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Snoring though common may be an indicator of an underlying problem. In India there is a traditional misconception that one who snore's is in sound sleep but the contrary is true. Snoring may be a symptom of obstructive sleep apnea which is associated with a variety of diseases from cardiometabolic diseases like diabetes, cardiac disease to sexual dysfunctions like erectile dysfunction and impotence. All snoring should be evaluated by a multidisciplinary team of doctors including ENT specialist, pulmonologist and sleep specialist.

Today we are interviewing Dr.Prakash Manoharan, a Chennai based ENT surgeon with special interest in evaluation and management of snoring. We have covered the topic of snoring in depth but if you have any further questions use the contact information displayed below. 

What is snoring?
Snoring is abnormal  rough rattling noise during inspiration during sleep by vibration of the soft palate  and the uvula due to high resistance in the upper airway canal causing turbulence flow of air. 

How does one snore?
On inspiration, air to the lungs pasess thru the tongue, the soft palate, the uvula, and the tonsils. When a person is awake, the muscles in the back of the pharynx tighten to hold these structures in place and prevent them from collapsing and vibrating in the airway. During sleep, the soft palate and uvula(due to laxity) may vibrate causing the sounds of snoring. Snoring is believed to occur in anywhere from 30% of women to over 40% of men.

Is all snoring abnormal?
It cannot be commented whether all snoring are abnormal or not as there is nothing called normal snoring. Children should not snore; it is considered abnormal always. It may indicate sleep apnea and some possible pathology in the nasopharynx like Adenoid. Snoring is just one symptom of sleep apnea. Primary snoring in adults is the term used when snoring is present without apnea events. So an adult can snore and not have apnea. But all who have apnea do snore.

Is snoring familial?
Yes,  data are available to support the concept that inheritable or shared environmental factors contribute to the development of snoring  and that maternal components may be more important than paternal ones.

Snoring is an important indicator of obstructive sleep apnea. What percentage of individuals with snoring has sleep apnea?
Habitual snoring is seen in 44% of males and 28% of females. Occational snoring is almost universal. Population-based studies suggest that 2 percent of women and 4 percent of men over the age of 50 years have symptomatic obstructive sleep apnea.

What is sleep apnea?
Sleep apnea is a sleep disorder characterized by abnormal pauses in breathing or instances of abnormally low breathing, during sleep. Each pause in breathing, called an apnea, can last from a few seconds to minutes, and may occur 5 to 30 times or more in an hour. Each abnormal low breathing event is called a hypopnea. Sleep apnea is diagnosed with an overnight sleep test called a polysomnogram, or "sleep study".

What are the forms of sleep apnea?
There are three forms of sleep apnea: central (CSA), obstructive (OSA), and complex or mixed sleep apnea (i.e., a combination of central and obstructive) constituting 0.4%, 84% and 15% of cases respectively. In CSA, breathing is interrupted by a lack of respiratory effort; in OSA, breathing is interrupted by a physical block to airflow despite respiratory effort, and snoring is common. This is the most common cause of sleep apnea and needs intervention by an ENT surgeon.

What are the causes of snoring?
There are a variety of factors that can lead to snoring, such as the abnormal anatomy of oral cavity, nose and the para nasal sinuses, alcohol consumption, allergies, upper respiratory tract infections, and obesity. During sleep the muscles of the soft palate, tongue and pharynx relax enough that they vibrate and may partially obstruct the airway. And, the more narrowed the airway is, the more turbulent the airflow becomes. This causes tissue vibration to increase, thence snoring. The following conditions can possibly affect the airway and cause snoring:

Oral cavity anatomy. Having a low, thick soft palate or enlarged tonsils or adenoids can narrow the airway. In elongated uvula, enlarged tonsils more commonly adenoid,  airflow can be obstructed and vibration increased producing snoring.

Obesity . Deposition of adipose tissue in the pharynx can contribute to narrowing of upper airway. Truncal obesity with BMI > 30 are more prone to have snoring. It is also common in people with large neck circumference or short neck.

Alcohol consumption. Alcohol relaxes pharyngeal muscles hence causing airway obstruction. Snoring can be brought on by consuming too much alcohol before bedtime.

Nasal problems. Chronic Rhino Sinusitis or deviated nasal septum may contribute to  snoring. Sleep apnea is often characterized by loud snoring followed by periods of silence when breathing stops or nearly stops. Sometimes, complete obstruction doesn't occur, but rather, while still snoring, the airway becomes so small that the airflow is inadequate. Eventually, the lack of oxygen and an increase in carbon dioxide signals awakening. This pattern may be repeated many times during the night. For diagnosis of obstructive sleep apnea,  at least five episodes of apnea should be present in an hour.

When do we suspect sleep apnea in a snorer?
People who awake up in night with choking, gasping, smothering; who have restless sleep; have episodes of cessation of breathing; morning headache; reduced libido and impotence ; pass urine in the morning more than 4 times. It should also be suspected in patients having h/o high blood pressure, cardiovascular diseases, cerebrovascular diseases, renal diseases, type 2 diabetes.

What are the effects of snoring?
50% of snorers with sleep apnea have high blood pressure which is more often elevated in the morning. Apart from hypertension,uncontrolled snoring can lead to cardiac problems, stroke, carotid artery atherosclerosis, marital dissatisfaction, increased incidence of road traffic accidents and many more. Snoring is also associated with sudden deaths.

How do you evaluate snoring?
The most reliable method to identify obstructive sleep apnea is a nocturnal polysomnograph.5 This test measures a variety of parameters. The most common parameters used for nocturnal polysomnograph testing include the following.

Right and left eye movements or electro-oculograph;

Electroencephalograph, two to four separate channels;

Chin muscle activity, known as electromyography;

Electrocardiograph;

Leg electromyography, usually right to left anterior tibialis muscles;

Snoring or tracheal sounds, measured with a microphone taped to the throat;

Air flow through the nose and mouth;

Movement of the chest;

Movement of the abdomen;

Oxygen level, measured with a finger oximeter;

Body position; and

Esophageal manometry -- in some laboratories.

What is Dynamic MRI or sleep MRI?
It is a procedure in which Magnetic Resonance Imaging of the upper airway is done when the patient is sleeping. In this we can locate the exact site of collapse of the airway which is causing the patient to snore.According to the obstructive site, the different types of obstructive-type sleep-disordered breathing are classified as the soft palate type, palatine tonsil type, soft palate and depressed lingual root type, depressed lingual root type and epiglottis type. This is a valuable tool for deciding the surgical procedure to be done for each patient.

What are the non-surgical options available for the treatment of snoring?
The main categories of non-surgical treatment of snoring are:

Behavioral changes- avoidance of alcohol at bed time, weight control

Dental devices- prosthesis to relieve the airway obstruction

Nasal devices and medications-  nasal strips, drugs to curtail allergy and saline nasal douchs

Nasal CPAP- best non surgical treatment for snoring. It creates a positive pressure in the airway to relieve the obstruction. Only problem is that it is cumbersome to use.

What are the surgical options available for the treatment of snoring?
A number of surgical procedures designed to address OSA. Effective surgical management of OSA depends upon developing a complete database and determining different levels of obstruction, which may include nasal, nasopharyngeal, oropharyngeal, and hypopharyngeal/retrolingual, or a combination of these sites. A systematic approach to clinical evaluation,treatment planning and surgical management is recommended and is likely to result in more predictable outcomes. Surgical treatment may involve various procedures that are performed in different stages depending on the patient’s sites of obstruction. The most commonly performed procedures include nasal reconstruction, uvulopalatopharyngoplasty (UPPP), advancement genioplasty, mandibular osteotomy with genioglossus advancement, and hyoid myotomy and suspension. In more severe cases, maxillomandibular advancement (MMA) with advancement genioplasty may be indicated.

Sleep apnea is primarily treated with CPAP. But surgeries including uvulopalatopharyngoplasty (UPPP) are also done for the management of obstructive sleep apnea. How effective are the surgeries done for sleep apnea?
Even after appropriate surgical treatment, some patients may demonstrate continued obstruction with associated symptoms. Indications for surgical treatment include an elevated respiratory disturbance index (RDI) with excessive daytime somnolence (EDS), oxygen desaturations below 90 per cent, medical co-morbidities including hypertension and arrhythmias, anatomic abnormalities of the upper airway and failure of medical treatment. The success of surgery in OSA is generally measured by achieving a (RDI) of less than 5, improvement of oxygen nadir to 90 per cent or more with no desaturations below 90 per cent and quality of life improvements with elimination or significant reduction of OSA symptoms. From a practical point of view, achieving these goals may be extremely difficult without patients’ cooperation, most notably in achieving  weight loss and maintenance of a healthy lifestyle.

Contact Information
Dr.Prakash Manoharan
Phone: 09884353900
Email: This e-mail address is being protected from spambots. You need JavaScript enabled to view it