Snoring & Obstructive Sleep Apnea: Causes and Treatment
Most people snore some of the time. Snoring and obstructive sleep apnea (apnea or apnoea means not breathing) are part of a number of conditions. However, simple snoring is usually not a disease or a serious problem in itself although the noise can disturb others, especially those who are sharing the bed. Many relationships are strained as a result of snoring of one of the partners. Simple snoring can in some cases progress to obstructive sleep apnea over time.
People’s muscles relax while they are asleep. When some individuals inhale during sleep, their upper airways at the back of the nose and throat collapse inwards and vibrate, generating noise. A more severe form of snoring called obstructive sleep apnea (acronym OSA) occurs when the upper airways collapse more severely and obstruct breathing. This can be a serious medical problem.
Sleep apnea causes people to wake up briefly during the night but they usually do not remember most of these episodes. However, patients with severe obstructive sleep apnea wake up hundreds of times every night. Their sleep quality is severely disturbed which leads to daytime sleepiness and impaired mental function. In children, lack of sleep can interfere with growth hormone secretion and cause slow growth and behavioural problems.
In addition, when a person stops breathing, their blood oxygen levels fall and carbon dioxide levels rise. This can put strain on their heart and lungs, and result in elevated blood pressure and a greater risk of abnormal heart rhythms, heart attacks and strokes.
Symptoms of Obstructive Sleep Apnea
In fact, most people with mild snoring are not aware of a problem until their sleep partner starts to complain. However, patients with obstructive sleep apnea may wake up with a headache and experience daytime sleepiness and poor concentration. In children this often leads to some behavioural disturbance. When breathing stops during sleep, the condition may become obvious to the sleep partner or parent. The patient may appear to stop snoring and hold their breath for 10-60 seconds and then suddenly gasp and start breathing again.
A simple snorer who does not exhibit any of the symptoms suggestive of obstructive sleep apnea mentioned above and does not have any other medical problems that might be linked to this condition, such as abnormal heart rhythms, probably does not need to see a doctor. However, patients with symptoms suggesting that apnea might be present should definitely see a doctor to prevent serious medical consequences.
Causes of Obstructive Sleep Apnea
When a person inhales their lungs expand to decrease their air pressure relative to the outside pressure. In fact, there happens to be a gradual pressure drop from outside the nose down towards the lungs. Also, there is a natural tendency for any collapsible part of the airway outside the chest to collapse inwards and vibrate or obstruct, depending on how hard it is sucked in. When a person is awake this force is counteracted by normal muscle tone. The degree of collapse during sleep is determined by several factors, including:
- Some people’s throat muscles appear to relax more than others
- Certain drugs such as sleeping pills or alcohol can contribute to relaxing the muscles
- Narrowing of the airway at any point from the nostrils down to the voice box causes an increased pressure drop and, hence, tendency to collapse
- Nasal inflammation or deformity
- Large adenoids and tonsils
- A bulky tongue base
- A bulky soft palate
Thus, the most common causes and risk factors that contribute to snoring are:
- Being overweight
- Drinking too much alcohol, especially near bedtime
- Having a blocked nose (e.g. because of hayfever, cold or smoking)
- Taking sleeping pills, tranquilisers and anti-histamines before bed
- Lying on the back
- Having a heavy meal near bedtime
- Tumour growth in the airway
- Down syndrome
Diagnosing Obstructive Sleep Apnea
The general practitioner will refer the patient to an ear, nose & throat specialist for a detailed assessment of snoring if obstructive sleep apnea is suspected. One of the most common tests is called polysomnography, which is a type of sleep study. The patient will be attached to various sensors to measure their pulse, blood pressure, ECG (electrical heart tracing), lung activity, EEG (brain waves), blood oxygen levels and muscle activity during sleep. The results of the polysomnography test will help determine whether the individual just snores or has a more severe form of apnea. This study usually involves an overnight stay in hospital but, sometimes, the doctor may give the person an at-home version of the equipment for polysomnography so that they can do this test at home.
There are also some other rare causes of sleep-related breathing abnormalities, which will need to be excluded during diagnosis. These for example include abnormalities of the larynx that can cause obstruction resulting in a noise called stridor or some rare forms of epilepsy that can cause abnormal behaviours during sleep.
Treatment of Snoring and Obstructive Sleep Apnea
For simple snoring there are a number of self-help measures to try first, including:
- For obese or overweight individuals the most important thing they can do is to lose weight.
- People who drink and smoke heavily should cut back on their habit. In particular, alcohol before bedtime should be avoided.
- The most usual medications that contribute to snoring are sleeping tablets, antihistamines and decongestants. Although it is often not possible to avoid using them, patients should speak to their doctor to see what other options there are.
- Patients should try and train themselves to sleep on their side. In addition, elevating the head of the bed can help prevent the tongue from collapsing against the back of the throat. However, contrary to general belief using more pillows will not help as fluffy pillows can kink the neck and make the problem yet worse.
- Snorers should try to keep their bedroom free of dust mites.
If these measures fail and snoring is particularly distressing, it is sensible to see a doctor to discuss other treatment options. However, if obstructive sleep apnea is suspected, a visit to the doctor is inevitable in order to avoid serious consequences that can be prevented by timely treatment.
When snoring or obstructive sleep apnea is due to nasal obstruction it may be appropriate to perform surgery. Otherwise, it is possible to treat them with medications, small ventilating machines or oral breathing devices.
Medications: They are used if the cause of snoring is inflammation of the lining of the nose (rhinitis), which often occurs as the result of allergies. Rhinitis can be controlled with antihistamines, steroid-based nasal sprays and avoidance of the allergenic substances.
Nasal CPAP: For some patients, it may be helpful to wear a mask over their nose. The mask is attached to a small ventilating machine known as nasal continuous positive airway pressure (nCPAP or nasal CPAP). This device increases the pressure within the upper airway and prevents it from collapsing and vibration. Nasal CPAP is an effective treatment for most cases of obstructive sleep apnea. It can greatly improve a patient’s quality of life.
Oral breathing devices: A simple treatment option is to wear nasal strips and dilators at night to prevent nostrils from collapsing and thus allowing more air into the nose.
Palatal surgery is usually considered only if non-surgical treatments have failed. Depending on the type of anatomical abnormalities causing the problem and patient’s preferences, four surgical techniques can be used, including:
Laser-assisted uvulopalatoplasty (LAUP): The most commonly performed surgical procedure for snoring is the laser-assisted uvulopalatoplasty. It is a milder and safer alternative to uvulopalatopharyngoplasty (mentioned below) suitable for patients with snoring or mild forms of obstructive sleep apnea where palatal vibration is the main problem. The laser is used to remove the free edge of the uvula and the soft palate. The surgery is usually performed under local anaesthetic. However, the laser burns can be very painful for up to two weeks after operation. This operation is not always effective, especially in overweight patients.
Uvulopalatopharyngoplasty (UPPP): This procedure was popular before development of LAUP. It involves removing the uvula and pharyngeal arches as well as a rim of soft palate using electrical cutting instruments. UPPP is usually performed under general anaesthetic and is associated with significant post-operative pain.
Somnoplasty (Radio-Frequency Ablation): Electrical probes designed to heat tissue are used in a controlled manner to shrink redundant tissue of the soft palate. This procedure is performed under local anaesthesia and causes much less postoperative pain than LAUP or UPPP.
Cautery-Assisted Palatal Stiffening Operation (CAPSO): The procedure consists in burning the palate to induce fibrosis that helps stiffen the floppy palate. The local anaesthesia is used. Although this technique is less invasive than LAUP or UPPP, it still causes considerable post-operative pain.
In extremely severe cases of obstructive sleep apnea when all other methods have failed, tracheostomy can sometimes be highly effective. In this surgery, an incision is made in the neck just below the voice box to open the windpipe (trachea). A tube is then inserted into this opening through which the patient can breathe, bypassing the obstruction of upper airway. By attaching a valve to the tube it is still possible to speak during the day when the valve is closed.
However, there are several major disadvantages to tracheostomy such as the necessary postoperative care and an increased risk of lung infections in the future. In addition, the tubes interfere with speech and may also cause problems when swallowing, they need to be regularly suctioned and changed while many patients find them cosmetically unattractive.
Other Possible Therapies
Dietary supplements: Some experts believe that the two dietary supplements, chondroitin sulfate and methylsulfonylmethane, which are often taken by arthritis sufferers, can also help snorers. However, there isn’t enough evidence for this, just as there isn’t for any herbal medicine or homeopathy.
Singing lessons: Although this may sound anecdotal, singing lessons that strengthen the throat muscles have been shown to help some snorers.
Preventing Snoring and Obstructive Sleep Apnea
Children usually grow out of snoring after a few years as their adenoids and tonsils shrink and the rest of the airway grows. However, this problem tends to get worse in adults (who normally start snoring in early middle age) as they are gaining weight over time. They can help the situation by watching how much alcohol they drink, avoiding the use of tranquilizers and sleeping pills, sleeping on their side, promptly treating colds and allergies as they occur, quitting smoking, and keeping their weight down.
Where to Get Help: British Snoring & Sleep Apnoea Association