SNORING IS NO LAUGHING MATTER!

 

·       DOES YOUR SNORING KEEP OTHERS AWAKE?

 

·       IS YOUR SNORING KEEPING YOU AND YOUR SLEEP PARTNER IN SEPARATE ROOMS?

 

·       IS SOMEONE ELSE’S LOUD SNORING YOUR “NIGHTMARE”?

 

·       DOES YOUR SLEEP SUFFER FROM FREQUENT MIDDLE OF THE NIGHT ELBOW THRUSTS OR SHOVES?

 

SNORING IS DISRUPTIVE BREATHING DURING SLEEP

 

Excessive snoring can be a sign that something is wrong with your breathing during sleep.  Snoring indicates that the breathing passage is not fully open.  The noise of snoring comes from trying to force air through a narrowed airway during sleep.  Loud nightly snoring may be a very important sign of a potentially dangerous sleep disorder called obstructive sleep apnea.

 

LOUDNESS OF SNORING

 

Relief from the noise of snoring that disrupts someone else’s sleep is the most frequent reason for consultation in dental and medical offices.  Loudness is a subjective term based on the ears’ sensitivity to the particular frequencies contained in the sound.  Loudness merely describes the ears’ perception of the unpleasant sound.  The distance of the ear from the sound source affects loudness.  The further away, the greater the loss of loudness.  Sounds dissipate over distance.  Getting a larger bed or simply turning the snorer away reduces the perceived loudness.  The magnitude of loud snoring however, can approach or exceed that of a loud rock concert depending on proximity of the bed partner to the snorer.

 

Relative loudness values:

Jet engine at 30 meters…………………………………………….130 Decibels

Jet engine at 150 meters…………………………………………..120 Decibels

Loud human snoring measured by a Medibyte™……...................100 Decibels 

Heavy expressway traffic, car windows open………..…................100 Decibels

Very loud 75 piece orchestra, 3^rd row seats………………..............90 Decibels

Alarm clock on nightstand………………………………………….....80 Decibels

Quiet radio, background music in a dental office………...................60 decibels

 

Loudness of the noise however, does not define or relate to the cause of the snoring.

 

CAUSES OF SNORING

 

Three conditions are necessary for snoring:

1.   Structure capable of vibrating

2.   Limitation of airflow

3.   Sleep

 

Snoring may be generated at multiple sites because there are varying reasons for the narrowing of the airway.  The narrowing can be in any membranous part of the upper airway.  From the nose to the vocal cords, any part that lacks rigid i.e. cartilaginous or bony support may vibrate.  Examples are swollen nasal membranes, soft palate, tonsils, adenoids, uvula, tongue, faucial pillars and pharyngeal walls.

 

 

 

The tonsils are designed to detect and fight infections.  They are located at the back of the mouth on each side of the throat.  Like other infection-fighting tissues, the tonsils swell while they are fighting invasive germs.  Often, the tonsils do not return to their starting size after the infection is gone.  They can remain enlarged and narrow the airway, vibrate from air flow and cause snoring.

 

The soft palate separates the back of the mouth from the nose.  During nasal breathing it keeps the airway open and during swallowing it closes, directing food and liquids down the esophagus.  It is the flap of tissue that hangs down in the back of the mouth.  If it is too long or floppy it can vibrate and cause snoring.

 

The uvula is the finger-like extension that hangs in the midline from the end of the soft palate into the back of the mouth.  An abnormally long or thick uvula can also vibrate with turbulent airflow and cause snoring.

 

The tongue is important in speech, chewing and swallowing.  It is a unique, complex muscle because it has both origins and insertions in muscle.  It must be free to move in all directions to function properly.  Unlike other animals in which the entire tongue is horizontal, in humans the rearmost one-third of the tongue is vertical in the throat.  If the vertical one third of the tongue gets too relaxed during sleep it can slip backwards and narrow the airway, facilitating vibrations and snoring.

              NORMAL AIRWAY                                     NARROWED AIRWAY OF SNORER

 

MOUTH-BREATHING AND SNORING

 

It is ideal for humans to breathe through the nose.  The nose is nearly perfect in its design as the humidifier, heater and filter for incoming air.  Some people cannot breathe through the nose because their nasal passages are obstructed.  Allergies, enlarged tonsils and adenoids, sinus infection, nasal polyps, deviated septum, and nasal infections are conditions that can result in mouth-breathing.  In mouth-breathers the functions of warming, filtration and humidification are compromised, but accomplished by the throat.  The compensations to accommodate mouth-breathing are retrusion of the tongue, parting of the lips, lowering of the mandible and narrowing of the airway.  The soft palate can thus provide warming, cleansing and moisturizing of air inspired through the mouth.  Many mouth-breathers snore.  Snoring, in fact, may be a beneficial adaptation in mouth-breathers, bringing about vasodilation that warms inhaled air. Mouth-breathing involves much greater activity on the part of the tongue muscles.  Daytime hyperactivity may result in tongue muscle fatigue or atonia at night, predisposing it to collapse.

 

STAGES OF SLEEP AND SNORING

 

Snoring can occur during any or all stages of sleep.  Snoring is most common in rapid eye movement (REM) sleep, because of its associated loss of muscle tone.  During REM sleep the brain signals all the muscles of the body, except the breathing muscles to relax, actually an atonia.  Unfortunately the tongue, palate, and throat can collapse when their muscles become atonic.  This sleep associated atonia in turn causes the airway to narrow and can worsen snoring.

 

SLEEP POSITION AND SNORING

 

When human beings sleep on their backs (supine), gravity pulls on all the tissues of the body.  The tissues of the pharynx are relatively soft and floppy.  In supine sleeping gravity pulls the palate, soft palate, tonsils and tongue backwards.  This may narrow the airway enough to cause turbulence in airflow, tissue vibration and snoring.  When patients sleep on their side, the tissues are no longer pulled backwards and the snoring often lessens.

 

MEDICATIONS, ALCOHOL AND SNORING

 

The conditions necessary for snoring are vibration of the tissues as a result of limitation of airflow during sleep.  Alcohol as well as medications cause muscle relaxation that can enhance airway collapse during sleep.  The more the muscles of the palate, tongue, neck and throat relax, the greater the airway narrowing.  A smaller airway facilitates greater tissue vibration.  Some medications encourage a deeper level of sleep, which can also worsen snoring.

 

DANGERS OF SNORING

 

Because almost all patients who have obstructive sleep apnea (OSA) snore, snoring must be evaluated as a potential indicator of significant medical problems.  Upper airway resistance syndrome (UARS) is also characterized by snoring.  These patients may exhibit all the clinical symptoms of OSA but do not have apneic or hypopneic events.  Therefore the differentiation of benign snoring from these other morbid conditions is imperative.

 

Snoring is thought by some to be the first step in a continuum that progresses to UARS and winds up with all the morbid consequences of OSA.  OSA is associated with such symptoms as diabetes, weight gain, depression, excessive daytime sleepiness, fatigue, sexual dysfunction, and high blood pressure, leading to significantly increased risk for heart attack and stroke. 

 

Victor Hoffstein, a preeminent researcher in snoring defines benign non-apneic snoring as having an Apnea Hypopnea Index (AHI) below 10 with an absence of such symptoms as nocturnal cessation of breathing and awakenings with gasping or choking.  No studies have implicated benign non-apneic snoring as a risk factor for hypertension, vascular disease, heart attack, stroke or cognitive daytime dysfunction.  Daytime sleepiness has been documented in benign non-apneic snorers, but arousal frequency and sleep fragmentation did not correlate to amplitude or frequency of snores.

 

In a large clinical study, Hoffstein reported that 54% of a population of snoring patients had an AHI less than 10 when measured by polysomnography.  While snoring usually accompanies sleep apnea, snoring by itself provides a low diagnostic predictability for sleep apnea.  It is important that the differential diagnosis be established.  Does the snoring patient have benign non-apneic snoring or Obstructive Sleep Apnea (OSA)?

 

DIFFERENTIATING OSA FROM BENIGN NON-APNEIC SNORING

 

Reliable ambulatory sleep testing devices for evaluating treatment outcome in oral appliance therapy are important, and in fact their use is recommended by the American Academy of Sleep Medicine.  Ideally an ambulatory polysomnographic (PSG) device would measure obstructive apneas, central apneas, mixed apneas, hypopneas, apnea-hypopnea index (AHI), drops in blood oxygen, body position, nasal/oral airflow resistance, pulse rate and of course snoring.  One such device is the Braebon Medibyte™.  This small device measures less than three inches by three inches.  The patient connects an abdominal belt, a chest belt which holds the recorder, a nasal/oral cannula, the pulse oximeter, and a tiny snore microphone.  They sleep in the comfort of their own bed at home.  The software allows the doctor to evaluate the entire study, rescore any events or accept the computer interpretation.  It records snores in decibels and allows the user to click and listen to any snore or series of snores chosen.  The cost of the Medibyte™ is very reasonable, the cost per study for expendibles is cheap, its reliability is excellent.  The data is presented in a language that facilitates excellent communication and reports to referring doctors.  It allows a clinician to practice at the state of the science and test as frequently as needed to get it right.

 

 

It is inherent that treatment of snoring either be by prescription of a sleep physician or properly documented as non-apneic benign snoring.  Devices such as the Braebon Medibyte™ make documentation of baseline condition and evaluation of treatment outcome for snoring easy.  The Braebon Pursuit Advanced Software™ objectively records all snores, measures them in decibels and offers the healthcare provider the ability to listen to any or all of them.  Being able to listen to a patient’s baseline snoring sound and then comparing it to that after successful therapy using a night time oral appliance is a powerful tool.

 

TREATMENT OF SNORING

 

The good news is that snoring is treatable in most cases.  The standard treatment for OSA is a mechanical pump that delivers continuous positive air pressure (CPAP) through a mask or nosepiece.  The positive air pressure pushes the air through the site of collapse and holds the airway open.  Most non-apneic snorers tolerate CPAP poorly and are generally non-compliant.  In those benign snorers who tolerated CPAP and were compliant, studies have shown that the excessive daytime sleepiness and the cognitive deficits did not improve.

                                                   

                                 Examples of CPAP masks, full face and nasal pillows

 

Physical problems that may contribute to snoring can sometimes be corrected with surgery.  Such conditions as enlarged tonsils, adenoids, nasal polyps, deviated nasal septum, long soft palate, or large uvula may be amenable to surgery, but because of their invasiveness and post-operative pain are usually reserved for OSA.  Surgical procedures directed at reduction of nasal stuffiness may help alleviate some snoring.

 

The most comfortable, non-invasive treatment for benign snoring is oral appliance therapy.  Mandibular advancement devices (MADs) are the most commonly prescribed type of oral appliance.  The purpose of a MAD is to anteriorly reposition the mandible to prevent the airflow being blocked by hypotonic collapse of the tongue onto the airway, or to prevent the tongue from being so close to the posterior pharyngeal wall as to get sucked closed by negative airway pressure.  MADS cause active mandibular protrusion, and the tongue, by virtue of its attachment to the mandible, passively follows. MADs are made in a great variety of configurations and attachment systems but basically in two styles, 1) adjustable or nonadjustable, and 2) open-anterior which facilitates anterior tongue movement, or closed anterior which restricts anterior movement of the tongue.

 

   Moses Appliance™ open anterior                 TAP™ Appliance restricted anterior

 

MADs are preferred by patients over CPAP primarily because they are more comfortable, more portable, more socially acceptable, make no noise and have fewer undesirable side effects. 

 

ARE YOU A GOOD CANDIDATE FOR A MANDIBULAR ADVANCEMENT DEVICE?   

Recent studies reported that if the airway collapse occurring in OSA patients was in the oropharyngeal area, it was predictive of success by oral appliance therapy.  There are significant differences between patients with oropharyngeal versus nasopharyngeal or velopharyngeal collapse during sleep.  By testing with a portable spirometer it is possible to predict success

using a MAD to between 83-89%.

      Viasys Spiropro™ portable spirometer shown above. 

 

 

Cone beam CT scanners allow clinicians to noninvasively view discrete anatomical structures such as a narrowed oropharynx which could contribute to the etiology of OSA and snoring.  CT can identify the specific area in the oropharynx that is involved in causing the airway blockage, such as soft palate, tonsils, base of tongue, uvula or epiglottis.

 

Lack of success with other treatment modalities such as CPAP, surgery, nasal decongestants, nasal breathing strips or other medications also add to the evidence pointing to success with MADs.

 

Take control of your life and stop snoring NOW

BECAUSE SNORING IS NO LAUGHING MATTER!

·      Lower your blood pressure

·      Get more restful sleep

·      Better daytime concentration

·      Less sleepiness during the day

·      Marital bliss, peace and quiet in the bedroom

 

For more information or to schedule a consultation:

 

 

ALLEN J. MOSES DDS

SEARS TOWER

233 SOUTH WACKER DRIVE

CHICAGO, IL

(312) 993 0430

 

 

 

 

Dr Moses is an Assistant Professor at Rush University Medical School in the Department of Sleep Disorders and Diplomate of the American Board of Dental Sleep Medicine

Click here to learn more about Dr. Moses' treatment of snoring.