Snoring Treatment

Snoring

Snoring indicates that the air passage in the respiratory tract is not sufficiently open; quite severe snoring shows that air is forced to pass through a narrow area. Snoring is estimated to occur in 10% to 30% of adults. In most of these people, snoring is simple snoring and is not of a magnitude that leads to serious health problems. In approximately five out of every 100 people, severe snoring together with pauses in breathing during sleep is predicted, meaning that a disease called obstructive sleep apnea syndrome is present.

Sleep Apnea Syndrome

In normal children and adults, the upper airway remains open thanks to the contraction of the muscles that keep the respiratory passage open. When these muscles relax during sleep, a slight narrowing of the upper airway occurs, but this does not reach a level that causes a problem with airflow. In obstructive sleep apnea syndrome, however, the narrowing of the upper airways that occurs during sleep seriously impairs breathing. The narrowing in this area, which may sometimes lead to complete closure, alerts the brain that breathing is difficult, causing breathing effort to gradually increase. As a result of these events, an arousal reaction occurs in the brain, and with awakening, the respiratory muscles become active and open the upper airway. With this relief, it becomes possible to fall back asleep. This cycle, characterized by difficulty breathing and relief, causes continuous fragmentation of sleep throughout the night, leading to waking up tired in the morning. The condition in which a person’s airway becomes blocked during sleep, who experiences repeated awakenings during the night and is tired and sleepy the next day, is called “Obstructive Sleep Apnea Syndrome.”

There are two types of sleep apnea:

• Obstructive sleep apnea: This more common type of apnea is caused by the muscles in the throat relaxing in such a way that they close the area through which air passes.
• Central sleep apnea: This type of apnea occurs when the brain does not send signals to the muscles that control breathing.

Symptoms

• Daytime drowsiness
• Severe snoring
• Breathing pauses during sleep being observed by others
• Waking up with a feeling of breathlessness
• Waking up with dry mouth and sore throat
• Morning headaches

Causes

Obstructive sleep apnea occurs as a result of the muscles in the throat relaxing in such a way that they close the area through which air passes. These muscles belong to the soft palate, uvula, pharynx and tongue. When these muscles relax, the airway narrows during breathing and breathing stops for a period of time. As a result, the amount of oxygen in the blood decreases; the brain detects this decrease and tries to reopen the airway by reducing sleep depth. Following the reduction in sleep depth, breathing resumes with one or two short deep breaths in some people, and with severe snoring and swallowing sounds in others. This can repeat 20-30 times per hour throughout the night. When sleep apnea is at this degree, it becomes impossible to enter deep sleep; the person spends the entire night struggling to breathe and needs to nap during the day. People with sleep apnea are generally unaware that their sleep is being interrupted and believe they sleep well. Central sleep apnea is much rarer and occurs as a result of the brain not sending signals to the muscles that control breathing. An increase in carbon dioxide and a decrease in oxygen in the blood result in awakening. People with central sleep apnea remember their awakening periods more than people with obstructive sleep apnea.

Risk Factors

Obstructive sleep apnea

• Excess weight: Having a short and thick neck causes narrowing of the airway in the throat. An increase in fatty tissue around the neck and throat due to excess weight is an important factor that worsens sleep apnea. A neck circumference, i.e., collar size, greater than 43 cm in men or 40 cm in women poses a risk for sleep apnea. However, sleep apnea can also be seen in thin people.
• Enlarged tonsils and presence of adenoids: Enlarged tonsils and adenoids are the cause of sleep apnea seen mostly in children; however, they can sometimes be responsible in adults as well.
• Narrow throat structure: In some people, the shape of the throat may be narrow from birth.
• Male sex: Sleep apnea is seen twice as often in men as in women. However, it is also common in overweight women.
• Age: Sleep apnea is 2-3 times more common in adults over middle age than in young people.
• Use of alcohol, sedatives and sleeping pills: These substances cause the throat muscles to relax during sleep.

Central sleep apnea

• Stroke or brain tumors: In the presence of these problems, the brain’s function of regulating the breathing rhythm may be impaired.
• Muscle and nervous system diseases: Sleep apnea may occur in nervous system diseases related to the brainstem and spinal cord, or in some diseases affecting the entire muscular system.
• High altitude: The risk of apnea during sleep increases at altitudes higher than you are accustomed to.

In both types of apnea, there is a risk of developing heart failure and hypertension. Sudden drops in blood oxygen during apnea cause blood pressure to rise and strain the heart and circulatory system. As a result, the risk of stroke due to brain hemorrhage and of heart failure increases. In people with heart disease, the drops in oxygen caused by sleep apnea increase the risk of sudden death during sleep due to a heart attack.

When should you consult a physician?

• If your snoring is severe enough to disturb others or yourself
• If you wake up from sleep with difficulty breathing
• If someone has observed that your breathing pauses during sleep
• If you experience daytime drowsiness (for example, while working, watching television, reading, on a bus, or driving a car)
• Many people do not know that snoring can be a sign of a serious problem; also, not all people with sleep apnea snore. If your snoring is very severe, if there are silent periods between snores, and especially if these occur while sleeping on your back, you need to see a doctor for an examination.

Evaluation and Diagnosis

Since the cause of sleep apnea and the problems it causes can involve multiple systems, evaluations by Ear, Nose and Throat (ENT), Chest Diseases, Cardiology and Neurology specialists may be needed separately. The ENT specialist’s evaluation begins with an examination. During this examination, your doctor will start from the nose and look for changes in shape that could cause narrowing in the areas through which air passes, down to the trachea. After that, a sleep study (polysomnography), an examination in which various body functions are recorded during sleep, needs to be performed. A sleep study can be done in a sleep laboratory or at home. In the sleep study, many criteria such as breathing and circulation activities during sleep, brain waves, airflow through the nose and mouth, arm and leg movements, blood oxygen levels, snoring sounds, and body positions are continuously recorded via cables connected from your body to a device, and are evaluated with computerized systems at the end of the examination. Your doctor may also ask you for a special X-ray called “cephalometry” in order to evaluate the narrow areas of the airway and take measurements on it.

Problems Caused by Sleep Apnea

• Heart and blood vessel problems: Sudden drops in blood oxygen during apnea cause blood pressure to rise and strain the heart and circulatory system. Approximately half of people with sleep apnea have hypertension, which increases the risk of heart failure and brain hemorrhage. It is known that in people with heart disease, the drops in oxygen caused by sleep apnea increase the risk of sudden death during sleep due to a heart attack.
• Daytime drowsiness: When deep sleep at night is not possible due to interruptions in sleep, daytime drowsiness, lethargy and irritability are seen. People with sleep apnea may doze off while working, watching television, reading, on a bus, and even while driving a car. In people with sleep apnea who drive, the risk of having a traffic accident increases 3 to 5 times. Sleep apnea in children usually manifests as a decline in school performance.
• Problems related to medical treatments that may need to be performed for other reasons: In people with obstructive sleep apnea, respiratory system problems related to general anesthesia may be encountered during surgeries that may need to be performed for other reasons.
• Problems related to the partner: When sleep apnea is accompanied by severe snoring, a social problem also arises, such as the bed partner being unable to sleep or even moving to another room.
• Problems related to brain functions: People with sleep apnea may experience forgetfulness, fatigue and lethargy, frequent urination at night, and impotence. Hyperactivity and attention deficit disorder may be seen in children.

What Should Be Done

• If you are overweight, lose weight. In people who are overweight, weight loss significantly reduces apnea.
• Avoid using alcohol, sedatives and sleeping pills. These substances cause the muscles of the throat to relax and affect breathing.
• Sleep on your side or on your stomach. Sleeping on your back causes the tongue and soft palate to fall backward and narrow the airway. To prevent unintentionally rolling onto your back during sleep, it is beneficial to place a ping-pong ball or tennis ball inside the waistband of your pajama bottoms.
• Have problems that cause nasal obstruction treated. Allergies, a deviated nasal septum, and low tension of the nasal wings are common causes that prevent comfortable breathing through the nose, forcing the person to breathe through the mouth and increasing apnea.

Treatment

Sleep apnea usually does not resolve on its own. There are many methods used in its treatment. Various devices can be used to keep the airway open. In some cases, surgical treatment gives better results.

Treatment of obstructive sleep apnea:

1. PAP devices: The most effective treatment for obstructive sleep apnea is sleeping with a device that delivers pressure to the airway through a mask placed over the nose. According to their operating principles, there are different types called CPAP (continuous positive airway pressure, biPAP (bilevel positive airway pressure), and aPAP (automatic positive airway pressure).

2. Surgical treatments: The aim of surgical treatments in sleep apnea is to remove, reduce, or tighten the tissues that close the airway.

• Pharyngoplasty surgeries: In surgery usually performed under general anesthesia, the tissues around the small tongue (uvula), soft palate and tonsils are reshaped. Often the tonsils are also removed during these procedures. Recovery after surgery is usually completed in 4-6 weeks. These surgeries are the most commonly used methods in the surgical treatment of sleep apnea.
• Radiofrequency surgery (RF): In this method, which is mostly used as an adjunct to other surgical methods in sleep apnea, radio waves are applied with a special device to the areas of the soft palate that are to be tightened and, if necessary, to the back of the tongue. The effect the radio waves create in the soft palate tissue and tongue gradually tightens the palate and reduces the size of the base of the tongue. For the treatment effect to appear with each application, 6 weeks must pass, and several repeat applications at 3-month intervals are required.
• • Radiofrequency application method to the soft palate
  • Radiofrequency application areas on the soft palate
  • Radiofrequency application areas on the base of the tongue



• Surgeries aimed at pulling the base of the tongue forward: These surgeries enable the airway to be widened, in patients whose tongue base blocks the airway, by pulling forward a part of the hyoid bone or jawbone to which the tongue muscles are attached.


• Other adjunctive surgeries: Correction of a deviated nasal septum, surgical treatment of chronic sinusitis, removal of large tonsils (tonsillectomy) and of adenoids if present (adenoidectomy), and jaw-correcting surgeries to reposition the jawbones if there is a jaw structure disorder are used to treat sleep apnea.


• Tracheotomy: This surgical method is rarely used only when other treatment methods have not worked and in severe, life-threatening sleep apnea. Breathing is provided through an opening made from the neck into the windpipe (trachea) and a cannula placed within it. This opening, which can be closed during the day, allows air to reach the trachea directly during sleep without passing through the obstructed throat area.

3. Intraoral appliances: Dental appliances are prostheses that aim to keep the airway open by pulling the lower jaw and tongue forward, and can only be used in mild apnea. These prostheses must be placed in the mouth every night during sleep, and each is custom-made for the individual patient from a dental impression.