Snoring is a very common problem. In the 30-40-age range, 20% of men and 5% of women snore. By the age of 60, 60% of men and 40% of women will snore most nights.

Snoring can be very loud indeed and cause severe social and marital upset. While many wives or partners, can fall asleep close to a snorer, it is often the unpredictability and irregularity of the snoring that keeps the listener alert and awake waiting for a change in the sound of snoring.

Snoring is the sound of a partially obstructed or vibrating upper airway. The sound of snoring arises in the collapsible or non-rigid part of the airway. The collapsible area is from just above the voice box (base of tongue) below to the back of the nose (posterior choanae) above and involves the soft palate, uvula, the tonsils, base of tongue and the pharyngeal (throat wall) lining. Any of the soft tissue in the collapsible part of the airway may vibrate and produce sound of snoring. The most commonly identified areas that vibrate and produce the sound of snoring are the uvula and soft palate, (the area that hangs down at the back of the throat) excessive pharyngeal mucosa and excess of tissue at the base of the tongue.

A number of factors can contribute to and worsen snoring.

1. Incompetence or weakness of palatal pharyngeal (throat) and glottal (tongue) muscles which help to maintain patency of the collapsible part of the airway during an intake of breath. If these muscles are weak, then the airway can collapse inwards on inspiration and the vibratory sound of snoring develops. Weakness of these throat muscles occurs with sedative drugs and alcohol. Swelling within the airway such as big tonsils and adenoids, cysts in the throat or an enlarged base of tongue may narrow the throat and contribute to an obstructed airway. Obesity is associated with an over all narrowing of the upper airway and consequently, an increase in snoring.
   
   
2. An excessively long and bulky uvula (the bit that hangs down at the back of the mouth) can create a slit like opening from the back the back of the nose into the throat. This produces a one way valve, which is worst when lying on the back. This one way valve worsens snoring.
   
   
3. A blocked nose produces a negative pressure during inspiration and this draws the soft structures such as the uvula and palate towards the back of the nose and produces vibration of snoring. This is why many people who do not normally snore may do so when they have cold. Large septal deformities enlarged turbinates and nasal polyps cause nasal obstruction and may produce snoring.

Lying on the back especially with your chin on the chest will worsen many of the factors that produce snoring. The upper airway is most narrowed, when someone is sitting in a seat and their chin slumps forward onto their chest. As they fall asleep in the chair snoring starts!

Snoring is both a social and medical problem. Heavy snorers are more likely to have high blood pressure and to suffer from strokes and angina than non snorers of similar age and weight. The most advanced stage of snoring is obstructive sleep apnoea (OSA). Snoring is the sound of a partly obstructed upper airway. Apnoea means a total obstruction of the upper airway and the person affected stops breathing! Obstructive sleep apnoea affects 4% of middle aged men and 2% of middle aged woman.

OSA (obstructive sleep apnoea) can cause the symptoms of daytime sleepiness and difficulty with concentration and results in the affected person having difficulty thinking clearly. There is an increase in heart attacks and strokes in patients with obstructive sleep apnoea and as a result more of these people die at a younger age group than those people without obstructive sleep apnoea. There are five fold increases in road traffic accidents and a nine fold increase in single vehicle accidents involving people who suffer from obstructive sleep apnoea. The increase in single vehicle accidents is likely due to the drivers falling asleep at the wheel. This situation is worsened on motorway driving and in monotonous drives.

Obstructive sleep apnoea is a total airway obstruction. The snoring gives way to an episode of total silence during which time the snorer struggles to get a breath. Hypoxia (drop of oxygen level in the blood) is associated with apnoea. At the end of a period of apnoea, a snort often occurs and the patient may become partially awake. There may be contortion or flailing of the arms as the patient kick starts their own breathing and subsequently snoring recurs. An occasional apnoeic event such as as this is quite harmless, but repetitive episodes particularly when each episode lasts longer than 30 seconds and occurs more than 30 times per night is very serious and considered pathological. There can be a surge in blood pressure associated with each severe apnoeic episode and this maybe the reason behind increase in heart disease and strokes in these patients. An overnight sleep study, in hospital, identifies the presence; frequency and severity of sleep apnoea.

In the assessment of an adult with snoring and possible sleep apnoea, the first question is how much difficulty the snoring is creating at home. One should identify whether the patient stops breathing at night and whether the partner has to wake the patient because they stop breathing. One should look for signs of sleepiness during the day (The Epworth Sleepiness Score) and also evidence of poor concentration. A history of heart disease or stroke in a patient, who is younger than one would expect for this disease, may suggest evidence of obstructive sleep apnoea. The Body Mass Index (BMI) is also important to assess, as surgery has no role to play (apart from tracheostomy) in patients with a BMI > 30.

In a child if there is evidence of severe snoring, or suggestion of stopping breathing at night, then this is often an indication for an adeno-tonsillectomy.

Often, the first line of management for patients with severe snoring is an improvement in lifestyle. Loss of weight is, of course, ideal and trying to improve a patient’s lifestyle by increased sporting activity is helpful. Patients should avoid alcohol for 4 hours before going to sleep. Tranquillisers and sleeping pills should be avoided if possible.

In those patients with nasal congestion or obstruction, a nasal steroid spray is tried first (Beconase, Flixonase, Nasacort, Nasonex). A cotton reel placed on the back of pyjamas or a night gown, may prevent a patient from sleeping on their back and thus reduce the volume of snoring. Raising the bed head or using a collar or pillow to extend the neck may help to open the airway and reduce the sound of snoring. A cup of coffee at night may help since the snorer may not fall asleep before his or her partner.

The out-patient assessment of snorer requires an endoscopic (miniature telescope) examination of nose, throat and voice box. If there were obvious blockage to the nasal or upper airway, then it would probably be appropriate for the block to be removed. If there is suggestion of obstructive sleep apnoea, then an overnight assessment to document and assess the degree of apnoea is helpful. If obstructive sleep apnoea (OSA) is identified is identified in the absence of any obstructive disease of the nose and throat, then the treatment is CPAP (continuous positive airway pressure) mask in the first instance.

If snoring is the only significant symptom without any evidence of apnoea, then surgery can be considered to reduce the volume of snoring. It is unlikely that any surgery will guarantee to remove the sound of snoring but there is likely to be reduction in volume of snoring. Such surgery may involve nasal surgery to correct nasal septal deviations or to remove nasal polyps. Such operations can be done as day case and the recovery time is 1-2 weeks.

The most common vibratory area of snoring is the soft palate and uvula. There are number of operations to reduce the size of palate and uvula and to tighten the palate. See the page on the treatment of snoring. The palate operation can be done with Diathermy, Laser or Radiofrequency (RF) machine (Somnoplasty). Palatal surgery (except for celon radiofrequency) is painful for 2 -3 weeks post operatively. Radiofrequency is also used to reduce the bulk of the base of the tongue. Base of tongue treatment is performed under general anaesthesia.