A hard night's sleep: all about snoring and sleep apnoea

Snoring is very common (affecting around 30 million people in the United Kingdom) and is not generally considered serious. However, in severe cases it may have an impact on quality of life, putting a strain on relationships and occasionally cause health problems. In this informative article, we hear from highly esteemed consultant ENT and thyroid surgeon Mr Julian Hamann on the causes and treatment options for snoring.

What causes snoring?

Snoring is caused by the airways becoming partially blocked during sleep. When this happens, the soft tissues of the upper airways vibrate during inspiration and/or expiration, and this is heard as snoring.

Muscles relax during sleep. When the muscles of the throat relax, the soft tissues are more likely to collapse into it, partially blocking the airways. Muscle tone is particularly low during the rapid eye movement (REM) phase of sleep.

Obesity is one of the most common causes of snoring in adults. This is because more muscle tone is required to keep the upper airways open, as there is more fat in the soft tissues of the neck. This often affects men more than women, as men and women store fat in different areas, with men tending to store more fat in the waist and neck area. However, after the menopause fat distribution in women seems to more closely resemble that of men, making the impact of weight on snoring similar in men and women.

Sleeping on your back also encourages the soft tissues to collapse into the upper airway. Weight gain will exacerbate this tendency. In certain circumstances, the tongue may fall back and partially obstruct the airway. This is more likely if the tongue is larger than average, or if the jaw is receding.

Other factors which contribute to snoring include:

• Alcohol, which acts as a depressant and contributes to muscle relaxation in the throat
• Smoking, which can lead to irritation and swelling in the lining of the nose and throat
• Large tonsils and adenoids can compromise the airways. This is the most common cause of snoring in children.
• Nasal problems such as rhinitis, polyps or a crooked middle partition (septum) can partially obstruct the upper airways.

How is snoring treated?

The treatment needs to address the underlying cause of the snoring. Many snoring treatments focus on lifestyle changes, although surgery may sometimes be appropriate.

Making lifestyle changes to treat snoring

It is advisable to address any lifestyle issues that may be contributing to your snoring. Things to consider include:

• Your weight (if you have a BMI over 25): losing weight is challenging, but your GP may be able to help. Try to combine changes in diet with exercise.
• Reducing or eliminating alcohol
• Stopping smoking
• Modifying sleep position
• Specialised mouth-guards, also known as mandibular advancement devices. These act by holding the jaw forward a couple of millimetres. This pulls the back of the tongue forward slightly, improving the upper airway.
• Nasal splints can sometimes help improve nasal airflow.

Snoring is frequently a problem due to the impact that it has on other people. Simple measures such as earplugs and masking background sounds can often be helpful.

Medical treatments

• Steroid nasal sprays may help improve the nasal airway. They are most effective in patients who have associated problems with nasal obstruction.
• Rhynil spray contains a herbal extract known as Eyebright. It is used in the mouth and nose, and can help tighten up the soft palate and improve the nasal airway.

Surgical solutions to snoring

Surgery for snoring should only be considered where lifestyle changes and nasal sprays have been unsuccessful; and after a careful examination of the nose and throat has ascertained the probable anatomical causes of the snoring. However, all operations carry the risk of complications, and the outcomes can often vary. It is important to discuss the likelihood of success and possible complications with your surgeon.

Some of the more common procedures include:

• Nasal operations to straighten the middle partition of the nose (septoplasty) or remove polyps (polypectomy). These operations are generally only recommended for individuals with associated nasal symptoms.
• Operations to stiffen the soft palate (palatoplasty). This may entail removal of parts of the soft palate, or the use of electrocautery or radiofrequency energy to induce the formation of scar tissue in the soft palate. A new technique involves the insertion of small plastic strips beneath the surface of the palate. These act like the batons in a sail and can effectively reduce snoring.
• The removal of the adenoids and tonsils. This is often a very effective treatment for children with snoring and obstructive sleep apnoea (OSA, see below).

Obstructive sleep apnoea

Snoring is caused by partial obstruction of the airways during sleep. In severe cases, the airways may become totally obstructed, causing an interruption in breathing (apnoea). This is a condition known as obstructive sleep apnoea (OSA).

An apnoea is defined as the suspension of breathing for more than 10 seconds, although it is not unusual for the suspension to last for more than 30 seconds. This is not life threatening, as people will automatically wake up in order to resume breathing. However, if this happens more than 10 or so times an hour, it can be extremely debilitating.

OSA can lead to daytime sleepiness, irritability, forgetfulness, and morning headaches. People with OSA are also at increased risk of heart disease and stroke. If you think you may suffer from OSA, you should talk to your GP. They will be able to refer you to a specialist sleep clinic.

As people with OSA are much more likely to have traffic accidents as a consequence of tiredness, you should inform the DVLA if you receive a positive diagnosis.

OSA can be treated with a small electric air pump that applies a continuous positive airway pressure (CPAP) to the airways via a mask that is worn over the nose. This treatment is usually immediately effective.

If you are concerned about snoring or symptoms of obstructive sleep apnoea, you can schedule a consultation with Mr Hamann by visiting his Top Doctors profile.