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SNORING: A COMPLEX PROBLEM BUT THERE IS SOME LIGHT AT THE END OF THIS “DARK” TUNNEL

Snoring is indeed a complex problem affecting a significant number of people and in severe cases leaving in it’s wake, a trail of disturbed nights, unhappy partners and on occasions marital break-up. Until relatively recently doctors could offer no significant help apart from sympathy and a shrug of the shoulders and home remedy, but the topic of snoring and its first cousin, various degrees of sleep apnoea, (that means actually stopping breathing completely with consequent drop in oxygen levels) has become intensively investigated.

Whereas there still remains no guaranteed cure because of the complexity of the several factors involved, there is without doubt a lot more we can now offer to problem snorers.

HOW MANY PEOPLE SNORE

Well although there’s an interesting variation between different countries, the average is that 31% of men and 20% of women are habitual snorers. Over the age of 60 it rises to some 60% and 40% respectively. So it isn’t uncommon. Especially with the passage of time.

CAN SNORING CAUSE PROBLEMS

It certainly can. First the social problems. This comes as no surprise to anyone. In this practice we’ve seen rather too many potentially tragic cases where marriages are about to break up on the simple basis of the husband snoring so loudly that his wife moves firstly out of the bedroom and then sometimes out of the marriage…. The consequence of this tragedy are obvious. Especially as more help can now be offered.

Apart from social problems there can be medical complications.These can be significant. Simple snoring will usually cause no more than a social disturbance but it can progress to a situation where breathing actually stops. This is called apnoea. If this occurs on an increasing basis, significant problems can and do occur. What happens is that your oxygen level drops while the breathing has stopped and carbon dioxide builds up.

In these cases various degrees of sleep deprivation take place and we all know how badly we perform when we go without good sleep. Physiologically we are all wired for 8 hours of sleep. Examples of sleep deprivation are waking tired, irritable and restless and then actually on occasion falling asleep during the day or while driving the car.

There can be impotence in that there’s evidence that the male hormone testosterone drops. Headaches, loss of concentration and in some 30% of people who stop breathing (apnoeic) high blood pressure can occur. In severe cases this can develop into heart irregularities and occasionally even a cardiac arrest.

WHAT IS SNORING

Snoring is mostly caused by the collapse of the upper airway.Firstly muscles which dilate the throat, muscles as your breathe in are apposed by the vacuum like pressure occurring on inspiration. When we sleep there is less muscle tone and there is more potential for muscle collapse. In affect what we have is a battle between the negative pressure on breathing in and the dilating reflexes of the upper airways. When you snore it means that the negative pressure has the upper hand.This happens more often as muscles lose resilience with age.

WHAT IS THE MOST COMMON SITE OF SNORING

The soft palate, base of tongue and side walls of the throat are the most common sites for snoring problems. Other factors include obstruction to nasal breathing, a large tongue falling back and a short, fat neck. So in cases of obesity, weight loss can be very important, but of course that’s a very difficult goal to achieve and maintain. In many cases the palate is the dominant area to which most surgical treatment is directed.

ALCOHOL AND SNORING

The reason snoring worsens after alcohol is because after alcohol the muscles dilating the throat don’t dilate and the reflexes knocked out. And then a snorer really comes into his own….

HOW IS A SNORER ASSESSED

The head and neck is examined with specific note of the structure of the nose, mouth, soft palate and neck. In some cases sleep study measurements will be required. This particularly in the cases with significant stopping of breathing (apnoea).

TREATMENT

 

What about all the patent snoring advices. Well there are almost as many of these as ineffective cough mixtures. Over 2 000 have been patented. That tells the story. I don’t doubt that some can and do work and there’s certainly no harm in trying one of them before you come to see your doctor.

In cases of severe snoring with marked apnoea and sleep debt, there is an apparatus (C-PAP) which is strapped over your nose, attached to an oxygen tank and which in essence breathes oxygen for you at an increased pressure.

This prevents airway collapse. As mentioned its main place is in people who have significant obstructive breathing and sleep debt. In these cases it is in fact literally a lifesaver by improving quality of life. Compliance in using it will of course remain a problem and one chuckles at the ladies comment that it’s “the ultimate contraceptive”. But in severe cases it’s a genuine star.

As mentioned there are over 2 000 patented oral devices and it’s always worthwhile trying these. Similarly for people who snore on their back, there’s the good old fashioned technique of sewing a squash ball or equivalent into the back of the pyjamas preventing the patient lying on their backs.

In these cases the tongue falling back can be a major factor and repositioning the patient on the side is always worth a try. Nasal strips dilate the front part of the nasal airway, which in fact can be a major site of nasal obstruction, and there certainly are cases which have improved with their use.

As regards the various sprays available, I don’t understand how these can help…but there’s no harm in trying. But when all these have failed and snoring remains a problem then the various surgical options come into discussion. Let’s go through these recalling that none of them of going to offer you a guarantee and that the best they can offer is a reduction in snoring.

Also recall that long-term results in all the surgical procedures are sometimes not available so one has to accept that producing an initial good result is not a guarantee that this will last forever. The body remodels and of course as time goes by, tissues become less resilient. It’s called “fair wear and tear”.

HOW’S THE PATIENT ASSESSED

Detailed examination is made of the mouth assessing the bite, size of the tongue, the tonsils, palatal size and resilience and examination of the tongue base and beyond. Then recalling that the nose can be a significant factor, a detailed examination of this must be carried out. So what you need is a comprehensive examination of the entire head and neck before a patient can be staged.

And staging is important in that it can influence the success rate significantly. Michael Friedman of the St Luke’s Medical Centre in Chicago has produced the Friedman Classification. This is both relevant and extremely useful in assessment.

DISCUSSION

Modification of the soft palate is the most common and in many situations the only surgical procedure carried out by ENT Surgeons for cases of snoring and mild apnoea. There are various procedures available, all of which attempt to modify the soft palate. This either by surgical or laser excision, radio frequency modification and injection snore plasty. All of these have their pro’s and con’s and if you go to Google you’ll see all the various possibilities. (Diagrams of all the different procedures)

What has become available recently is the PILLAR IMPLANT SYSTEM (click here for diagram) which utilises implantation of Dacron Mesh into pockets created in the soft palate. It’s aim is to stiffen the soft palate, reducing the fluttering movement, thereby reducing snoring. The Dacron causes scar occurring secondary to the implant. Its advantage over the other palatal procedures is its extreme simplicity.

It’s a one stage procedure requiring literally no narcotic pain relief and can be easily combined with other upper airway procedures for snoring or apnoea. In addition it is happily free from any significant complications. It’s results compare favourably with all the other palatal procedures and has the distinct advantage that firstly there is no excision of tissue in addition to lack of post implantation pain.

However the cost of the procedure may be a disadvantage. This is driven totally by the cost of the Implant.However this cost should be measured against the cost of alternative procedures. Of interest is that in cases of nasal dysfunction combining the Pillar Implant with nasal surgery has produced significantly better success.In addition, in cases with failed palatal surgery, the Pillar Implants can again be useful in offering a reduction in snoring and a safe alternative.

Sadly the Medical Aids are not prepared to cover this but as such the cost is the responsibility of the patient. One stresses that the Dacron Implants are the main cost driver. What is of interest is the comments of many bed partners.

Namely that although the snoring wasn’t completely eliminated, and in some cases only moderately so, in the vast majority of cases they were very happy with what had been done in reducing the partner’s snoring which meant that many relationships could get back onto happier ground. One stresses that long term results are not yet available but the Pillar Implant Technique is certainly something which a snorer should consider.

In conclusion the Pillar Implant Technique is a reasonable successful and virtually painless procedure in the reduction of snoring based on proper selection criteria. Obviously patients with areas obstructions other than the palate must be treated with adjunctive procedures and one stresses that success results are often dependent on the Friedman Staging.

For more information click here

SNORING & SLEEP APNEA

Snoring is something which afflicts a large proportion of our population.  It's more frequent in males but ladies to an extent, catch up as time goes by.  It can be mild or severe and in worst cases can be termed "sleep apnoea."  This is a potentially dangerous,  life-threatening situation. 

Be wary of anyone who says they guarantee to cure your snoring.  As with all surgery, miracles are rare and reality needs be fully understood.  Beware the conman.

Essentially snoring is due to collapse of the airway.  This due to a combination of the tongue falling back, the sidewalls of the throat collapsing, a long palate and the possibility of a dysfunctional nasal airway.  All this comes about largely at night when muscle tone goes due to the muscles being relaxed.

Basically  what you’ve created is a smaller airway.  With a smaller airway it means air must pass through a smaller space in which case it speeds up.  There's a "gas law" which points out simply, that the faster the air goes, the more the pressure drops and tissues collapse.  Rather like air flowing over the upper surface of an aeroplane wing, causing negative pressure where you get "lift off..."  it's as simple as that.

Important  to note is that weight is a contributing factor and those with a short heavy neck are more in trouble. 

For a simple snorer, weight loss or change of position can be helpful, as can the simple and effective approach of an appliance which goes in the mouth bringing both tongue and jaw forward.  There are several hundred oral appliances claiming to produce a miracle.   They  can be especially relevant as the next option is surgery, which, with few exceptions is extremely painful and not guaranteed.

The most common form of surgery involves shortening the palate and tightening up the sidewalls to create a larger opening to assist air passing through more slowly, hence less negative pressure.  There are approaches for putting pillars in the palate to strengthen it.  This done under local anaesthesia, but only in select cases.

These 2 types of surgery in essence tighten up the palate which is often a dominant cause of snoring.

 

The tongue is often a factor as it falls back and reducing the base of the tongue can be considered, but is painful and there's always a possibility of airway obstruction in the postop period.    

SLEEP APNEA

This is a dangerous condition and is when the snorer stops breathing and wakes with a start, gasping for breath to bring in oxygen.  Depending on the degree, symptoms vary from mild to significant sleep debt where the patient wakes tired, falls asleep at work and when driving a car, becomes sleepy leading to crashes.  A not infrequent scenario.  If not treated, this can lead to high blood pressure, heart attacks and strokes.  In essence the patients' oxygen level drops which can have significant negative effects for obvious reasons. 

We have patients who stopped breathing for almost a minute hence the poor quality of sleep.

Examination of these patients is critical, but they need a sleep study.  This measures all the parameters one needs establish.  The main one being how many times  and how long the patient stops breathing.  Treatment for most of these cases is a CPAP machine which pumps air under pressure into your mouth and blows the tissues apart.  They’ve become very sophisticated, in many cases are portable, and have a significantly reduced sound emission, which means the partner is not disturbed. 

They are in many ways the "gold standard" and continual innovations with regards technology of these machines are being made.
Obviously, when assessing these cases, discussion on whether any adjunctive surgery is necessary also needs be taken into consideration regards nose and throat.

What is CPAP treatment?

CPAP or ‘Continuous Positive Airway Pressure’ remains the gold standard for treating Obstructive Sleep Apnoea. It is a non-invasive method involving a bedside device that gently delivers pressurized air through a mask or nasal pillow system. This pressure acts like a splint to keep the airways open during sleep. This treatment does not involve drugs or surgery and has helped hundreds of thousands of people around the world enjoy a better night sleep and a healthier lifestyle. 

There are a variety of brands of CPAP devices and masks available for purchase. Different types of CPAP devices exist depending on one’s needs and comfort levels (the fully automatic device which adapts to your changing needs as well as constant pressure devices for those with lower pressure requirements). Integrated humidification is available with all the devices to increase the overall comfort of your CPAP treatment. Your service provider should be able to discuss all these matters with you personally to ensure the best possible purchase for you, as well as continuous, quality aftercare.

A NEW NON-SURGICAL TREATMENT FOR SLEEP APNEA

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