Snoring

Snoring affects about 50% of the adult population and occurs more often in males.  The incidence of snoring also increases with age.  There are significant differences in the shape of the oral cavity between the wake and sleep states.  During sleep the tongue and other muscles in the mouth are relaxed and the body is typically supine.  Consequently, the tongue will normally take a more posterior position in the mouth, the soft palate may slip backwards and the airway will tend to diminish in cross-section.  The most common cause of snoring is vibration of the uvula and soft palate when inhaling during sleep.  Most snorers experience little discomfort - other than a sharp blow to the ribs or nudge from their partner. 

There are four clinically proven methods of curing snoring:

1. Losing weight can be effective in reducing snoring but it is a gradual process that requires continued reinforcement.

2. The Continuous Positive Airway Pressure (CPAP) device is the Gold standard for moderate to severe obstructive apnoea (see below).

3. Mandibular advancement splint (MAS) therapy involves the use of dental splints that hold the jaw forward during sleep. There are variety of products ranging from over the counter boil and bite splints to custom designed versions that are designed and fitted by dentists to a patient's individual requirements. The custom designed splints are either non-adjustable to hold the jaws in a fixed position or have some means of adjustment to enable the patient to incrementally move the jaw forward to an optimum position. Experience shows the adjustable splint to have the greater potential for success as patients are more likely to wear them over a period of time. The condition and health of the temporomandibular joint (TMJ) must be evaluated prior to treatment to assess the suitability of splint therapy and subject to regular review for the period that the appliance is worn.

4. Surgery can be performed to remedy the anatomical factors causing snoring. This is normally the last option in stopping snoring.

Obstructive Sleep Apnoea

The situation is very different for the obstructive sleep apnoea patient who will tend to have a poor sleep and often feel tired during the day.  Unlike the snorer where there is a momentary restriction to the airway in obstructive sleep apnoea the airway becomes obstructed and the patient cannot breath.  This may be because the uvula and soft palate block the airway, the tongue may fall backwards to block the airway or all three may interact to cause a blockage.  Often the patient will wake momentarily to gasp a breath before falling back to sleep without being aware of the incident (apnoea).  These brief interruptions to breathing may last several seconds and happen several times during a night.  Often apoeas are accompanied by hypopneas, an event of shallow breathing  where is a 30% (or greater) reduction in flow and an associated 3% (or greater) desaturation in oxygen levels for 10 seconds or longer.  Sleep apnoea is normally diagnosed when 30 or more apnoea are observed during a seven hour sleep period. An apnoea/hypopnoea index of 5-15/hour is mild OSA. An apnoea/hypopnoea index of 16-30/hour is moderate OSA and an apnoea/hypopnoea of greater than 30 events/hour is considered severe OSA.

Diminished levels of REM sleep are observed and patients will tend not to feel rested after sleep. The consequences of untreated obstructive sleep apnoea can be severe and include heart attack, stroke, decreased libido, irregular heartbeat, high blood pressure and heart disease.

Sufferers are often unaware of their condition and seek attention only when prompted by their partner or because of excessive daytime drowsiness.  Other symptoms include:

• Significant daytime drowsiness
• Snoring with pauses in breathing
• Gasping or choking during sleep
• Restless sleep
• Large neck size (greater than 16” for women, greater than 17” for men)
• Problem with excess weight
• Frequent trips to the bathroom at night
• Morning headaches
• Reduced libido
• Depression
• Memory loss
• Short-tempered
• Mental confusion
• Quick to anger
• High blood pressure
• Night-time chest pain

It is best to advise your doctor if you experience any of the above symptoms or if your partner observes that you snore loudly or wake up often, gasping for breath.

The diagnosis of obstructive sleep apnoea involves a detailed medical history and physical examination.  Where excessive daytime drowsiness is observed then the Epworth Sleepiness Scale is used to assess the patient’s perception of daytime drowsiness.

Where obstructive sleep apnoea is indicated then a sleep study is the recommended course of action.

The treatment for obstructive sleep apnoea is dependent on the severity of the condition.  For mild cases weight reduction, avoiding sedatives/alcohol and advice on modifying sleeping position may be advised.

For moderate and moderate to severe cases, the Continuous Positive Airway Pressure (CPAP)  device is the gold standard.   A constant airflow of pressured air is passed through a face-mask to prevent the airway or throat from collapsing.  The device is used to manage the condition and symptoms will return if it is discontinued.   Some patients experience discomfort from the physical sensations of air being forced into the airway and/or the noise of the equipment. The use of CPAP should not be discontinued without discussing it beforehand with the prescribing physician. MAS therapy is indicated for patients who cannot tolerate the CPAP.

There are a number of surgical options available to address the anatomical factors that may be causing the obstructive sleep apnoea.