Snoring

Snoring

Snoring is a common phenomenon characterized by the production of sound during sleep, typically on inhalation, caused by vibrations of the upper airway. These vibrations result from a turbulent airflow, which occurs due to varying degrees of collapse in the upper airway lumen. Unlike obstructive sleep apnea, simple snoring is generally not associated with significant airway obstruction or frequent arousals from sleep. However, individuals who snore may still experience tiredness. This fatigue could be due to the increased effort required to overcome airway resistance, leading to brief awakenings, or due to being disturbed by their partner who is bothered by the noise.

The prevalence of snoring is challenging to determine precisely, but it is estimated that approximately 25% of adult males and 15% of adult females snore, with around 10% of these individuals experiencing some degree of obstructive episodes during sleep. Snoring is more commonly observed in men than in women.

Mechanism of Snoring

During sleep, the muscles of the pharynx relax, leading to partial obstruction of the airway. Breathing against this obstruction causes vibrations of the soft palate, tonsillar pillars, and the base of the tongue, producing the sound known as snoring. Sound levels as high as 90 dB have been recorded during snoring episodes.

Snoring can be categorized into two types:

• Primary Snoring: Occurs without the association of obstructive sleep apnea (OSA). It is not linked with excessive daytime sleepiness and has an apnea-hypopnea index of less than five.
• Complicated Snoring: Associated with OSA.

Causes of Snoring

• Children: The most common cause is adenotonsillar hypertrophy.
• Adults: The causes of snoring can originate from various anatomical regions, including:
  • Nose and Nasopharynx: Septal deviation, turbinate hypertrophy, nasal valve collapse, nasal polyps, or tumors.
  • Oral Cavity and Oropharynx: Elongated soft palate and uvula, tonsillar enlargement, macroglossia, retrognathia, a large base of the tongue, or tumors.
  • Larynx and Laryngopharynx: Laryngeal stenosis or an omega-shaped epiglottis.

Other contributing factors include obesity, a thick neck with a collar size exceeding 42 cm, and the use of alcohol, sedatives, and hypnotics, which can exacerbate snoring due to increased muscle relaxation.

Sites of Snoring

Snoring can originate from various sites, including the soft palate, tonsillar pillars, and hypopharynx. The specific site can vary from patient to patient and even within the same patient, complicating the decision-making process for surgical correction. Multiple sites of snoring may exist in a single patient.

Symptoms

Excessive loud snoring is socially disruptive and can lead to marital discord, sometimes resulting in divorce. A snorer with obstructive sleep apnea (OSA) may also experience:

• Excessive daytime sleepiness
• Morning headaches
• General fatigue
• Memory loss
• Irritability and depression
• Decreased libido
• Increased risk of road accidents

Table: Epworth Sleepiness Scale (ESS) Assesses the likelihood of an individual dozing off at the following situations (score 0 = never, 1 = slight chance, 2 = moderate chance and 3 = high chance of dozing)
Situation	Chance of dozing
Sitting and reading
Watching TV
Sitting inactive in a public place (e.g a theatre or a meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic
TOTAL

Treatment

1. Lifestyle Modifications:
   • Avoidance of alcohol, smoking, sedatives, and hypnotics.
   • Dietary modification for weight loss.
   • Sleeping on the side rather than on the back.
   • Regular exercises.
2. Devices.

• Mandibular advancement splints (MAS) function by displacing the mandible forward, which in turn brings the base of the tongue anteriorly. This forward movement increases the dimensions of the upper airway, reducing airway obstruction and facilitating smoother airflow during sleep.
• Continuous Positive Airway Pressure. CPAP functions as a pneumatic stent, providing continuous airflow that keeps the upper airway open during the various sleep phases.

3. Surgical Interventions:

1. • Removal of obstructing lesions in the nose, nasopharynx, oral cavity, hypopharynx, and larynx.
   • Radiofrequency volumetric reduction of tissues in the turbinates, soft palate, and base of the tongue.
   • Uvulopalatopharyngoplasty (UPP) is performed surgically, with options including cold knife surgery, radiofrequency-assisted (RAUP), or laser-assisted (LAUP) procedures.

Key Definitions

• Sleep Apnea: A condition characterized by the cessation of breathing for 10 seconds or more during sleep. Experiencing fewer than five episodes per hour is considered normal.
• Apnea Index: The number of apnea episodes occurring within one hour.
• Hypopnea: A reduction in airflow during sleep. Some define it as a 30% decrease in airflow from baseline, accompanied by an EEG-defined arousal or a 4% drop in oxygen saturation.
• Respiratory Disturbance Index (RDI): Also known as the apnea-hypopnea index, this measures the number of apnea and hypopnea events per hour. An RDI of less than five is normal. Severity is classified as mild (5–14), moderate (15–29), and severe (≥ 30).
• Arousal: A brief awakening from sleep due to apnea or respiratory efforts.
• Arousal Index: The number of arousal events per hour. An index of less than four is considered normal.
• Sleep Efficiency: The ratio of minutes spent asleep to the total minutes in bed after lights are turned off.
• Multiple Sleep Latency Test (Nap Study): A test where the patient is given four or five scheduled naps, usually during the day, to measure the time it takes to transition from wakefulness to sleep and to record REM sleep. This is performed when narcolepsy is suspected or to evaluate daytime sleepiness objectively.

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Learning resources.

• Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
• Susan Standring, Gray’s Anatomy.
• Frank H. Netter, Atlas of Human Anatomy.
• B.D. Chaurasiya, Human Anatomy.
• P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
   

  Author:

  

  Dr. Rahul Bagla
  MBBS (MAMC, Delhi) MS ENT (UCMS, Delhi)
  Fellow Rhinoplasty & Facial Plastic Surgery.
  Renowned Teaching Faculty
  Mail: msrahulbagla@gmail.com
  India

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