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Sawing lumber: have you snored your bedmate into another zip code? There are ways to silence the din - Health - treatment of snoring

May, 2002 by R. Daniel Foster

The beauty of snoring is that the perpetrator can plead temporary amnesia and get away with it. After all, you can saw wood for hours without disturbing yourself. To your other half, however, it's like sleeping next to a landing strip. And that, unless you're strictly into one-night stands, is the reason why many guys finally do something about it.

Nearly 90 million Americans snore, most of them men. The main culprits for all that racket are the muscles of the palate and the uvula. When the area relaxes and narrows during sleep, a steady stream of air forced over the slackened tissue causes it to flutter like a badly stretched drum. As you age, your tissues become looser and the decibel level leaps. By age 60, 60 percent of men are clear-cutting forests habitually.

There are numerous fixes for snoring, from folk traditions to what might be called a face-lift for your throat. Most methods attempt to open the compressed airway, either by tightening the collapsing tissue or preventing the obstruction.

Surgical solutions have advanced since the early 1980s, when doctors began slicing away loose tissue. Although traditional uvulopalatopharyngoplasty (UPPP) is still performed, it can be horrifically painful. The surgery, in which the uvula and soft palate are resectioned, requires a two-day hospital stay and two weeks of recovery time. One veteran of both Vietnam and UPPP calls the latter the more unpleasant experience.

The less invasive laser-assisted uvulopalatoplasty (LAUP) burns away excess tissue and is performed under local anesthesia on an outpatient basis. Yet its long-term effectiveness has yet to be established, and the pain can still land you in a new grotto of hell.

"The incision or the laser burn has to heal while you constantly breathe, talk and swallow, so the wound is always being stretched, causing considerable pain," says John Shepard, M.D., medical director of the Mayo Clinic Sleep Disorders Center in Rochester, Minn. "One patient said that if he'd had a gun he would have shot himself, the pain was so bad." To be fair, others experience less discomfort--the equivalent of a bad sore throat for three or four days.

Frequency of snoring is not reduced, only intensity. "It's like tightening the tension on a stringed instrument," says Shepard. "The low-frequency guttural sound goes away," leaving patients with "airy breathing" that's tolerable to bed partners.

But snorers may have to endure the ordeal again if results are not achieved, which happens "not infrequently," says Shepard. And interior tissue "lifts"--like their exterior cousins--may have a limited life span. "The concern now is that in five or 10 years, sagging will return along with louder snoring," says John Campana, M.D., a throat surgeon at the University of Colorado School of Medicine. "Skin also becomes less elastic as you age, which can counteract the surgery."

It's too soon to determine the lasting efficacy of LAUP, popular only over the past five years, but a recent study at Srinakharinwirot University in Bangkok found that patients are at risk of a snoring recurrence if they gain weight after the surgery. Also, a University of British Columbia investigation found that response to LAUP is "variable and unpredictable."

In an effort to lessen the agony factor, other snore-control techniques have been developed (see "Breakthroughs in Noise Reduction," at right).

OXYGEN BREAK

A snore is just a snore, right? Not always. Nocturnal noisemakers may be suffering from mild apnea, a condition in which tissues loosen considerably, causing a complete collapse of the airway during which breathing can stop for up to 30 seconds. Oxygen starvation eventually forces air through the obstruction, producing a loud snort.

Apnea sufferers sleep light, never achieving deep levels of rest needed for rejuvenation, and they are at higher risk for hypertension and cardiac arrest. Excessive daytime drowsiness is an early red flag; so are morning headaches. Consult a physician if you believe you suffer from apnea.

LAUP and UPPP are not effective for moderate to severe apnea, which is most often treated with continuous positive airway pressure (CPAP). A pressurized mask is worn over the nose during sleep, forcing oxygen through the mouth via a small pump, keeping the airway open.

"CPAP eliminates all snoring, in nearly every case," says Shepard. "Very few treatments for anything can claim such success. It acts like a bike pump: Deliver enough air pressure, and the tire"--your throat--"won't go flat." Yet CPAP, which isn't the sexiest apparatus you'll bring to bed, can be cumbersome. And the treatment isn't cumulative; you have to wear the mask every night.

For snoring and milder apnea cases, some people use a mandibular adjustment device, variations of which have done well in small studies. A mouth-guardlike apparatus positions the lower jaw forward, opening the throat and preventing the tongue from falling back, creating a larger airway. The gadget may take getting used to, and your bite may be affected for several hours upon waking (so no more beef jerky for breakfast). There are lots of models to choose from--priced from $350 to $1,500--so ask your doctor for guidance.

Finally, the simplest defense against snoring may be to ratchet up your fitness level. Being overweight is the most common denominator among snorers, so dropping a few pounds could work wonders. And what about anecdotal reports that singers, with their constantly exercised throat muscles, snore less?

"Slim, well-conditioned athletes of all kinds probably snore less than fat old guys that sit on the couch," says Campana, "and professional singers are athletes in many ways. But I'd bet you a buck that Pavarotti snores like a frickin' freight train."

DE-SNORE WITHOUT SURGERY

• * Trim a few pounds. If you're overweight, you're much more likely to snore.
• Sleep on your side, not your back, which causes your tongue and soft palate to fall back, narrowing the airway.
• Treat allergies and nasal congestion, which can further obstruct airways.
• Reduce alcohol and sedative use, which induces excessive muscle relaxation of throat tissues.
• Anti-snoring pills, nasal sprays and herbal throat sprays are dismissed by most physicians. Reports are mixed on nasal strips, which may help reduce snoring slightly for some people who sleep on their sides.

RELATED ARTICLE: Breakthroughs in noise reduction.

New techniques to control snoring without the torture of traditional surgery are showing promising results.

* Somnoplasty entails zapping the soft palate with low levels of radio frequency that essentially microwave the tissue from the inside out. In U.S. clinical trials, the tissue being treated died over the course of several weeks, tightening the area and causing the uvula to retract. The procedure is done under local anesthesia in less than 30 minutes, and patients typically return to normal activities that same day.

Somnoplasty has an improvement rate of 65 percent and a cure rate of 45 percent, concludes a study at Mannheim University Hospital in Germany, published in the journal Sleep and Breathing. Patients reported mild to moderate pain that lasted about four days, which was treated with anti-inflammatory drugs. The report supports an earlier study conducted at Stanford Sleep Research Center.

* If you don't mind needles, snoreplasty is another option. Performed in 15 minutes with a topical anesthetic, snoreplasty involves injecting the soft palate with medication that causes scarring and stiffening of tissue, reducing the fluttering that produces snoring. (The drug, a sclerosant, has been used for decades and is similar to that used to reduce varicose veins.) Scarring develops in two or three weeks, with about half the patients in one study requiring a follow-up shot in one or two months.

A report last year from the Walter Reed Army Medical Center in Washington, D.C., found that snoreplasty stops problem snoring in three-quarters of those who are treated. The downside: The effects often wear off after one or two years. Yet the procedure runs as little as $40, leading the researchers to suggest that snoreplasty, if not a cure, is a low-cost, low-pain alternative to more drastic treatments.

R. Daniel Foster's bedmate sleeps soundly.

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Treatment of snoring and obstructive sleep apnea with a dental orthosis

June, 1991 by Wolfgang W. Schmidt-Nowara, Thomas E. Meade, Marvin B. Hays

Snoring is caused by vibration of the soft palate and adjacent structures and represents partial obstruction due to narrowing of the upper airway at that site. [1,2] In some patients, snoring is associated with the obstructive sleep apnea syndrome, a condition of disturbed sleep caused by intermittent upper airway obstructions that requires frequent arousal for relief. In others, breathing is normal or minimally impaired, and there are no other symptoms. Patients often request treatment because of the social consequences of snoring; the occurence of sleep apnea and its consequences are additional reasons for medical intervention.

The treatments that have been developed for obstructive sleep apnea require surgery or adherence to a demanding medical regimen. [3] These options are not acceptable to all patients. Compliance is a problem with nonsurgical treatments, including continuous positive airway pressure, a treatment that, despite its effectiveness, is often not tolerated by patients with mild symptoms. [4,5] Thus, there is a need for alternative therapies that are effective and acceptable, especially to patients with minor complaints.

Mandibular advancement by means of a dental device was first reported by Robin [6] as treatment for upper airway obstruction in infants with mandibular hypoplasia. In recent years, several dental devices that modify the position of the mandible have been advocated as treatment for sleep apnea. The published experience with this approach has been reviewed. [7] The reports are limited by small patient numbers without long-term follow-up. In this paper, we report our experience with a dental device (Snore-Guard, Hays & Meade, Inc, Albuquerque, New Mexico) designed to advance the mandible and to relieve upper airway obstruction in sleep. The report consists of a follow-up survey of the first 71 patients who received the orthosis for treatment of snoring or sleep apnea or both. The survey investigated the patients' subjective assessments of the effect of treatment on snoring and other symptoms, the compliance with treatment, and the occurrence of side effects or complications. In addition, we report sleep studies in 20 patients with obstructive sleep apnea syndrome who had studies performed before and with use of the orthosis...

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HUKM's Breakthrough In Snoring Treatment

KUALA LUMPUR, Aug 18 (Bernama) -- Though there is no data on snoring, it can cause discomfort to one's sleeping partner and sometimes it can be more embarrassing if celebrities and VIPs snored in public.

However, the phenomenon common in all age groups, both male and female, can now be overcome by a new technique called "pillar procedure".

The technique has been introduced in Malaysia by a leading provider of medical devices to treat sleep disordered breathing, Restore Asia Pte Ltd, through its company in Singapore.

The Universiti Kebangsaan Malaysia Hospital (HUKM) in Cheras is the first to adopt the technique.

Disclosing the technique Thursday, HUKM's Head of Ear, Nose and Throat Department, Prof Dr Abdullah Sani Mohamed, said snoring was divided into habitual snoring (without sleep apnoea) and snoring with sleep apnoea.

He said snoring was a sign of obstruction of the upper airway during sleep and sleep apnoea occurred when the obstruction was completed.

Sleep apnoea might be graded as mild, moderate and severe, he said.

Dr Abdullah Sani said HUKM offered and had performed the full range of surgery from aggressive uvulo palato pharyngo plasty and laser uvuloplasty to the newer radio frequency ablation techniques.

He said the ideal cure for snoring caused by floppiness of the soft palate was to stiffen it without doing any cutting of the tissue.

These could be done with the pillar procedure, he said.

The procedure was designed to reduce airway obstruction where three inserts made from multiple polyester materials woven together about 18mm in length and 2mm in diameter, embedded in the soft palate using a specially designed preload delivery tool, he said, adding the palate was neither cut nor removed.

"It can be done in less than 15 minutes in the clinic with minimal pain. The patient can go home with normal diet and daily activities almost immediately," he said.

The pillar procedure, first introduced in the United States in April 2003, is now available in Australia, China, Hong Kong, Ireland, Israel, South Korea, Portugal, Singapore, South Africa and Turkey.

Malaysia is the second country in Southeast Asia to start this innovative treatment.

Dr Abdullah Sani, who performed the technique on five patients this year, said the complication risk was very low.

He said the therapy costs between RM3,000 and RM4,000 at HUKM.

He performed the technique on his fifth patient today, Syaiful Izam Jabar, 26, a secondary school teacher in Melaka.

After the implant procedure, Syaiful Izam, who has been snoring since Standard Four, said he did not feel any pain and was glad for the RM2,200 treatment he underwent.

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What are the medical treatments for snoring?

If your own efforts to stop snoring do not help, consult your physician or an otolaryngologist (ENT, or ear, nose, and throat doctor) If you choose to try a dental appliance for your snoring, you will need to see a dentist specializing in these devices. Some medical solutions to snoring are:

Continuous Positive Airway Pressure (CPAP): Continuous Positive Airway Pressure consists of sleeping with an air mask to maintain continuous air pressure in the throat. CPAP is a treatment for sleep apnea, as well as for snoring. For details on Continuous Positive Airway Pressure, see the Helpguide article on Sleep Apnea: Symptoms, Causes, Diagnosis, and Treatment.

Dental appliances, oral devices, and lower jaw positioners: A wide range of dental appliances, oral devices, and lower jaw adjusters are available to alleviate snoring. Some people experience significant improvement with these oral appliances, which bring the lower jaw forward during sleep. Most of the products fit inside the mouth, but some products on the market are worn around the head and chin to adjust the position of the lower jaw. (See the Helpguide article on Sleep Apnea: Symptoms, Causes, Diagnosis, and Treatment for more information on dental devices.)

Surgery

Thermal Ablation Palatoplasty (TAP) treats snoring and various types of Obstructive Sleep Apnea. The types of TAP include:

Bipolar cautery

Laser-Assisted Uvula Palatoplasty (LAUP) vaporizes the uvula and a portion of the palate with a laser in the doctor's office under local anesthesia. LAUP effectively removes obstructions to the airway, which may be causing snoring or sleep apnea.

Laser-Assisted Uvula Palatoplasty has a higher success rate than UPPP, but it requires a surgeon with expertise in laser procedures.

Radiofrequency ablation, or somnoplasty, shrinks excess tissue in the upper airway with a needle electrode. For snoring, the soft palate and uvula are reduced. For Obstructive Sleep Apnea, the base of the tongue is reduced. For chronic nasal obstruction, nasal turbinates are reduced. Somnoplasty does not require general anesthesia.

Tonsillectomy and adenoidectomy may help children with serious snoring problems. These procedures remove the tonsils and adenoids.

See your doctor or dentist to discuss the medical treatments available and to decide which might help you.

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