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February 2010
Snoring and Sleep Apnoea
Dr Sunil Narayan Dutt
Snoring is a common problem affecting both genders and all ages. The disturbance it causes is regarded as a joke about which little can be done. Snoring is also reckoned to be a major factor that contributes to marital discord. But doctors now know that snoring can indicate that there are problems with breathing at night, which may cause serious health hazards to the snorer.

The Snoring Mechanism
During sleep, all the muscles of the body become less active and are relaxed and even floppy. In most parts of the body this does not matter and indeed helps one to relax and sleep comfortably. However, the floppy segment of the airway between the back of the nose and the entrance to the voice box (larynx) including the throat (pharynx) gets affected too. When the muscles behind the tongue that help hold the throat open relax, there is partial collapse and narrowing of the airway resulting in vibrations which are heard as a 'snore'. The noise is generated by the curtain-like soft palate at the level of the roof of the mouth (flutter) or by the back of the tongue, or both.

Obstructive Sleep Apnoea
If the 'floppy segment' does not vibrate but collapses and locks off the airway instead, breathing is stopped for a variable period of time (few seconds). This is termed 'Obstructive Sleep Apnoea' (OSA). People who have this condition usually are big snorers. Apnoea refers to the actual stoppage of breathing. Fortunately, the body is able to sense this increased obstruction to breathing and the sufferer wakes briefly, takes a few deep breaths and rapidly returns to sleep. This obstruction and waking may become a continuous cycle that can go on several times each night.

Health Hazards of OSA
OSA can damage your health as it reduces the amount of oxygen in the blood. You may not be aware of the number of times that your sleep is disturbed because of these apnoeic episodes. In the morning you are likely to feel extremely tired, and you may tend to nod off frequently during the day. This is termed 'excessive daytime somnolence (sleepiness)'. In the beginning, this occurs only during potentially boring activities such as reading, watching television or long distance driving on the motorways. Not only is this a nuisance, but this may also become a dangerous issue, especially if you are driving regularly, or if you work with machinery (sleep apnoea sufferers are about seven times more likely to have car accidents). OSA can also affect the heart as this can raise the blood pressure and cause abnormalities of the heart rhythm, and in severe cases, congestive cardiac failure.

Snoring Fundas
  • Snoring increases as we grow older, as tissues tend to get floppier with age.
  • Men snore three times more than women. Men tend to have fatter necks, and there may be a hormonal influence too.
  • People who are overweight snore three times more than those who are of normal weight for their height. Extra fat in the neck (17-inch collar or more) squashes the throat from outside, particularly when the throat muscles become floppier with sleep.
  • Conditions that make the airway narrower, such as a blocked nose due to allergy, nasal polyps, or enlarged adenoids and tonsils, or a large tongue or a set back lower jaw, tend to cause snoring and possibly, sleep apnoea.
  • Alcohol is a major contributor to snoring. Even a small amount of alcohol tends to make snoring worse. Smoking may also indirectly contribute to conditions that worsen snoring.
  • Sedative medications (sleeping tablets, sedative antihistamines) also make snoring worse.

12 Ways to Snore Less
  1. First for the exception (which you could also use as a defence when questioned on your snoring): maybe it's not that your snoring has got worse, it may be that the other person has become a lighter sleeper!
  2. If your snoring is worse when lying on your back, try to sleep on your side.
  3. If you are overweight, the first thing any doctor is going to tell you is that you should lose the excess weight. The advice of a dietician may be desirable before embarking on a weight reduction exercise regimen.
  4. If you drink alcohol regularly, you should seriously try stopping it. Smoking may also lead to inflammation in the throat and respiratory airways, contributing to snoring and sleep apnoea. It is wise to quit smoking as well.
  5. Avoid getting 'overtired' and avoid taking any sedative pills at bedtime.
  6. If you have a significant nasal blockage, clearing this will help. An ENT specialist may put you on antihistamine tablets and/or nasal steroid sprays. Occasionally, there are patients who have reported reduction in snoring by using a simple nasal dilator device at night.
  7. Some doctors prescribe a throat spray believed to stiffen the soft palate, for use before going to sleep.
  8. Music therapy in which the patient is required to practise specific 'keys' and 'notes' to strengthen the palatal muscles is also available.
  9. If it seems likely that you have Obstructive Sleep Apnoea, you need a 'sleep study' to confirm the diagnosis, and to assess the severity of the condition. This would involve a night's stay in a well-equipped sleep lab of a good hospital. The study records values such as pulse rate, snoring, ECG, oxygen levels in blood, number of episodes of apnoea, sleep quality and the activity of the brain during sleep.
  10. Surgery on the soft palate (with or without laser) may also be advised. Excess redundant soft tissue in the back of the throat (soft palate and pharynx) can cause mild to severe snoring, and sometimes, certain degrees of sleep apnoea. This surgery is indicated when a sleep study shows snoring alone, with little or no sleep apnoea.
  11. Occasionally, the use of the jaw and palatal support devices (Mandibular Advancement Prosthesis) for use in the night may be advised.
  12. If you have significant obstructive sleep apnoea, you may be made much better by wearing a mask at night which blows air into your throat through the nose. This stops the airway from collapsing and allows you to sleep well. This apparatus is called Continuous Positive Airway Pressure or CPAP. The response with this apparatus is quite dramatic, with greatly improved sleep and disappearance of daytime sleepiness.
Dr Sunil Narayan Dutt is Senior Consultant and Coordinator, Department of Otolaryngology (ENT) and Head & Neck Surgery at Apollo Hospitals, Bangalore

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