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Snoring and Sleep Apnea

Snoring may affect up to 1/2 of the United States population. Upwards of 20 million Americans may have obstructive sleep apnea. Sleep apnea often goes undetected or undiagnosed. An important distinction must be made between snoring and sleep apnea, as there are many medical consequences to sleep apnea. Ultimately, only an overnight sleep study (polysomnogram) is able to distinguish the two conditions. Options for treatment include dietary and behavioral changes, positional therapy, CPAP, mouth appliances, and surgery. Often looking at the airway while asleep, a procedure known as a drug-induced sleep endoscopy (DISE), is required to determine the best treatment options. Surgical approaches include addressing obstruction at the level of the nose, roof of the mouth, back of the tongue, or lower in the airway.

Do You Have Snoring or Sleep Apnea?

Snoring. Snoring is abnormally loud breathing sounds produced during sleep. These sounds occur because of vibrations of structures within the throat. Most often, snoring comes from the roof of the mouth because the soft palate and uvula are too long. Occasionally, snoring can come from the back of the tongue or other structures in the throat.

Many people snore. It has been estimated that anywhere from 30 - 50% of the United States population snore at some time or another. Significant snoring is sometimes described as "heroic" snoring, in which the snoring loudness may be heard more than two bedrooms away.

Snoring is not sleep apnea, and sleep apnea is not snoring. Snoring (noisy breathing during sleep) is a social problem, which can cause sleep disruption to both the snorer and bed partner, and may be associated with significant sleep disturbances and waking episodes. However, many patients with loud snoring have significant obstructive sleep apnea (possibly up to 2/3’s).

Obstructive sleep apnea (OSA). Apnea literally means without breath, in which an individual stops breathing. Obstructive sleep apnea occurs at night because an individual has a physical obstruction, often in the nose, roof of mouth, tongue or throat. Obstructive sleep apnea is characterized by significant and prolonged interruptions of breathing and airway obstructions at night.

Obstructive sleep apnea prevents someone from obtaining restful sleep. Individuals with sleep apnea may complain of:

  • Constant “tired” feeling
  • Sensation of never fully being rested
  • Need to take daytime naps
  • Excessive sleepiness during the day
  • Falling asleep while driving
  • Headaches
  • Lack of energy
  • Mood changes
  • Lack of libido
  • Loss of memory

Obstructive sleep apnea not only affects the quality of life of individuals, but when uncontrolled may be harmful to one’s health. It is well established that obstructive sleep apnea is a serious disorder which may become a major risk to one's health, causing significant lung and heart problems over time. OSA can cause a decline in cognition, including problems with memory, attention, and thinking skills.

Obstructive sleep apnea is associated with:

  • Stroke
  • Heart attack
  • High blood pressure
  • Rarely, premature death

Obstructive sleep apnea is characterized by significant interruptions of breathing (airway obstructions) during the night. These cessations of breathing may be associated with a substantial decrease in blood oxygen levels, high blood pressure, cardiac arrhythmias (irregularities in the heart's normal beating pattern) and may in fact be a cause of sudden death. Your spouse may have noticed you stop breathing while asleep (that is sleep apnea).

Take a test to determine if you are too sleepy during the day. This questionnaire, known as the Epworth Sleepiness Scale, can help screen for people with sleep problems. A score of more than 10 can suggest you have a problem sleeping at night:

Take the Test

ESS scores can be interpreted as follows:
  • 0-5 -- Lower Normal Daytime Sleepiness
  • 6-10 -- Higher Normal Daytime Sleepiness
  • 11-12 -- Mild Excessive Daytime Sleepiness
  • 13-15 -- Moderate Excessive Daytime Sleepiness
  • 16-24 -- Severe Excessive Daytime Sleepiness

If you have some of the symptoms mentioned in the test and are a loud snorer, you should have a sleep study (polysomnogram) performed. This is an overnight test that can be performed in your own home or in a sleep laboratory where you are monitored while you sleep. During this sleeping time, sensors keep track of a number of important processes, including the heart rhythm (EKG), blood oxygen levels, sleep state, the number and duration of spells when your breathing is altered. All of this information is analyzed and used to determine whether you have snoring or sleep apnea.

What can you do?

Based on the results of the polysomnogram, you will be classified as having “primary snoring” (snoring only), or a person with OSA. People who suffer from loud snoring but not OSA have treatment options, as do those with OSA.

Snoring Treatments

Primary snoring treatment begins with behavioral and lifestyle changes. Non-surgical treatment methods include weight loss and positional changes (sleeping on your side). There are positional devices that vibrate when you are on your back to bumps that help you to sleep on your side. One of the simplest “devices” is to sew a tennis ball in the pocket of a T-shirt and wear the T-shirt backwards at night. Elevating the head of the bed 4-6 inches can make a difference or alternatively using a foam wedge pillow. Nasal strips or other types of nasal dilators may improve snoring if you have tight nasal passages. Avoid or limit alcohol use and treat environmental allergies. In some cases, an oral appliance (see below) may be beneficial. Office-based procedures include radiofrequency procedures to the palate, injection snoreplasty, and CAPSO (Cautery Assisted Palatal Stiffening Operation). Treatments for snoring are not covered by medical insurance, so they are an out-of-pocket cost and non-reimbursable.

Sleep Apnea Treatments

Treatment of sleep apnea initially involves conservative, or non-surgical treatments, including weight loss when indicated, positional changes during sleep and the use of a positive airway pressure device.

Positive airway pressure (CPAP or BiPAP) therapy is usually the primary treatment in the management of sleep apnea. In PAP, pressurized air is delivered by a face mask which is worn during sleep. The pressure of the air is adjusted in order to maintain adequate pressure to overcome airway obstruction. In this way, most airway closure episodes are eliminated. Many patients find that while wearing this device, they experience a much improved sleep pattern with an overall better night's sleep. Some patients find, however, that the CPAP device is cumbersome and difficult to use. For those who tolerate PAP, it is very effective. CPAP should be used every night. Self-titrating PAP (AutoPAP) adjusts the air pressure throughout the night to deliver just enough pressure to keep your airway open. Many people find this type of PAP the easiest to tolerate.

Mandibular Advancement Appliance. These devices are worn at night to improve your airway. Typically, they are composed of an upper and lower tooth guard that are connected to each other.  Using the upper teeth as the focal point, the lower teeth and jaw are moved forward. This brings the tongue forward opening the airway. Most are adjustable so that they can be customized to your needs. You wear the appliance nightly. In some people, this prolonged pressure on the teeth can result in movement of the teeth or cause discomfort of the jaw joint (TMJ). Most people without pre-existing problems with TMJ do well wearing the appliance.

Drug-induced Sleep Endoscopy or DISE. The ability to examine your throat while asleep can provide additional information about how it collapses. In a controlled environment, such as the operating room, you are given medication that will put you in light sleep. Once you begin to snore, a flexible, very thin video camera is placed through the nose and your airway is examined. A precise location of the site(s) of obstruction, for instance the palate, tongue, tonsils, sides of the throat, or epiglottis, is identified. This is usually a very quick procedure with little down time and anticipate returning to normal activities the next day.           

Treatments Involving the Nose

Septoplasty. The nostrils are separated by a sheet of cartilage and bone called the septum. In some people this sheet is not straight but has a curvature to one or both sides of the nose. This is called a septal deviation. This can cause a blockage leading to difficulty breathing through the nose especially at night. Also, a septal deviation can contribute to closure lower in the airway. There can also be an outcropping that is called a septal spur that can cause further blockage of the nose. Septoplasty is a surgical procedure that removes a portion of the septum and/or alters the underlying cartilage and bone so that the septum is in the middle of the nose. Once the septum is in the middle it no longer contributes to blockage and people breathe easier through the nose. This procedure is performed entirely inside the nose (there are no external incisions) through a small surgical opening near the front of the septum. The lining of the nose is separated from the underlying cartilage and bone, structural changes are made, and the lining is sewn back in place. Sometimes supports (splints) are placed that are removed a few days later.

Turbinate Reduction. Nasal turbinates are lateral outcroppings in the nose that may become enlarged, contributing to snoring or OSA. There are three turbinates on each side of the nose, with the lowest one (inferior turbinate) responsible for most of the blockage. The size of the nasal turbinates may be reduced using multiple procedures. Radiofrequency ablation uses radiofrequency energy delivered to the turbinate tissue, reducing the size of the tissue over time, increasing the size of the airway. Sometimes the turbinate is trimmed in a procedure called a submucous resection.  Alternatively, the tissue of the turbinates may be removed in a targeted fashion using a ‘microdebrider’ device.  Some of these procedures may be performed in the office using local anesthesia, or combined with other procedures in the operating room under general anesthesia.

Rhinoplasty. Sometimes the external portion of the nose contributes to obstruction. In this case, a rhinoplasty may be performed to improve nasal breathing. When performed to improve nasal airflow, it is called a functional rhinoplasty. Mis-shaped or enlarged cartilage, and sometimes bone, can be trimmed, re-positioned or supplemented with cartilage from the ear or rib to open the nasal passages. Rhinoplasty can be done inside the nose or through small incisions in the base of the nose.  The skin over cartilage and bone is lifted, cartilage and/or bone is adjusted and the skin is replaced and sewn together.

Nasal Valve Surgery. The nasal valve is located just inside the nostril. It is the narrowest portion of the nasal airway, therefore, small changes in the area of the valve can make a big difference in breathing. Classically, small grafts of cartilage can be placed through an incision inside the nose, under the skin, in the outer aspect of the lower nose. These cartilages act to strengthen the nostril so the nostril does not collapse when breathing.

Newer techniques are also available. VivAer® uses low-temperature radiofrequency energy to reshape the soft tissues of the nasal valve. This can be performed in the office using local numbing and does not use any incisions. The exterior appearance of the nose is unchanged.

Latera® is an absorbable nasal implant that is used to support the outer cartilages of the nose. The implant is inserted in the nostril with a specialized needle-like instrument (cannula). Over time the body forms tissue around the implant which stabilizes it in place and eventually it is restored. 

Treatment of the Palate

Uvulopalatopharyngoplasty (UPPP). UPPP for many years was the main surgical treatment for sleep apnea, introduced in the United States by Dr. Fujita in the early 1980's. The surgery takes out extra tissue from the roof of the mouth. The first step of the procedure is to remove the tonsils (if they are still present). Then a portion of the palate is trimmed and the entire uvula is removed. Dissolvable sutures are placed to close the area. The UPPP is performed under general anesthesia, and may require an overnight hospital stay for observation. Postoperatively, patients typically experience a severe sore throat and some difficulty swallowing which may last as long as 10 to 14 days, although some patients find they can return to work sooner. Changes may occur in your voice or with swallowing, but these are usually temporary.

Expansion Pharyngoplasty. This technique is a newer method to prevent the palate from falling back in the airway, while preserving muscle integrity as much as possible to optimize breathing, swallowing and voice quality. The procedure begins with removing the tonsils on both sides. Then a muscle in the outer aspect of the palate and throat, the palatopharyngeus muscle, is mobilized. Some of the fibers of the muscle are often cut and a series of dissolvable sutures are placed, pulling the palate forward and outward in the throat. The effect is to enlarge the airway behind the palate and prevent it from falling back into the airway. 

Lateral Pharyngoplasty. This is also a newer technique that mainly involves moving muscles of the roof of the mouth to open the outer walls of the back of the throat. In the operating room under general anesthesia the tonsils are removed. Then, making small cuts in the outer muscles of the throat and soft palate, the muscles are moved to open the throat and held in place with dissolvable sutures. The goal is to keep the muscles and lining of the throat and palate mostly intact, while opening the throat. Swallowing and talking are less affected because the muscles and tissue are preserved as much as possible.

Treatment of the Tongue and Lower Throat

Radiofrequency Ablation. Radiofrequency ablation (RFA) can be performed on the palate and the tongue. It is usually performed in a doctor’s office and most people can return to work in a short period of time, even the next day. The palate or tongue is numbed, so no discomfort is felt during the procedure. RFA uses a needle to deliver an electric current to heat up surrounding tissue, destroying some of the tissue with subsequent scarring that shortens the palate and shrinks the back of the tongue. Scarring also stiffens the tongue and palate, so these structures are less likely to fall back in the throat when sleeping. Multiple areas are treated to optimize shrinkage during each session.  Often times, the procedure is repeated over time to maximize tissue removal and scarring. A large palate is often the cause for snoring, so reducing the palate can reduce the volume and frequency of snoring.

Lingual Tonsillectomy. There is tissue on the side of the throat commonly referred to as tonsils. This tissue is called lymphoid tissue and is usually removed for repeated infections or because, when large, the tonsils can obstruct the airway. There is similar lymphoid tissue in the back of the tongue (called lingual tonsils), that can be enlarged and block the airway as well. This tissue can be removed from the back of the tongue keeping most of the underlying muscle of the tongue. Removal is accomplished typically using Coblation®, which is low temperature radiofrequency ablation that minimizes damage to the underlying tongue muscle. The procedure is performed through the mouth under general anesthesia.

Midline Glossectomy. In essence, sometimes the tongue is too large for the space behind the jaw. The only free direction that the tongue can move is back, further blocking the airway. There are a number of techniques that reduce the overall size of the tongue. In a midline glossectomy, excess tongue tissue is removed, usually with Coblation®, in the middle of the tongue.

Genioglossal Advancement. Several of the muscles of the tongue attach to the back surface of the jaw.  When lying on your back these muscles can stretch and block your throat. The major muscle that attaches in the middle of your jaw is the genioglossus muscle.  This surgery releases a central fragment of bone, with the genioglossus muscle attached, and advances that bone forward moving all of the tongue forward opening up your breathing passage. Access to your jaw occurs by a small incision on the inside of the lower lip. The central part of the bone of the jaw is exposed and a portion of the bone with the genioglossus muscle attached is moved forward and attached to the front portion of the jaw bone.  The incision is closed. This forward placement of the tongue helps to keep the tongue from falling too far back in the throat.

Hyoid Suspension. The hyoid bone is the only free-floating bone in the body. A number of muscles that help stabilize the airway are attached to the hyoid bone. By altering the position of the hyoid it is possible to open up the airway. A small incision is made under the chin and the hyoid is suspended via sutures to an anchor on the undersurface of the jaw bone. The sutures are tightened and the hyoid is drawn forward to maximize the airway. The hyoid bone can also be repositioned and secured over the cartilage housing the voice box (the Adam’s apple) to open the airway in an alternative direction.

Epiglottis Surgery. The epiglottis is a flap of cartilage and soft tissue that helps to close off the windpipe when swallowing and helps direct liquids and food to the food pipe. Sometimes when it is too long or floppy it can contribute to blocking the airway. Surgery entails removing the upper portion of the epiglottis while retaining the majority of the base. Swallowing is sometimes affected in the short-term, but it is unlikely to be a permanent issue.

Maxillomandibular Advancement. This is a procedure that moves the upper teeth/bone and jaw forward as a unit. This movement of the bone forward causes many of the muscles of the airway that are attached to the jaw and bony palate to be pulled away from the back of the throat. In this way both the tongue and soft palate are moved forward. This procedure makes major movement of the muscles of the airway possible. This technique can often help people with severe sleep apnea, but since the surgery is more extensive there is a longer recovery time.

Upper Airway Stimulation Therapy. This is one of the newer options for the treatment of sleep apnea. The hypoglossal nerve stimulator is an implanted medical device that provides an electrical pulse to the nerve controlling tongue movement. While asleep, every time you take a breath the device provides a stimulus to the tongue, opening your airway. If you cannot tolerate CPAP, you are not significantly overweight (BMI <35), have 15 to 65 blockages per hour in your throat (AHI 15-65), and do not have a high percentage of central apneas, you may qualify for this treatment.  Once you are evaluated by our sleep surgeon and determined to be a possible candidate, a drug induced sleep endoscopy (see above) will be performed.  If your airway collapses in a complete circle (concentric collapse) you are unlikely to respond to this type of therapy. Other types of collapse respond well to this therapy.

The stimulator is placed surgically and is composed of three elements. There is a generator that provides the stimulus to the nerve that is implanted under the skin and on top of the chest muscles. A sensor will be placed in your rib cage with a wire connected to the generator. The sensor will tell the generator you are about to take a breath. A second wire with an electrode that is wrapped around the nerve to your tongue (hypoglossal nerve) is also connected to the generator. This will activate the nerve and open your airway. Many adjustments to the stimulator are possible to fine-tune it to your individual needs and these are performed once you have healed from the operation. You will be provided with a remote controller to turn the device on and off, or pause it briefly during the night.

Dr. Douglas Trask (sleep surgeon) and Dr. Roger Crumley (sleep specialist) are physicians with many years’ experience in treating people with sleep disordered breathing.  At UC Irvine Health, we believe in a tailored, individualized approach that incorporates the latest techniques and advances to treat snoring and sleep apnea. To make an appointment with one of our sleep experts, please call 714-456-7017 or click here to request an appointment via internet. Patients have received care at our center from Orange County, Los Angeles, and throughout Southern California.