Snoring and Sleep Apnea

What is Snoring?

Snoring is a respiratory noise with an intensity greater than 60 dB that occurs during sleep due to the vibration of the soft tissues in the upper airway.

It should be considered a sign of partial airway obstruction and, consequently, an early indicator of an obstructive breathing disorder that may progressively worsen over time. The origin of snoring is generally located in the palate and pharynx area, although the nasal passages can also contribute to a lesser extent.

Simple or primary snoring refers to snoring that is not accompanied by significant airway obstruction to the point of affecting blood gas levels. Within this, habitual loud snoring or social snoring is defined as snoring that disturbs a partner or household members.

When snoring is accompanied by airway obstruction that affects blood gas levels, it is referred to as Obstructive Sleep Apnea Syndrome (OSAS) or Obstructive Sleep Apnea-Hypopnea Syndrome (OSAHS). This condition is associated with micro-awakenings, inflammatory changes in the respiratory tract, and effects on the cardiovascular system, nervous system, and metabolism.

The term Chronic Snoropathy encompasses all the aforementioned conditions, treating them as a single disorder where snoring is the common symptom. It’s important to note that mild forms may evolve into OSAHS, although this is not always the case, and the more severe forms are always preceded by simple snoring.

What is Sleep Apnea?

Sleep apneas are breathing pauses lasting 10 seconds or more. Shorter pauses are not considered apneas. Hypopneas are reductions in ventilation by at least 50% for a minimum of 10 seconds; although they are not full apneas, they also reduce blood oxygen levels. Both apneas and hypopneas can be:

• Central: caused by neurological disorders affecting the brain’s control of breathing.
• Obstructive: caused by a collapse of the upper airway (these are the ones seen in OSAS).

A small number of apneas can occur during normal sleep, commonly during silent intervals between snores in cyclic simple snoring. The number of apneas per hour of sleep—apnea index (AI)—or more commonly, the number of apneas and hypopneas—apnea-hypopnea index (AHI) or respiratory disturbance index (RDI)—determines the presence and severity of OSAHS, classified as:

• Normal sleep: fewer than 5 apneas-hypopneas per hour
• Mild OSAHS: 5–14 apneas-hypopneas per hour
• Moderate OSAHS: 15–29 apneas-hypopneas per hour
• Severe OSAHS: 30 or more apneas-hypopneas per hour

Epidemiology of Snoring

Chronic snoring affects more than 50% of people over 50 years old. OSAHS affects approximately 5% of men and 3% of women.

Main risk factors include age, obesity, male sex, menopause, congenital or acquired craniofacial or neck abnormalities, hypothyroidism, family history of snoring/OSAHS, and the use of sedatives, tobacco, or alcohol.

 

Clinical Signs of Chronic Snoropathy

Symptoms vary with severity. While simple snoring can be nearly asymptomatic, severe OSAHS can lead to serious consequences.

Nighttime symptoms:

• Loud and persistent snoring
• Apneas (breathing pauses), often unnoticed by the patient
• Micro-awakenings (arousals) the patient is unaware of
• Restless sleep, abrupt movements, night sweats, salivation, nightmares, and night terrors
• Nocturia (frequent nighttime urination)
• Gastroesophageal reflux and burning chest pain (heartburn)

Daytime symptoms:

• Morning or post-nap headaches
• Throat discomfort and dry mouth
• Reduced attention span, memory issues, and intellectual decline
• Irritability and personality changes
• Decreased libido and erectile dysfunction

 

Complications of Snoring

• Cardiovascular: high blood pressure, arrhythmias, worsened heart failure, coronary artery disease
• Neurological: increased risk of strokes (ischemic or hemorrhagic)
• Metabolic: impaired glucose metabolism
• Increased risk of accidents: traffic, domestic, and workplace

 

Diagnosis of Snoring

Diagnosis is primarily clinical. If symptoms like those described above are present, OSAHS must be ruled out. A specialist will perform a full clinical history, an upper airway exam, and likely a polysomnography (PSG), a sleep study that objectively assesses sleep and diagnoses related disorders.

Treatment of Snoring

Medical Treatment

Includes all non-surgical interventions to reduce snoring and OSAHS:

Lifestyle and dietary measures:

• • Weight loss in overweight or obese individuals
  • Eliminate alcohol and tobacco
  • Stop sedatives or CNS depressants
  • Positional therapy (avoid sleeping on the back; sleep on the side)

Mandibular advancement device (MAD)

Intraoral device that gently moves the jaw forward, increasing muscle tone and airway diameter to reduce or eliminate snoring and apnea-hypopnea episodes. Suitable for simple or mild-to-moderate OSAHS. Must be prescribed by a doctor and fitted by a dentist.

CPAP (Continuous Positive Airway Pressure)

It is a device consisting of an electric compressor that delivers pressurized air to the airway through a mask that is applied over the nose or over both the nose and mouth. In this way, airway collapse is prevented and ventilation is ensured during sleep. It is a very effective treatment and the first-line option in cases of severe obstructive sleep apnea (OSA).

 

Surgical Treatment of Snoring

Various surgical techniques are available for chronic snoring and OSAHS. A specialist must assess the patient thoroughly to determine the causes and sites of airway obstruction.

Nasal Surgery

While rarely the sole cause, nasal obstruction can contribute to snoring or OSAHS. Correcting nasal issues like a deviated septum, turbinate hypertrophy, or nasal polyps can help.

Pharyngeal Surgery

Surgical options to widen the naso/oropharyngeal airway when obstruction is located there. Success depends on proper patient selection. Options include:

• Adenoidectomy (removal of adenoids)
• Tonsillectomy (removal of tonsils)
• Tonsillotomy (reduction in tonsil size)
• Somnoplasty (radiofrequency treatment of soft palate)
• Uvulopalatopharyngoplasty (UPPP) (removal of the uvula and part of the soft palate)

Other Surgeries

Obstructions in the lower pharynx (hypopharynx) may require more complex procedures involving the tongue base, hyoid bone, or jaw:

• Tongue base reduction (radiofrequency or laser)
• Anterior stabilization techniques (tongue base and hyoid)
• Maxillomandibular advancement surgery
• Tracheostomy