Snoring is bold. Obnoxious, loud, persistent and the ultimate sleep disruptor. The snore drags on, it perpetuates nightly and turns dreams into nightmares, the beauty of rest into anarchy of the mind. It’s the violent drumming in our ears that causes us despair. A horrible beast that we are ignorant of in the fight for somnojustice. But the snorers paradox is the heaviest of burdens to bear. You see, it’s unintentional. There’s no motive or premeditation behind the rumbling siren that causes relationships to fail, health to decline and windows to shatter (well maybe not shattered windows). Simply put, it’s not your fault. But that doesn’t mean there’s nothing you can do about it. Let’s explore how far we’ve come in tackling this beast, what are the underlying threats to social and psychosocial wellbeing and your health. Buckle your seatbelts, it’s a bumpy road ahead.
History of Snoring
Dionysus, probably my favourite Greek god, the Greek god of wine, knew that a few too many glasses of the good stuff would bring out the raging beast within during the evening slumber. Ebers, an Egyptian medical papyrus of herbal knowledge dating back 1550 BC, recommended using thyme to reduce snoring and there’s a few similar remedies available in the market today. You only have to google “husband murdered for snoring” to have a sense of the prolific impact snoring has had on relationships over time throughout modern history. One thing that is profoundly clear is that we’ve been looking for simple solutions to the snoring problem for centuries and still we find the vast majority of sufferers aren’t being treated or even know it’s something that can be improved. Unfortunately, the snoring paradigm is far more complex and is a strong risk factor for a far more serious condition called obstructive sleep apnea.
To understand snoring we must first understand the mechanism that causes snoring. In short, snoring is the vibration of soft tissues in the nose and/or throat when you breathe. This is made worse in a few different ways. Firstly, let’s talk about the nose; Breathing through your nose is actually the optimal way to breathe during sleep. Breathing through your mouth results in the jaw falling back and the soft tissue attached to the jaw to fall back which inadvertently causes the airway to be obstructed. Breathing through the nose is superior as mouth breathing causes turbulent airflow and doesn’t allow for a smooth transition of airflow down the airways to the lungs.
There are some simple tests to see if the snoring you are experiencing is from mouth or nose breathing. These are generally done by an ear, nose & throat (ENT) specialist or sleep/respiratory physician. Nasal obstruction can result in adverse pressure changes in the mouth which in effect cause the soft tissue in the airways to collapse. A patient will then often open their mouth while asleep to then help open the airways. A good test for this for yourself would be to notice if you wake up with a dry mouth or experience an increase in thirst during the night.
Nose breathing warms and humidifies inhaled air and breathing is really the nose’s core function. There are very few exceptions to when we should be breathing through the mouth such as vigorous exercise.
In children, we need to address mouth breathing due to the fact that it may have long term consequences such as malocclusion and other teeth alignment issues. If your child is mouth breathing it is important to go see an ENT specialist to see what options are available to you to avoid the potential consequences.
Breathing through the nose filters and humidifies the air we breathe into our lungs. In turn this improves gas exchange in the lungs and heaps improve sleep. If we breathe predominantly through our mouths it becomes more likely that the soft tissue in our airways will collapse and create snoring and blockages.
By design the nose creates more resistance whilst breathing than breathing through the mouth. This helps to slow down and control breathing rate which in turn keeps the PH in the blood balanced which helps cells all around the body feel happy and healthy. Replicating this kind of breathing through the mouth would be next to impossible and require a lot of conscious effort.
To surgery or not to surgery
Firstly, nasal blockage or congestion can be treated with medication. If people have allergies they can try nasal corticosteroids. For people that don’t have allergies a simple nasal decongestant can be simple and effective. If problems persist then the best option is to work out a solution with your doctor.
Oral appliances that position the lower jaw forward open the airways and result in a reduction and/or disappearance of snoring. These appliances work best when custom made for individuals and are usually prescribed by a dentist.
Weight loss can be an extremely effective method for reducing snoring in individuals particularly in those with a BMI of 30 and over. Alcohol and sedative avoidance can also significantly improve snoring and should be avoided as much as possible to improve overall quality of sleep.
In some cases none of the above solutions can help to achieve a significant result for a patient and surgical interventions may need to be considered. Your best bet is to see an ENT specialist for the most up to date advice on current treatments.
How common is snoring in different parts of the world?
1 billion people have sleep apnea worldwide. Even more snore. And some suffer from a condition known as upper airway resistance syndrome. In Europe, the Americas, the UK, Australia and New Zealand we see sleep apnea related heavily to exercise (lack of), diet (poor) and weight (unhealthy BMI). In Asian countries (60% of the world’s population) sleep apnea is as prevalent with a largely lower proportion of patients who are concurrently overweight and suffer from sleep apnea. The reason we see this more in Asia is the difference in craniofacial morphology with Asian patients, particularly of South-East Asia descent.
Why people snore?
The base of the tongue and the soft palate can fall back in deep sleep occluding the airways. When we don’t have a full blockage the soft tissue vibrates creating loud noises that we describe as snoring. There are a lot of contributing factors to snoring including drug and alcohol use, weight, age, gender, neck circumference, strength of the muscles around the neck and the muscles we use to breathe.
Snoring in Kids
Snoring in children is usually related to enlarged tonsils and adenoids, which can give rise to upper airway resistance. Adenotonsilectomy (AT) is the treatment of choice worldwide for these cases in children. However in recent research, it has been found that 60-70% of these children experience residual OSA (obstructive sleep apnea), meaning they still have obstructive sleep apnea and snoring following the procedure. Three main minimally invasive co-adjunctive therapies can be used, which have seen success in these cases. 1. Rapid maxillary expansion 2. Use of oral appliances 3. Myofunctional therapy.
Why is snoring so annoying?
Around 45% of Men and around 25% of women frequently snore. There have been studies that show the bed partners of snorers often suffer more than the snorer themselves so the question remains “why is that”. One of the reasons is that you are so close to the person snoring. Snoring is loud and annoying enough from a distance let alone 2 feet away. But more than any of this is the fact that snoring is irregular, the frequency and pitch and the intervals of sound are constantly changing. Unlike white noise or other helpful “get to sleep” soothing sounds, snoring sits on the other end of the spectrum. And from there the bed partner can become focused on the fact that the snoring is keeping them awake which will amplify the effects and sustain sleeplessness.
What are the consequences of untreated snoring?
There are a number of consequences of snoring that vary depending on the severity, frequency and whether or not the person is also suffering from obstructive sleep apnea. Just some of the issues arising from snoring are listed below.
Excessive daytime sleepiness – If you don’t sleep well it’s no secret that you’ll likely be tired during the day. We can monitor daytime sleepiness using the epworth sleepiness scale which is a self reporting tool that identifies just how sleepy we get performing different activities and tasks. Sleepiness will be amplified depending on a number of factors ranging from how loudly they snore, whether or not they suffer from obstructive sleep apnea and how severe it is, and some other factors that affect the quality of a person’s sleep.
Difficulty concentrating – Poor sleep has been closely linked to a reduced mental acuity and snoring and obstructive sleep apnea are two of the biggest culprits for poor sleep. Treating these conditions will likely improve your capacity to function mentally during the day.
Morning headaches – In patients with sleep apnea the lack of oxygen in the blood and the build of carbon dioxide tend to cause morning headaches for people suffering from moderate to severe sleep apnea.
Sore throat upon awakening – a common trait for patients that snore and those suffering from sleep apnea is that they will breathe through their mouth while they sleep.
Restless sleep – Patients that snore and suffer from sleep apnea can sometimes develop other sleep problems over time if left untreated. This includes conditions such as insomnia.
High blood pressure – Drops of oxygen concentration in the blood caused by blockage of the airways in sleep apnea puts undue stress on the heart. To make up for the lack of oxygen the heart works harder and the blood vessels become stressed. Over time this leads to an increase in blood pressure and puts you at risk of stroke, heart attack and sudden death.
Your snoring is so loud it’s disrupting your partner’s sleep – disrupting your partners sleep should be taken seriously as this has a number of health related consequences.
In children, poor attention span, behavioral issues or poor performance in school.
Besides the physical consequences psychosocial consequences of snoring and sleep apnea include: Relationship breakdown, Mental illness exacerbation, Increase risk of depression and anxiety, Irritability.
What are the available treatments?
The current gold standard treatment for sleep apnea and snoring is CPAP or APAP therapy. This is where you are connected to an “air pump” that creates Positive Airway Pressure and pumps air into the lungs. You are connected to a mask and hose to the machine.
Mandibular advancement devices are becoming increasingly commonplace in the treatment of sleep apnea. These devices push the lower part of the jaw forward which helps open the airways. The relatively higher compliance rate when using these devices as opposed to CPAP is one of the main reasons clinicians chose these devices for their patients.
Surgery can be utilised for patients that do not achieve adequate therapy with the above therapeutic options. It can be used as a last result by doctors to open the airways but should never be considered or presented to patients as a first option.
Pillows and devices to keep a snorer on their side can be utilised and can be relatively effective for those that often snore or have apneas on their side.
Inspiratory muscle training can be effective in improving snoring and sleep apnea as it strengthens the muscle around the upper airways and the diaphragm which is the main muscle that brings air into the lungs.