BY CULLEN T. VOGELSON

Treatments for snoring can help provide a good night’s rest.

If you don’t snore, you must certainly know—or have spent many a frustrating night listening to—someone who does. This conjecture isn’t much of a gamble since some scientists estimate that 40% of the total population regularly snores. Additionally, sleep studies have shown that young to middle-aged men and senior women exhibit the highest frequencies of what otolaryngologists gleefully call “sleep-induced airway obstructions”. So what causes these sleep-disruptive symphonies, what connection do they have to one’s overall health, and how can they possibly be silenced?

Snoring occurs during sleep when the tongue and throat muscles relax. This relaxation results in either a narrowing or partial blocking of the throat’s airway. The subsequent passage of air through these narrowed or blocked regions then causes the soft palate and adjacent structures to vibrate, thus producing the characteristic sound known as a snore. It has been reported that snoring decreases during REM sleep, and depends, at least partially, on specific factors of anatomy and chemistry. For example, the reason that men tend to snore more frequently than women is that their airways are often smaller. However, as women progress through menopause, their changing hormone levels cause a destabilization of the oropharynx musculature that results in a dramatic increase the overall frequency of their snoring.

Wordzzzz of mouth
Snorers tend to fall into one of three categories: mild, moderate, or severe. Although you can probably identify in which category your sleep partner falls without further description, researchers follow certain criteria in labeling their patients. People with mild cases snore occasionally, only when reclined, and stop immediately after changing sleep position. Moderate snorers, on the other hand, experience problems every night, commonly while sleeping on their backs, and in almost any location (e.g., propped upright in a favorite chair while watching television). Unfortunately for their friends and neighbors, those burdened with severe cases tend to snore quite loudly and find that they experience problems during every sleep cycle regardless of position or location.

Physicians recognize two different forms of snoring, each with a unique set of medical concerns and possible treatments. Most people suffer from what doctors call “primary snoring”, and the causes are extremely varied. The most common causes are anatomic, including narrow oropharynx, tongue enlargement, and deviated septa. But there are other causes. Smoking (yes, even secondhand) and excessive alcohol use can result in a loss of throat musculature that can allow air passages to collapse during sleep. In addition, medications such as tranquilizers and benzodiazapines have been linked to snoring, as have medical conditions such as hypothyroidism, hypertension, heart disease, and asthma. Even simple sinus congestion is implicated as it forces the afflicted to breathe exclusively through the mouth.

The second, and potentially more serious form of snoring, is related to sleep apnea. People who suffer from this condition actually stop breathing for 10 or more seconds during sleep. Often, they end up gasping for air and then resume snoring. Quite commonly, those with sleep apnea are men who present with additional symptoms such as obesity and otherwise unexplained daytime drowsiness. Sleep apnea has serious health consequences, and patients who believe they may suffer from it should seek immediate medical attention. (It should also be noted that primary snoring is often an early predictor of the onset of sleep apnea.)

Treatmentzzzzz
Snoring is not really curable, despite product claims to the contrary. In fact, the chances of finding a guaranteed method of gaining a snore-free night are about the same as the odds of being struck by lightning. So, with literally thousands of promoters advertising “cures” for snoring, consumers should consider all product claims with a great deal of skepticism. Many of the products routinely sold online and in stores include dietary supplements and nose and throat sprays that have no demonstrated efficacy, as well as seemingly medieval devices that fit in the mouth and claim to keep the tongue from sliding back into the throat.

There are, however, several products that can help reduce the frequency of primary snoring. The most pervasive product line consists of fabric nasal strips that are applied over the bridge of the nose. These strips claim to open nasal passageways, thus allowing one to breathe through the nose rather than the mouth. As it happens, not only do these strips do what they claim, but several brands have gained FDA approval. One important caveat to using these strips, however, is that they won’t necessarily work immediately; mouth breathing is often habitual, and it may take several days to even a few weeks before the user begins breathing exclusively through the nose. Other common snore-relief aids include head and neck support pillows and either topical or oral decongestants. Finally, there are a couple of additional—albeit invasive—products on the consumer market. One is an airway pressure device. It consists of an air blower attached to a mask that is worn during sleep. The idea is that the positive pressure from the airflow will keep the airway open and prevent snoring. Another device, which must be fitted by a physician or a dentist, is placed in the mouth, fits over the teeth, and moves the jaw and tongue forward, thereby preventing the airway from becoming blocked.

Several surgical procedures to reduce snoring are available when all other attempts to reduce snoring frequency and severity have been exhausted or in cases of serious sleep apnea. The oldest technique is uvulopalato-pharyngoplasty (UPPP). In this procedure, the patient, under general anesthesia, is subjected to a tonsillectomy followed by the partial removal of the soft palate, the uvula, and the pharyngeal arches. Although UPPP is highly effective in the short term, it is expensive, requires significant recovery time, and is not altogether successful in the long run, for reasons that elude the medical community. However, researchers suggest that the lack of standardized measurements and the use of subjective reporting by patients are behind the apparent incongruity.

A second procedure, called a laser-assisted uvulopalatoplasty (LAUP), is similar to the UPPP technique without the tonsillectomy but is conducted in several stages. (The purpose of the laser is to vaporize the palatopharynx.) LAUP is a less invasive procedure, which also costs less, requires only local anesthetic, and has fewer complications than UPPP. On the other hand, the procedure is about as effective as UPPP, but patients experience increased postoperative pain.

Cheaper still, less painful, and more convenient for surgeons to perform than either of the previously mentioned methods is the cautery-assisted palatal stiffening operation (CAPSO). Here, a longitudinal strip of mucosa along the soft palate is removed in a single operation. As its name implies, this surgery causes the soft palate to stiffen, a result markedly different from the other two techniques, both of which cause it to lengthen. The overall result of the procedure seems highly promising, although the long-term effects are currently unknown.

Radio-frequency ablation (RFA, and also known by the trademark, Somnoplasty) is the least invasive of all the possibilities. A surgeon inserts an electrode-tipped needle into the soft palate and then transmits a burst of radio-frequency energy into the tissue, which causes the underlying muscles to tighten and scar. Although this is an expensive procedure—almost as much as UPPP—its lack of associated pain, shorter recovery time, and relatively few possible complications make it highly attractive to patients and physicians alike.

At the September 24, 2000, meeting of the American Academy of Otolaryngology—Head and Neck Foundation in Washington, DC, Scott E. Brietzke and Eric A. Mair, physicians at Walter Reed Army Medical Center (Washington, DC), introduced a novel technique that they called “injection snoreplasty”. This procedure is inexpensive—they estimate the cost at $35—relatively painless, requires no recovery time, and is fast and simple enough to perform during a patient’s office visit. The technique involves nothing more than injecting a sclerotherapy agent into the midline of the patient’s soft palate. Thus far, the doctors report a high efficacy rate within the first year after injection, with only minor side effects. The long-term results are obviously unknown, but Brietzke and Mair predict that even if the effects do diminish, the treatment’s overall cost to patients (in terms of money, time, and pain) will make subsequent treatments highly attractive.

Given the concern and medical research focused on this matter, snoring clearly involves more than just a big snooze. Its causes and associated medical conditions are well established, and increasingly, there are less expensive and invasive treatments available. In addition, although this is wonderful news for the snorer, it’s also good news for the people who spend fitful nights listening to them. After all, a 1999 Mayo Clinic study found that bed partners lost as much as one hour of their own sleep each night they spent with a snoring spouse.

References

1. Lugaresi, E.; Cirignotta, F.; Coccagna, G.; Piana, C. Sleep 1980, 3, 221–224.
2. Pray, W. S. U. S. Pharmacist 2000, 25 (7), 37. www.uspharmacist.com/NewLook/DisplayArticle.cfm?item_num=549.
3. Littlefield, P. D.; Mair, E. A. Ear Nose Throat J. 1999, 78 (11), 861–865.
4. Brietzke, S. E.; Mair, E. A. Injection Snoreplasty: How to Treat Snoring Without all the Pain and Expense. Presented at the annual meeting of the American Academy of Otolaryngology—Head and Neck Surgery Foundation, Washington, DC, Sept 24, 2000.
5. Beninati, W., et al. Mayo Clin. Proc. 1999, 74, 955–958.

Cullen T. Vogelson is an assistant editor of Modern Drug Discovery. Send your comments or questions regarding this article to mdd@acs.org or the Editorial Office by fax at 202-776-8166 or by post at 1155 16th Street, NW; Washington, DC 20036.

 © 2001 American Chemical Society.  

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