Questions and Answers from a Board-Certified Sleep Specialist

You know snoring when you hear it. It's the the harsh, unpleasant, staccato-like sound of air going through a narrowed throat opening. Snoring is a sign that the airway is being partially blocked. It occurs almost exclusively when people sleep, and is very common in adults. Better than any word description are actual recordings. Check out these YouTube videos of snorers. (I've provided links to several since at any given time some may be inactive).

Chopping down lumber
Summer snoring
Sarah snoring
Ann snoring
Dad snoring
Snoring not boring

There are two ways of answering this question: 1) Harmful effects on the bed partner and 2) Harmful effects on the snorer.

1) The bed partner can be affected from interrupted sleep and/or inconvenience amd/or a strain in the relationship. Many husbands and wives sleep in different rooms because one of them snores so loudly that the non-snoring spouse can't get a good night's sleep. Marriage is unlikely to break up over this, but nonetheless some strain is inevitable. On the positive side is that the non-snoring spouse will often drive the snorer to seek medical attention, which then uncovers a more significant problem (such as sleep apnea) that can be effectively treated.

2) Potentially more serious is what snoring may mean for the snorer. If snoring is present without any daytime effects (sleepiness, tiredness, etc.) or any evidence for sleep apnea (including high blood pressure) it is called simple snoring. Otherwise, if there are any effects from the snoring, it is not simple and instead indicates a medical problem. In that case snoring may be a sign of sleep apnea, where the person has actual obstruction of air flow. While snoring is itself a sign of turubulent air flow, people with 'simple snoring' are able to overcome the turbulence and bring in sufficient air with each breath. On the other hand, many snorers have actual reduction of air flow, which can lead to interrupted sleep, low oxygen levels, high blood pressure and other bad effects; this situation is called obstructive sleep apnea (OSA). With OSA the snorer slows or stops his breathing intermittently throughout the night, causing harmful effects. We sleep 1/3 of our lives, so the effects can be very significant, even life threatening in some circumstances. See "Doctor, my husband stops breathing during sleep".

Some people refer to snoring as the 'tip of the iceberg' because it may signify a serious problem, i.e., sleep apnea. As a rule of thumb, an obese person with heavy snoring who is sleepy or fatigued during the day has sleep apnea until proven otherwise.

It depends. If the problem is simple snoring, one may try any of the dozens of widely advertised 'snoring remedies' sold in stores or on-line (see below). These remedies may or may not help the snorer, but they have one potential serious 'side effect'. They may delay treatment for a serious medical problem, one for which the snoring is only the 'tip of the iceberg'. The problem is knowing whether or not you have simple snoring or snoring that indicates a potentially serious medical problem (sleep apnea).

If you snore most nights and have any of the following, the snoring may be medically significant and should be discussed with your physician. You may need a sleep study to evaluate for possible sleep apnea.

• daytime fatigue or sleepiness not otherwise explained
• history of witnessed apneas (i.e., bedpartner has noted you stop breathing during sleep)
• high blood pressure
• congestive heart failure
• a body Mass Index (BMI) of 30 or greater

There are so many that it's best to categorize them into groups. (The U.S. Patent office has over 300 "cures for snoring".) Within each group I've provided links to web sites, some blatantly commercial. THESE LINKS ARE NOT AN ENDORSEMENT OF ANY SPECIFIC PRODUCT, BUT MERELY AN EXAMPLE OF WHAT'S OUT THERE. In fact many ads for anti-snoring devices are mis-leading, in that they advertise relief from sleep apnea or daytime sleepiness, for which there is no scientific evidence. Also, note that a large number of ads for anti-snoring remedies are similar to patent medicine ads of the 19th century: promising instant cure and at one low price. (See also Put An End To Snoring for more information on the variety of snoring remedies.)

Snoring Treatments 1. No cost outlay, no prescription - life style changes. In this category are position therapy, alcohol and smoking cessation, and weight reduction. SLEEP POSITION: Most snoring is worse when you lay on your back, so avoiding supine sleep is often helpful. Wearing a pajama top with one or two tennis balls sewn into the back is one method. There are also commercial products to help you stay off your back (see #4). ALCOHOL makes snoring worse by relaxing the throat muscles. SMOKING makes the throat membranes 'sticky' with mucous and more prone to close up. Stopping both should help reduced snoring. WEIGHT REDUCTION takes time but is no doubt helpful in some people. Presence of sleep apnea correlates with increased weight, so reducing fat tissue in the neck and throat should help lessen snoring. However, weight reduction is difficult and takes a long time, and most chronic snorers choose one of the other methods listed below. 2. Throat sprays. All are proprietary and heavily advertised; no prescription needed. They generally work by lubricating the throat tissues. BreatheRight Throat Spray Snor-enz throat spray List of throat sprays 3. Appliances worn inside the mouth. While these can be fitted by a dentist, many are sold on-line, without a prescription. SleepPro SnoreMender SnoreMate Non CPAP Snoring Device 4. Devices used outside the mouth, touted to keep the throat or nasal passages open. Sold on-line or in stores, they include jaw positioning devices, anti-snore pillows and nasal strips. Jaw Supporter BreatheRight Throat Strips Sona Pillow ZZOMA Positional Sleeper 5. CPAP - continuous positive airway pressure. The patient puts on a tight-fitting nasal or face mask, which in turn is attached to a machine that increases the air pressure entering the nose (or nose and mouth, depending on the type of mask). This incresed pressure "stents open" the airway and prevents it from collapsing during sleep. Picture of man with a nasal CPAP mask. The hose leading from the mask is attached to a machine that delivers air under increased (positive) pressure. While CPAP is invariably effective, it is not used for snoring alone, as third party payors will not cover it unless there is also sleep apnea. See also: CPAP equipment CPAP masks 6. Procedures that are performed by ENT surgeons. Such procedures usually involve removing soft tissue from the back of the throat and/or shortening the palate, thereby enlarging the throat opening. The ENT Health Information web site lists 3 general types of surgical procedure. Uvulopalatopharyngoplasty (UPPP). This surgery "tightens flabby tissues in the throat and palate, and expands air passages." [Note: for many years UPPP was the standard operation for surgical treatment of sleep apnea. Studies have now shown it is not nearly as effective as CPAP for sleep apnea.] "Thermal Ablation Palatoplasty (TAP) refers to procedures and techniques that treat snoring and some of them also are used to treat various severities of obstructive sleep apnea. Different types of TAP include bipolar cautery, laser, and radiofrequency. Laser Assisted Uvula Palatoplasty (LAUP) treats snoring and mild obstructive sleep apnea by removing the obstruction in the airway. A laser is used to shrink the uvula and tighten a specified portion of the palate in a series of small procedures in a doctor’s office under local anesthesia. Radiofrequency ablation -- some with temperature control approved by the FDA -- utilizes a needle electrode to emit energy to shrink excess tissue in the upper airway including the palate and uvula (for snoring), base of the tongue (for obstructive sleep apnea), and nasal turbinates (for chronic nasal obstruction)." "Genioglossus and hyoid advancement is a surgical procedure for the treatment of sleep apnea. It prevents collapse of the lower throat and pulls the tongue muscles forward, thereby opening the obstructed airway."

Regarding surgery, it is important to note that all the operations carry the potential for significant side effects, and there is very little PUBLISHED evidence that they are effective for either snoring or sleep apnea. Accoring to an article in the journal Sleep (Franklin, et al. Effects and Side Effects of Surgery for Snoring and Obstructive Sleep Apnea - A Systematic Review. Vol 32, Issue No. 1, 2009; pages 27-36):

"Only a small number of randomized controlled trials with a limited number of patients asssessing some surgical procedures for snoring or sleep apnea are available. These studies do no provide any evidence of effect from laser-assisted uvulopalatoplasty or radiofrequency ablation on daytime sleepiness, apnea reduction, quality of life or snoring...Persistent side-effects were reported in a majority of the patients undergoing uvulopalatopharyngosplasty and uvulopalatoplasty, especially in the form of difficulty swallowing, globus sensation in the throat, and voice changes."

It's also important to realize that sprays and appliances aimed at treating snoring DO NOT effectively treat sleep apnea. Of all the treatments listed above, the only one that can treat both snoring and sleep apnea with reasonable success is CPAP. Some operations in some people have also been successful for both conditions, but the result is not predictable and side effects are potentially permanent. The fact is, most upper airway surgery is NOT useful for fully correcting obstructive sleep apnea. As a rule CPAP should be tried before any patient resorts to surgery.

See also Treatment of Snoring and Obstructive Sleep Apnea and "Doctor, my husband stops breathing during sleep".

• Wikipedia
• Consumer-Search: Unbiased report of available snoring remedies
• SleepEducation.com
• Help Guide to Snoring
• ENT web site on surgical procedures for treating snoring
• ENT web site on CPAP
• Put An End To Snoring

Books on SNORING and SLEEP APNEA:

• Snoring from A to ZZZZ, 1997. Derek S. Lipman, MD
• No More Snoring: A Proven Program to Conquer Snoring and Sleep Apnea, 1998. Victor Hoffstein and Shirley Linde
• The Snoring Cure: Simple Steps to Getting a Good Night's Sleep, 2000. Laurence A. Smolley, Debra Fulghum Bruce
• Sleep Apnea - The Phantom of the Night: Overcome Sleep Apnea Syndrome and Win Your Hidden Struggle to Breathe, Sleep, and Live, 2003. T. Scott Johnson
• Snoring and Sleep Apnea: Sleep Well, Feel Better, 4th edition, 2008. Ralph Pascualy, MD