Snoring can range in significance from disturbing a bed partner to being a symptom of obstructive sleep apnea, a risk factor for cardiac disease and stroke. Snoring that is unrelated to obstructive sleep apnea may respond to a combination of nonsurgical treatments. However, if the problem persists despite conservative therapy, then surgical options may be considered.
This article explores why people snore, provides guidance for evaluating it and ruling out obstructive sleep apnea, and describes the available surgical treatments. Snoring associated with obstructive sleep apnea requires a different surgical treatment strategy that is beyond the scope of this article.
WHY PEOPLE SNORE
Humans go through four stages of sleep in each sleep cycle (and four or five cycles per night), and each stage has unique physiologic characteristics. As we progress deeper into sleep with each successive stage, the skeletal muscles of the body relax and eventually become atonic, except for the respiratory and ocular muscles. Soft tissues of the upper aerodigestive tract also lose their muscular tone.
Snoring is an undesirable vibratory sound that originates from the soft tissues of the upper respiratory tract during sleep, as airflow causes the relaxed tissues to vibrate.
The upper airway can be obstructed by the nasal septum, inferior nasal turbinates, adenoids, tonsils, uvula, soft palate, and base of the tongue—and often by more than one (Figure 1).3 In rare cases, obstruction can occur at the level of the larynx, such as from a tumor, laryngomalacia, or a laryngeal defect.
A SPECTRUM OF SLEEP-DISORDERED BREATHING
The American Academy of Sleep Medicine’s International Classification of Sleep Disorders1 defines a number of sleep disorders. In clinical practice, the first-line diagnostic test for sleep disorders is polysomnography.
Snoring is only one sign of sleep-disordered breathing; others are excessive daytime somnolence, restless sleep, and witnessed apnea.
Considerable evidence links obstructive sleep apnea with serious medical problems including hypertension, coronary artery disease, heart failure, cardiac arrhythmia, and stroke.2 Others include mood disorders, decreased libido, and cognitive impairment, with changes in attention, concentration, executive function, and fine-motor coordination.4 Therefore, ruling out obstructive sleep apnea is essential before pursuing interventions for primary snoring, although both disorders may warrant surgery.
Most patients who present to the office because of snoring have snored for many years. Many seek medical attention at the request of a long-suffering bed partner.
Associated symptoms in primary snoring may include mouth breathing, chronic nasal congestion, and morning dry throat. Witnessed apnea, frequent awakenings during sleep, restless sleep, daytime somnolence, frequents naps, and memory impairment may be signs of more significant sleep-disordered breathing, such as obstructive sleep apnea.
The Epworth sleepiness scale may help quantify the severity of daytime somnolence.5 It is measured in a short questionnaire in which the patient indicates, on a scale of 0 to 3, his or her likelihood of dozing in a variety of situations.
The STOP-BANG questionnaire consists of eight yes-no questions:
- Snore: Have you been told that you snore?
- Tired: Are you often tired during the day?
- Obstruction: Do you know if you stop breathing, or has anyone witnessed you stop breathing while you are asleep?
- Pressure: Do you have high blood pressure or are you on medication to control high blood pressure?
- Body mass index: Is your body mass index higher than 35 kg/m2?
- Age: Are you age 50 or older?
- Neck: Do you have a neck circumference greater than 17 inches (men) or greater than 16 inches (women)?
- Gender: Are you male?
A score of three or higher has shown a sensitivity of 93% for detecting moderate obstructive sleep apnea and 100% for severe obstructive sleep apnea.6