A silent night? Sounds dreamy
You’re ON the verge of falling asleep, and then it starts. The snorting. The choking sounds. Sometimes there’s even a little whistle to it. A family member or roommate sleeping nearby has launched into an all-night bout of snoring, and you’re the one who is going to lie awake all night listening to it.
According to the American Academy of Otolaryngology-Head and Neck Surgery, 45% of normal adults snore at least occasionally, and 25% are habitual snorers. Of the habitual snorers, about 10% have obstructive sleep apnea, a serious medical problem in which people stop breathing completely, multiple times per night, for at least 10 seconds at a time. Apnea raises the risk for dangerous daytime drowsiness and a range of ills, including elevated blood pressure, heart attacks and strokes.
But risky or not, snoring is an embarrassment to the many who honk and saw their way through the night -- and can be a significant trial for their nearest and dearest. A 2005 “Sleep in America” poll by the nonprofit National Sleep Foundation found that 23% of couples resort to sleeping in separate rooms due to one partner’s sleep troubles, most often snoring.
And snorers’ bed partners who stick it out can end up losing a lot of sleep, according to a 1999 Mayo Clinic study. In that sleep lab study of 10 couples, wives were woken up so many times by their snoring husbands that they were predicted to miss out on about one hour of sleep per night.
There is hope, however, for noisy sleepers and those who sleep near them. Simple lifestyle changes or inexpensive over-the-counter remedies may do the trick -- even, for some spouses, something as simple as earplugs.
But if the low-tech options fail, medical intervention is available. Nonsurgical medical devices for snoring are getting smaller and more comfortable, and surgical options have become more and more refined, reducing pain and recovery time. There are even options that can be performed on an outpatient basis.
Dr. Rafael Pelayo, a professor at Stanford School of Medicine and a physician in its Sleep Disorders Clinic, says that of all the ailments he treats, “snoring is the one we can resolve.”
“Nobody should ever snore,” he says.
How it happens
Snoring occurs when the free flow of air through the passages at the back of the mouth and nose is obstructed. Interrupted air flow leads to vibrations, and this leads to noise. For many people, such noises can be traced to excess or loose tissue in the soft palate and uvula -- the little punching bag-like structure that dangles in the back of the throat.
“It’s like a flag flapping in the wind,” says Dr. Eric Mair, an otolaryngologist and adjunct clinical professor at the University of North Carolina at Chapel Hill.
Behavioral modification may be all that is needed for light or occasional snoring, says Dr. Eric Kezirian, director of the division of sleep surgery at UC San Francisco.
You can sleep on your side instead of your back to keep airways open. You can also avoid alcohol and other sedatives that relax muscles in the mouth and throat before bedtime. Giving up cigarettes can help too -- smoking can cause inflammation in the upper airways that leads to snoring.
Exercise and weight loss can improve muscle tone in the throat and may reduce the amount of tissue pushing on airways.
Dr. Lawrence Kline, medical director of the Scripps Clinic Sleep Center, says it is hard to predict how much weight a person will need to lose in order to reduce their snoring, but “weight loss clearly helps.” Even for someone who is 100 pounds overweight, losing just 20 pounds may be enough to see improvement, he says.
Taking up a musical hobby might strengthen throat muscles and could be a fun and effective treatment for snoring. A study published earlier this year in the journal Sleep and Breathing compared 52 semiprofessional choir singers with a group of 55 nonsingers and found that the singers snored less. And a 2006 study in the British Medical Journal found that four months of regular practice of the didgeridoo -- the long, cylindrical indigenous Australian wind instrument -- led to improved sleep apnea symptoms and less partner disturbance by snoring. (Disturbances stemming from the sound of didgeridoo-practice were not investigated, however.)
If more help is in order, there are plenty of remedies for sale in drugstores and catalogs -- strips, sprays, pillows, wristbands and vests. But what really works?
“There’s a lot of voodoo out there,” Mair says.
Treating stuffy noses is a good place to start: A blocked nose forces breaths to be taken through the mouth, upping the likelihood of snoring. A 2001 University of Wisconsin study of 4,916 men and women ages 30 to 60 found at the start of the study that those who reported they always, or almost always, had nasal congestion were three times more likely to snore than those who were never congested.
The congestion-snoring link was independent of other factors that might make someone snore, such as sex, age, body weight and smoking. If this is your problem, relief may be as close as the corner drugstore. Using a decongestant pill or spray before bedtime may help quiet your nocturnal aural emissions.
Adhesive external nasal strips that lift nostrils up and out, such as those made by Breathe Right, may also help to some extent. Several studies have shown that people with congestion, as well as those who just have narrow nasal passages, get some relief from these strips.
In one of them, published in 2000 in the European Respiratory Journal, 12 snorers with chronic stuffy noses used either the strips or a placebo during overnight analysis. Monitoring of both groups found that although sleep quality and snoring loudness were not reduced, the total amount of snoring lessened in those with the strips.
Also available over the counter are sprays that claim to lubricate throat tissues and prevent noisy vibrations.
But there is little scientific evidence that these work, Kline says. A 2004 study of one spray published in the journal Otolaryngology-Head and Neck Surgery had 20 snorers try both an oil-based throat spray and a water-based placebo for one night each. It found that there was no improvement in snoring either when measured objectively with audiotape analyzed for frequency, duration and volume of snoring, or subjectively, via questionnaires filled out by bed partners.
Devices and alarms
Oral appliances that fit in the mouth like a double retainer are an option for treating both regular snoring and obstructive sleep apnea. These devices work by pulling the jaw forward, repositioning and opening up the airway. They must be worn nightly to be effective, Kezirian says -- and they are not without risks. They can cause jaw pain and orthodontic problems such as tooth movement.
A dentist trained in sleep medicine can fit you for a prescription oral appliance, but there are nonprescription versions sold through TV infomercials. These rely on a “boil and bite” method of customization -- you plunge the plastic mouthpiece into hot water and then bite down to create a custom fit.
The dentist-prescribed oral appliances have been shown to be a good option for sleep apnea and snoring treatment. A 10-year follow-up of patients using these devices published in the Journal of Prosthetic Dentistry in April found that 47 of 72 patients were still using their device at least six nights a week. Of these, 31 felt more refreshed upon waking. No measurements of actual snoring were made, however.
Kline believes the home variety are probably of limited utility. But if you are aware of the risks and are otherwise well -- that includes being sure you don’t have sleep apnea -- they may be worth a try.
Finally, there are vibrating “snore alarms” that you strap to your wrist. The idea is that if you snore, the alarm will arouse you and you will readjust yourself and go back to sleep in a new, quieter position.
Kline says that although a bed partner may think these alarms work wonderfully, all they are doing is continually waking the snorers, keeping them from entering the deeply relaxed stages of sleep where snoring is more likely to occur. This can backfire. By depriving the snorer of sleep, you can end up making them so tired that when they do finally rest, they conk out so hard and their muscles relax so deeply that the snoring is actually worse.
If you find that your snoring is at its worst when you are on your back, but you just can’t keep yourself from rolling over during the night, anti-snore pillows can force you into a side sleeping position or at least keep your head elevated and airways open when you are on your back. There are also vests and backpacks with balls or hard foam in them that can make it so unpleasant to be on your back that you’ll roll over.
Of course, before purchasing any of these solutions you can always try home-brew remedies such as building a barricade of regular normal bed pillows behind yourself, raising the head of your bed, or sewing a tennis ball into the back of a nightshirt to help maintain a side-sleeping position.
For some so-called socially unacceptable snorers -- those whose snoring is so bad that they disturb those around them -- over-the-counter remedies just don’t work. In these cases, stronger measures may be needed.
Continuous positive airway pressure, or CPAP, involves a machine that blows air at a prescribed pressure into a patient’s nose, and is traditionally prescribed for those who have obstructive sleep apnea. Though it can also be used for simple snoring, the discomfort of the procedure -- plus the cost, which is usually not covered by insurance for regular snoring -- makes this rare.
Some people turn to surgery. A surgeon may be able to cure snoring by removing excess tissue in the palate, tongue, throat or nasal passages. There are several techniques available. The tissue can either be cut away or heated and damaged using radio waves. The healing process causes shrinkage and tightening that can reduce vibrations and noise.
Several new medical techniques offer the benefits of surgery, but with less pain and expense.
In 2001, Mair of UNC Chapel Hill introduced a new technique, injection snoreplasty, to treat snoring. It stemmed from wind tunnel tests of models of human palates, in which he discovered that creating a little scar right in the middle of the palate could put an end to vibrations that are the source of snoring. To make this kind of scar in patients, he uses a drug called Sotradecol that has been used for many years to treat varicose veins.
A patient’s palate is first numbed, and then a tiny, half-pea-sized drop of Sotradecol is injected just under the skin on the top of the mouth in front of the uvula. After a few weeks, a scar forms. The healing process also stiffens the palate. Patients sometimes need to repeat the treatment after a year or so if the body reabsorbs the scar.
“We’re not looking for a cure, just control,” Mair says.
The results of the first trial of this procedure were published in 2001 in Otolaryngology-Head and Neck Surgery. Twenty-five of 27 patients were completely cured of their snoring after the procedure. A follow-up study in 2003, published in the same journal, found that only five of the patients who had been successfully treated had a relapse of their snoring after 19 months.
Mair says that compared with other medical treatments for snoring such as surgeries that remove tissue, injection snoreplasty is much less painful, invasive and expensive, costing hundreds instead of thousands of dollars.
The Pillar Procedure, introduced in 2004 by the medical device company Restore Medical Inc., is another popular treatment for snoring. Three small rods are inserted into the roof of a patient’s mouth. Over time, the rods and the body’s healing response add stiffness to the soft palate that can eliminate vibrations -- and thus snoring. The company’s website claims that more than 30,000 people worldwide have had the procedure.
Several studies, including a randomized, double-blinded, placebo-controlled, clinical trial published this year in Otolaryngology-Head and Neck Surgery, have shown the Pillar Procedure to be effective at treating snoring. Sixty-two non-obese adults with a history of snoring and mild to moderate sleep apnea were randomized to receive palatal implants or a placebo procedure. The treatment group had significant improvement compared with the controls on measures of quality of life, sleepiness, and snoring intensity.
Kezirian and Mair say that the Pillar Procedure has been a bit over-hyped to doctors by the company, leading some surgeons to push the procedure on too many patients. They stress -- as does Restore Medical’s website -- that the procedure will only provide relief for those whose snoring is definitely coming from their soft palate. Although this is the case for most snorers, a thorough evaluation of other possible sources of snoring should be conducted by a doctor.
There is also a roughly 1-in-5 risk that the implants will work their way out of the palate, requiring a second procedure.
Don’t be seduced
Each of the medical treatments for snoring may work for some and not others. Kline’s advice is to see a physician trained in sleep medicine who is willing and able to evaluate all possible causes of your snoring. He warns that the old adage “when you have a hammer, everything looks like a nail” can apply to doctors and dentists too.
If a health professional seems too tied to one procedure as a cure-all for snoring, you should probably ask to see someone else.
“Simple solutions look very seductive,” he says.
One final thing to bear in mind: If a procedure quiets the sounds of snoring but fails to address underlying sleep apnea, a patient could be in danger. Thus Stanford’s Pelayo stresses that habitual snorers should be checked for obstructive sleep apnea before any kind of snoring surgery is done.
“Snoring is like a smoke alarm,” Pelayo said. “You can disconnect the smoke alarm, but still have the fire.”