments. Careful patient selection is important in determining whether surgical treatment is appropriate.
Surgery to open the nasal passages tends to help snoring and apnea problems and can help patients become more compliant with CPAP. Nasal surgery may involve reducing the turbinates, straightening a deviated septum, or endoscopic surgery to remove nasal polyps or treat chronic sinusitis.
Surgical procedures to enlarge the entry into the pharynx from the mouth are often recommended in patients who need surgical treatment. The most common surgical procedure for sleep apnea in adults is a Uvulopalatopharyngoplasty (UPPP). This operation includes removing tonsils (if present) and excess tissue of the soft palate and sides of the throat. Not all patients with sleep apnea will respond the same way, so a careful evaluation of the throat is needed to determine whether a given patient is a good candidate for this surgery.