Snoring is one of the main causes of sleep disturbance and marital disharmony. It affects men and women (up to 50% of males snore regularly), becoming worse with age and weight. Snoring can also be a great social embarrassment, when visiting friends / relatives, on holiday, on long-haul overnight flights, in the train, etc. Classically, snoring becomes a problem when we reach our thirties. It’s usually because by then we are settled and may have children. The urge to go out and exercise is lessened, whereas the desire (and requirement) to go home and help with the children increases. Often the partner at home with young children will spend more time cooking tasty meals and cakes. So weight increases, and triggers off all the other issues like nose blockage, large tonsils and long soft palate which then lead to snoring. Often a bottle of wine will be consumed with dinner, and this alcohol adversely affects the level of sleep, leading to more prolonged muscle relaxation sleep, which again will trigger snoring. Finally, the mother’s brain becomes more aware of noise at night as she is listening for crying children. She is therefore easily roused by any noise. hence snoring is more commonly complained about by females. Sleep apnoea is when throat collapse/obstruction is so severe that there is no flow of air, and there is temporary reduction in the body’s oxygen saturation.
Patients who come to us have usually tried the standard remedies, such as sleeping on their side, nose clips, throat sprays etc. These solutions may be effective in mild problems. Generally our patients need more investigation and treatment than this. Snoring and sleep apnoea are two ends of the same disease spectrum. If left untreated, simple snoring may develop into mild apnoea, then severe apnoea and so on.
Snoring can cause increased sleepiness during the day, due to poor quality sleep caused by a range of conditions from sleep arousal (nearly waking up due to the sound of your own snoring) to obstructive sleep apnoea, to your partner constantly digging you in the ribs. Daytime tiredness obviously affects the ability to function / perform properly. Often when you wake up, it is like you have had little refreshing sleep – you feel tired.
Assess Your Daytime Sleepiness
You can assess the significance of your own daytime sleepiness by working out your Epworth sleepiness score, which has been designed and validated by sleep experts in Australia:
Score these day to day situations as to the likelihood of you falling asleep, 0=never, 1=sometimes, 2=often 3=most times
The Epworth Sleepiness Scale
How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just
tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently try to work out how they would have affected you. Use the following scale and tick the most appropriate number for each situation. Add the total of each ticked number to get your score.
0 = Would never doze; 1 = Slight chance of dozing; 2 = Moderate chance of dozing; 3 = High chance of dozing
|Sitting and reading|
Sitting inactive in a public place
(for example a theatre or meeting)
|As a passenger in a car|
|Sitting and talking to someone|
|Sitting quietly after a lunch without alcohol|
|In a car, while stopped for a few minutes in traffic|
How Did You Score?
A total score of 10 or more is said to be indicative of possible sleep apnoea or significantly disturbed sleep, and warrants at least an initial consultation with one of our ENT surgeons, who will thoroughly asses your whole upper airway, and will perform flexible endoscopy (not painful) and the Muller manouevre.
Medical Conditions Associated With Snoring
The feeling of tiredness during the day has been very strongly linked to an increased risk of car/lorry accidents, for understandable reasons. Sleep apnoea is also related to other significant disease, such as heart attacks, heart rhythmn disturbances, high blood pressure, insulin resistance, loss of memory/libido/concentration. Therefore, addressing snoring as a problem can lead to a distinct improvement in general health, and, since the treatment is mainly aimed at improving breathing, your quality of life and ability to exercise etc should also improve.
Cause Of Snoring
The cause of snoring is sound production at the back of the throat due to turbulent (noisy) airflow, which occurs at night due to loss of muscle tone in sleep, with collapse and narrowing of the breathing passages. We don’t snore whilst awake because muscle tone holds our airway open. Turbulent airflow occurs because the airway narrows/blocks. The causes of this are: a) Nose blockage leading to mouth breathing/opening. This causes the tongue to slide back and obstruct the back of the throat. b) A long and thick soft palate which sits behind the tongue, compromising the airway. c) Large tonsils which block the back of the throat. d) Excessive weight on the neck, causing pressure on the airway when muscles relax in sleep.
The treatment of snoring from a surgical viewpoint is focused on the cause of the problem – factors in the airway that precipitate obstruction to the breathing tube, and high velocity, turbulent, noisy breathing. The main procedures for this include nose unblocking surgery, laser palatal surgery and laser tonsillectomy/tonsillotomy (see elsewhere on this site). Weight loss can be vital in those whose body mass index is high. Always bear this in mind that it may be part of your treatment plan, without it any other treatment may be less effective.
Palatal Surgery (LAUP)
Going out of fashion somewhat, I still occassionally perform this operation, almost always under local anaesthetic. It certainly helps snorers, it can also help in mild cases of sleep apnoea. Scientific evidence based on observation of the airway and correlation with sound analysis of the patient’s snoring suggests that if snoring is of a low pitched, rumbling nature, it comes from the soft palate area. It is also called laser palatoplasty and uses the scanned Carbon Dioxide laser to remove a small part of the central section of the soft palate, usually under local anaesthetic. This effectively takes away the vibrating part of the airway responsible for a large proportion of the snoring sound, and causes scar tissue to build up, meaning the palate is stiffer and less likely to vibrate. Other procedures which solely cause palatal stiffening, such as Somnoplasty and Pillar implants, have not been as effective in reducing snoring, and are not provided. I have performed many LAUP procedures over the past 20 years, which have been generally successful, although unblocking the airway remains a prime concern in treating snorers. It is a procedure associated with quite a lot of postoperative pain however. This can go on for 10 days. Thats why it is less commonly perfomed, as a combination of airway unblocking surgery (septoplasty, turbinoplasty, laser tonsillectomy etc), weight loss and Mandibular Advancement Devices have successfully treated this problem without the pain.
The initial consultation is with one of our Consultant Ear, Nose and Throat Surgeons. The cause of snoring and sleep apnoea is always found in this area. A full history will be taken, your Epworth Sleepiness Score will be measured, as will your body mass index (BMI). Nose, throat and neck examination will be carried out, as will flexible endoscopy and the Muller manouvre. At this stage your doctor will have a pretty good idea as to what is causing your snoring / apnoea problem. You will be advised as to what is the correct treatment for the cause of your problem, which may involve a number of different treatments. Nose unlocking surgery, tonsil reduction, palatoplasty, mandibular advancement device, CPAP (Continuous Positive Airway Pressure), weight loss, allergy testing and treatment. A sleep study may be required pre and post treatment., to analyse the extent of any sleep apnoea, and to make sure treatment has been effective.