What is Snoring? An In-Depth View

Snoring is the sound produced by the vibration of soft tissues when air passes through narrowed air passages during inhalation. Sleep results in relaxation of our body’s muscles including those at the back of the throat (upper airway) and the muscles that hold our jaw and tongue forward. When these muscles relax during sleep, the air passages narrow and the air passing through this narrowed passageway causes vibration of the tissues. Certain conditions are likely to increase the risk for snoring. These include obesity, nasal congestion/blockage, hypothyroidism, enlarged tonsils and adenoids, acromegaly and other abnormalities affecting the anatomy of the face and head. Use of alcohol, opioid pain medications, and other muscle relaxants can worsen snoring by increasing relaxation of the upper airway muscles.

The breathing process


How common is Snoring?


Almost everyone snores occasionally, especially if they have a cold or seasonal allergy. Habitual snoring, which is defined as snoring 3 days a week or more, is also fairly common. Over 40% of males and close to 30% of females snore regularly.


Are there different forms of Snoring?


Based on the location of narrowing of the airway, snoring may be produced by several different mechanisms. There may be narrowing of the air passages of the nose (nasal snoring), soft palate (palatal snoring), at the level of tongue (lingual snoring) or throat muscles (oropharyngeal snoring).


Snoring may also be differentiated based on how it presents.


Primary snoring in absence of any other sleep or airway disorder is an acoustic phenomenon that usually disturbs the sleep of bed partners.


Upper airway resistance syndrome is a condition during which increases in respiratory effort to maintain adequate air-flow through narrowed air passages can result in frequent awakenings and sleep disruption. Sufferers of this condition may experience increased sleepiness during the day.


Sleep-disordered breathing occurs when snoring is actually a symptom of the sleep disorder – obstructive sleep apnea. Although snoring commonly occurs in patients with sleep apnea but its absence does not exclude this condition.


Does Snoring change with time?


Snoring generally increases with age as the airway muscles may have a reduction in tone with age. In women, snoring is particularly common after menopause due to the changes that occur in muscle tone with this condition. The most important factor that may result in worsening of snoring over time is weight gain. While aging is irreversible but losing significant weight (5-10% of body weight) may result in a decrease in snoring.


Why is Snoring considered a problem?


Several scientific studies suggest that snoring adversely affects the sleep of the snorer’s bed-partner and results in increased sleepiness in them.


An Australian study in 2008 reported that snorers have increased narrowing (atherosclerosis) of their carotid arteries. These are the blood vessels that supply blood to the brain. This study showed that those with heavy snoring had up to 65% narrowing of their carotid arteries compared to 20% in those with mild snoring. This narrowing likely occurs due to the mechanical damage to their lining from repeated vibration of these arteries. Carotid artery narrowing is associated with increased risk of certain types of stroke.


A Korean study in 2016 reported that snoring alone is associated increased markers of inflammation, cell aging, and cell stress.


Some earlier studies also suggested that snoring may be associated with increased risk for high blood pressure and heart disease but these studies did not account for the presence of sleep apnea in the participants.


Should Snorers undergo any testing or evaluation?


Snoring is generally diagnosed based on the history provided by the sufferer or their bed-partner. Further testing and evaluation is usually for diagnosing conditions that are associated with or may be causing snoring. Those who have consequences of poor nighttime sleep, are known to repeatedly stop breathing during sleep, may have high blood pressure, a large neck or are overweight should undergo testing for sleep apnea with a sleep study. Concern for certain other conditions which result in narrowing of nasal passages may require radiological imaging or endoscopic testing by an Ear Nose and Throat specialist.


Why should Snoring be treated?


Treatment of snoring is generally considered if it causes disturbance of the bed partner’s sleep or results in embarrassment to the sufferer. Treatment of snoring is currently not recommended to prevent high blood pressure or heart disease. If snoring is a symptom of sleep apnea then treatments aimed at sleep apnea will also help eliminate snoring.


How is Snoring treated?


There are several treatment options for snoring as discussed below:


  1. Weight loss: Significant reduction in body weight (5-10%) generally results in improvement in snoring, although the extent of these effects may not be predicted accurately.


  1. Alcohol and tobacco cessation: Consumption of alcohol in the hours preceding sleep and tobacco smoking at any time during the day may result in increased snoring. Discontinuing these is expected to improve snoring however this strategy has not been tested in clinical trials.


  1. Use of nasal decongestants: If the source of airway narrowing is within the nose, then using medications like topical pseudoephedrine, nasal steroids or nasal saline irrigation may result in improvement in snoring. Some of these medications should only be used for 2-3 days at a time due to their side effects.


  1. Avoiding sleeping on back: Since the chances of airway narrowing are higher when sleeping on the back, techniques that restrict sleeping to sides only may improve snoring. This may be achieved by the use of position restriction devices such as head positioning pillows, body worn pillow belts, postural vibratory alarms and a tight T-shirt with tennis balls in pockets sewn on the back. Most of these techniques have shown benefit in treating sleep apnea in those whose sleep apnea is significantly worse while on the back compared to on the side. Clinical trials of treatment of snoring alone with these techniques have not shown consistent results.


  1. Dental appliances: Use of custom-made dental appliances that widen a narrowed upper airway by either protruding the jaw forward or changing the tongue position has been proven to improve snoring in multiple clinical trials. Most over-the-counter dental appliances are usually not effective for this purpose and should be avoided. The dental appliances may also be used to treat mild to moderate sleep apnea. Some disadvantages of these devices include excessive drooling, TMJ (jaw) pain or permanent changes to the bite.  Dental appliances are recommended as a treatment option for snoring alone by the American Academy of Sleep Medicine, however, these devices have a significant out-of-pocket cost, and their use is not covered by health insurance for treatment of snoring alone.


Dental appliances can be used to reduce snoring


  1. CPAP: Continuous positive airway pressure devices are very effective in treating snoring with or without sleep apnea. When used for the treatment of snoring alone, these may prove to be burdensome and are usually not covered by health insurances, thus resulting in a significant out-of-pocket cost.


CPAPs are typically for people with sleep apnea


  1. Palatal implants: The pillar procedure involving deployment of plastic cylindrical implants to stiffen and reposition the soft palate has been used for the treatment of snoring. Most clinical trials have reported only subjective improvement with no improvement in recorded intensity or frequency of snoring. These devices are not recommended for treatment of snoring.


  1. Nasal dilator strips: Use of stiffened adhesive strips applied across the bridge of the nose to open the nasal aperture has been proposed for treatment of snoring. Not many clinical trials have evaluated their benefit for the treatment of sleep disorders. Only one study reported on objectively recorded snoring with these strips but failed to show any improvement in snoring and other sleep measures.


  1. Upper airway exercises: Since snoring is caused by relaxation and collapse of upper airway muscles during sleep, it may potentially be treated by improving the function of these muscles with specific exercises aimed at improving their strength and coordination. Extensive exercise regimens designed to strengthen several different groups of muscles have been tested in clinical trials and have been found to be effective in reducing both patient-reported snoring and objectively recorded snoring in some patients. Another clinical study that looked at the effect of training to play the wind instrument didgeridoo showed improvement in snoring and mild to moderate sleep apnea. Like any exercise regimen, all of these require significant motivation on part of the snorer.


  1. Nasal surgery: Those with deviation of nasal septum or enlarged nasal turbinate may benefit from surgical correction of these abnormalities although the effect on snoring is generally not predictable. Such surgeries are currently not recommended for treatment of snoring alone.


  1. Upper airway surgery: Tonsils and adenoids are small soft tissues that are situated at the back of the throat, and when enlarged, may result in narrowing of the upper airway. Removing these by a procedure called tonsillectomy and adenoidectomy, can result in an opening of the airway in children with a reduction in snoring and sleep apnea but is generally ineffective in adults. Another surgical procedure called Uvulopalatopharyngoplasty (UPPP) involves removing parts of the soft palate and tonsillar pillars have been utilized for the treatment of snoring and sleep apnea. This procedure is usually effective in reducing snoring in the short term but majority of patients have the return of snoring after 2 years. Radiofrequency ablation of the soft palate that involves reducing the size of the palate with use of high energy radio waves has similarly shown reasonable early benefit for treatment of snoring but only very few patients see sustained benefits. Given the invasive nature of all surgical techniques, these are not recommended for treatment of snoring unless all other therapies have failed.


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