What is snoring?
Snoring, like all other sounds, is caused by vibrations that cause particles in the air to form sound waves. For example, when we speak, our vocal cords vibrate to form our voice. When our stomach growls (borborygmus), our stomach and intestines vibrate as air and food move through them.
While we are asleep, turbulent airflow can cause the tissues of the nose and throat to vibrate and give rise to snoring. Essentially, snoring is a sound resulting from turbulent airflow that causes tissues to vibrate during sleep.
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Any person can snore. Studies estimate that 45% of men and 30% of women snore on a regular basis. Frequently, people who do not regularly snore will report snoring after a viral illness, after drinking alcohol, or when taking some medications. People who snore can have any body type. We frequently think of a large man with a thick neck as a snorer. However, a thin woman with a small neck can snore just as loudly. In general, as people get older and as they gain weight, snoring will worsen.
What causes snoring?
While we are breathing, air flows in and out in a steady stream from our nose or mouth to our lungs. There are relatively few sounds when we are sitting and breathing quietly. When we exercise, the air moves more quickly and produces some sounds as we breathe. This happens because air is moving in and out of the nose and mouth more quickly and this results in more turbulence to the airflow and some vibration of the tissues in the nose and mouth.When we are asleep, the area at the back of the throat sometimes narrows. The same amount of air passing through this smaller opening can cause the tissues surrounding the opening to vibrate, which in turn can cause the sounds of snoring. Different people who snore have different reasons for the narrowing. The narrowing can be in the nose, mouth, or throat.
The function of the nose in normal breathing
For breathing at rest, it is ideal to breathe through the nose. The nose acts as a humidifier, heater, and filter for the incoming air. When we breathe through our mouth, these modifications to the air entering our lungs occur to a lesser extent. Our lungs are still able to use the colder, drier, dirtier air; but you may have noticed that breathing really cold, dry, or dirty air can be uncomfortable. Therefore, our bodies naturally want to breathe through the nose if possible.
The nose is made up of two parallel passages, one on each side, called the nasal cavity. They are separated by a thin wall in the middle (the septum), which is a relatively flat wall of cartilage, bone, and lining tissue (called the nasal mucosa). On the lateral side (the wall of the nose closer to the cheeks) of each passage, there are three nasal turbinates, which are long, cylindrical-shaped structures that lie roughly parallel to the floor of the nose. The turbinates contain many small blood vessels that function to regulate airflow. If the blood vessels in the turbinates increase in size, the turbinate as a whole swells, and the flow of air decreases. If the vessels narrow, the turbinates become smaller and airflow increases.
Everyone has a natural nasal cycle that generally will shift the side that is doing most of the breathing about every eight hours. For example, if the right nasal turbinates are swollen, most of the air enters the left nasal passage. After about eight hours, the right nasal turbinates will become smaller, and the left nasal turbinates will swell, shifting the majority of breathing to the right nasal passage. You may notice this cycle when you have a cold or if you have a chronically (long standing) stuffy nose. The turbinates may also swell from allergic reactions or external stimuli, such as cold air or dirt.
Mouth breathing and snoring
As discussed above, we naturally want to breathe through our noses. Some people cannot breathe through their noses because of obstruction of the nasal passages. This can be caused by a deviation of the nasal septum, allergies, sinus infections, swelling of the turbinates, or large adenoids (tonsils in the back of the throat).
In adults, the most common causes of nasal obstruction are septal deviations from a broken nose or tissue swelling from allergies.
In children, enlarged adenoids (tonsils in the back of the throat) are often the cause of the obstruction.
People with nasal airway obstruction who must breathe through their mouths are therefore sometimes called "mouth breathers." Many mouth breathers snore, because the flow of air through the mouth causes greater vibration of tissues.
The soft palate and snoring
The soft palate is a muscular extension of the bony roof of the mouth (hard palate). It separates the back of the mouth (oropharynx) from the nasal passages (nasopharynx). It is shaped like a sheet attached at three sides and hanging freely in the back of the mouth.
The soft palate is important when breathing and swallowing.
- During nasal breathing, the palate moves forward and "opens" the nasal airway for air to pass into the lungs.
- During swallowing, the palate moves backward and "closes" the nasal passages, thereby directing the food and liquid down the esophagus instead of into the back of the nose.
The palate and attached uvula often are the structures that vibrate during snoring and surgical treatments for snoring may alter these structures and prevent guttural fricative sounds. Therefore, if you speak a language that uses guttural fricative sounds, a surgical treatment for snoring may not be recommended or appropriate for you.
Narrowed airways and snoring
The tonsils are designed to detect and fight infections. They are located at the back of the mouth on each side of the throat (oropharynx). They are also called the palatine tonsils. Like other infection-fighting tissue, the tonsils swell while they are fighting bacteria and viruses. Often, the tonsils do not return to their normal size after the infection is gone. They can remain enlarged (hypertrophied) and can narrow the airway vibrate, and cause snoring.
The soft palate, as described above, is the flap of tissue that hangs down in the back of the mouth. If it is too long or floppy, it can vibrate and cause snoring.
The uvula is suspended from the center and back of the soft palate. An abnormally long or thick uvula also can contribute to snoring.
The base of the tongue is the part of the tongue that is the farthest back in the mouth. The tongue is a large muscle that is important for directing food while chewing and swallowing. It also is important for shaping words while we are speaking. It is attached to the inner part of the jaw bone (mandible) in the front and to the hyoid bone underneath.
The tongue must be free to move in all directions to function properly. Therefore, it is not attached very tightly at the tip or top of the tongue. If the back of the tongue is large or if the tongue is able to slip backwards, it can narrow the space through which air flows in the pharynx, which can lead to vibrations and snoring.
Stage of sleep and snoring
Sleep consists of several stages, but in general they can be divided into REM (rapid eye movement) and non-REM stages. Snoring can occur during all or only some stages of sleep. Snoring is most common in REM sleep, because of the loss of muscle tone characteristic of this stage of sleep.
During REM sleep, the brain sends the signal to all the muscles of the body (except the breathing muscles) to relax. Unfortunately, the tongue, palate, and throat can collapse when they relax. This can cause the airway to narrow and worsen snoring.
Sleeping position and snoring
When we are asleep, we are usually (though not always) lying down. Gravity acts to pull on all the tissues of the body, but the tissues of the pharynx are relatively soft and floppy. Therefore, when we lie on our backs, gravity pulls the palate, tonsils, and tongue backwards. This often narrows the airway enough to cause turbulence in airflow, tissue vibration, and snoring. Frequently, if the snorer is gently reminded (for example, with a gentle thrust of the elbow to the ribs or a tickle) to roll onto his or her side, the tissues are no longer pulled backwards and the snoring lessens.
What is the clinical importance of snoring?
It is important to recognize determine if snoring is related to an underlying medical condition or is an isolated (primary) problem (not associated with any underlying disease).More specifically, primary snoring is not associated with obstructive sleep apnea, upper airway resistance, insomnia, or other sleep disorders. This distinction is important because of the associated link between the underlying conditions and other adverse health effects.
For example, obstructive sleep apnea (OSA) is associated with higher risks of cardiovascular disease such as heart attacks and strokes. This association is thought to exist because of higher prevalence of high blood pressure (hypertension) in individuals with obstructive sleep apnea. On the other hand, studies have shown that people with primary snoring did not have higher rates of elevated blood pressure compared to the general public.
How should someone with snoring be evaluated?
To thoroughly evaluate someone with a snoring problem, it is important to also talk to that person's bed partner or family members. A complete history and physical examination is often performed.In addition, more detail about their snoring and sleep problems needs to be obtained. The patients may be asked about their sleep pattern and sleep hygiene, daytime symptoms of sleepiness, daytime napping, and frequency of awakening at night.
A thorough physical examination may also be performed including assessing the patient's body weight and body mass index (BMI), assessment of the neck circumference (area around the neck), and visualization of the throat, nasal, and oral cavities to determine how narrow the oral and nasal passages are.
How is it determined if snoring is a medical problem?
People who sleep (or lie awake not sleeping) near a snorer often report signs that may indicate a more serious problem. Witnessed apnea (stopping breathing) or gasping can suggest a breathing problem like sleep apnea (see below) or heart problems. Leg kicking or other jerking movements can indicate a problem such as periodic limb movement disorder or restless leg syndrome. Referral to a sleep specialist may be recommended if obstructive sleep apnea, restless leg syndrome, and periodic limb movement disorder are suspected.If someone's sleep is disrupted because of snoring, the person may also notice other symptoms. Frequently, people complain of difficulty waking up in the morning or a feeling of insufficient sleep. They may take daytime naps or fall asleep during meetings. If sleep disruption is severe, people have fallen asleep while driving or performing their daily work.
Daytime sleepiness can be estimated with a sleepiness inventory, and a sleep study can be performed if a sleeping problem is suspected. There are two general types of sleep studies:
- Home (unattended sleep study
- Full sleep study (polysomnography)
A home (unattended) sleep study can measure some basic parameters of sleep and breathing. Often, it will include pulse oximetry (a measurement of the level of oxygen in the blood), a record of movement, snoring, and apneic (stop in breathing) events. A home study can prove that there are no sleeping problems or suggest that there may be a problem.
If a home sleep study suggests a problem, a full sleep study (polysomnography) often is performed in a clinic. (For a complete description of sleep studies, see below).
If the sleepiness inventory and sleep study suggest there are no sleeping or breathing disorders, a person is diagnosed with primary snoring. Treatment options then can be discussed.
Epworth Sleepiness Scale
The Epworth Sleepiness Scale is a "test" based on a patient's own report that establishes the severity of sleepiness. A person rates the likelihood of falling asleep during specific activities. Using the scale from 0-3 below, patients rank their risk of dozing in the chart below. (This chart can be printed out and taken to the doctor.)
| 0 = Unlikely to fall asleep |
| 1 = Slight risk of falling asleep |
| 2 = Moderate risk of falling asleep |
| 3 = High likelihood of falling asleep |
| Situation | Risk of Dozing |
| Sitting and reading | |
| Watching television | |
| Sitting inactive in a public place | |
| As a passenger in a car riding for an hour, no breaks | |
| Lying down to rest in the afternoon | |
| Sitting and talking with someone | |
| Sitting quietly after lunch, without alcohol | |
| In a car, while stopped for a few minutes in traffic |
After ranking each category, the total score is calculated. The range is 0-24, with the higher the score the more sleepiness.
Scoring:
- 0-9 = Average daytime sleepiness
- 10-15 = Excessive daytime sleepiness
- 16-24 = Moderate to severe daytime sleepiness
What are the treatments for snoring?
The goals for the treatment of surgery may be difficult to determine. The problem of snoring usually is a problem for the bed partner or roommate. Therefore, successful treatment should also include the goal of achieving a successful night's sleep for the bed partner or roommate. This makes treatment of snoring a difficult challenge. For example, someone may have a successful treatment if his or her snoring decreases from a jackhammer level to that of a passing truck. If their bed partner is happy, then the snoring problem is "cured." However, another person whose snoring decreases from a mild sound to the level of heavy breathing may still have an unhappy bed partner.It is wise to look at the "success" reports for various treatments with a critical eye. If the number of nights that a bed partner has to leave the room decreases from seven nights per week to one night per week, is that success? Some would say that it is. However, the bed partner (or snorer) still has to leave the room one night per week. It is important to know what the expectations for a "cure" are before considering any treatments.
What are some non-surgical treatments for snoring?
The main categories of non-surgical treatment of snoring are:- Behavioral changes
- Dental devices
- Nasal devices and medications
- Nasal CPAP
- Over-the-counter products
Behavioral changes are the easiest to identify, but some of the hardest to accomplish. For example, if a person gains ten pounds, his or her snoring may become a problem. It is easy to tell a person to lose the ten pounds, but it is difficult to accomplish. Behavioral changes include weight loss, changing sleeping positions, avoiding alcohol, smoking cessation, and changing medications that may be the cause of snoring.
Losing weight may improve snoring. Snoring usually is worse when lying flat on the back, as discussed previously. To help this problem, a pocket can be sewn into the back of the snorer's pajama tops. A tennis or golf ball in the pocket will "encourage" the snorer to roll over to sleep on his/her side. Alcohol or sedative medications make snoring worse, and therefore should be avoided.
Dental devices
As previously discussed, snoring is exacerbated by normal airflow through a narrowed area in the throat. Part of the narrowing is caused by the tongue and palate falling back during sleep. Some dental devices have been developed that hold the jaw forward. Since the tongue is attached in the front to the jaw, the tongue also is held forward when these devices are used. Some devices are designed to hold the palate up and forward.
All dental devices (similar to a mouthpiece) are best made by a dentist to ensure a correct fit without causing problems. These devices may improve snoring in 70% to 90% of cases. There are some drawbacks to dental devices, however. They must be worn every night in order to work, can cause or exacerbate temporomandibular joint (TMJ) problems, can cause excessive salivation, and can be moderately expensive.
The available data on some of these devices revealed both subjective and objective improvement in snoring. These devices may be appropriate and recommended for those individuals with primary snoring or mild obstructive sleep apnea who did not benefit or did not qualify for the aforementioned behavioral changes.
Nasal devices and medications
For people with narrow nasal passages, snoring can be alleviated with nasal devices or medications. Breath-rite strips open the anterior nasal valve (front part of the nose). If this is the main or only area of narrowing, snoring may improve with use of these strips, but this is frequently not the case.
If nasal mucosal (lining) swelling from allergies or irritation is causing the problem, nasal sprays may help. Nasal saline irrigation spray is a way to clean and moisturize the nasal lining since environmental irritants that stay in the nose (dust, pollen, and smoke) continue to irritate as long as they are present. The nasal lining also swells when it is cold and dry. Nasal saline helps to wash away irritants and moisturizes the mucosa without side effects.
Other nasal sprays that may be used to improve nasal breathing include nasal steroid sprays and nasal decongestants. They are very helpful for swelling due to minor allergies or irritation. Steroid sprays decrease inflammation in the nasal passages. Very little of the steroid is absorbed into the body from the nose so there are few side effects with these sprays. Nasal decongestants that shrink the blood vessels in the turbinates also can be used to improve snoring that results from nasal congestion.
These measures may also be helpful for people who only snore when they have upper respiratory infections or colds, which typically cause swelling of the airway passages.
Nasal CPAP
CPAP or continuous positive airway pressure is a device that is commonly used in patients with a clinical diagnosis of obstructive sleep apnea. This device works by providing a constant, increased air pressure to prevent airway narrowing during inspiration and expiration. It entails wearing a mask that is connected by tubing to a pump that keeps the pressure of the inspired air at a higher than normal level.
This device has proven to cause subjective and objective improvement of snoring and other symptoms of obstructive sleep apnea. The air pressures are adjusted individually for each patient based on their parameters of a sleep study.
The main problem with CPAP is that the CPAP machine is bulky, noisy, and possibly uncomfortable for patients to wear all night, every night. Therefore, patient adherence to the use of CPAP often is not optimal.
Over-the-counter products for snoring
There are many other simple over the counter products available to help with snoring. Generally, they may not be scientifically studied and recommended. They may be useful in some people subjectively. Regardless, if snoring exists, then it needs to be fully evaluated by a physician to assure that there is no underlying potential medical condition and to choose a proven method of treatment.
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