How to stop the “snorechestra”

Regular snoring, even if relatively mild, does place the body under a little more strain than is normal, forcing additional effort when it comes to breathing. Reduced quality of sleep is an adverse effect which can result in frequently grumpy faces the following morning.

While behavioural adjustments addressing the direct cause of snoring are reasonably effective for the occasional light snorer, in other instances, treatment interventions may well be worth a try.

Lifestyle modifications for the light snorer

1. Shedding the kilos (weight loss)

Carrying excess weight is a key issue associated with snoring, as it is not only an underlying cause of snoring but can also exacerbate it. Additional fatty tissue causing or aggravating snoring (by narrowing the airways) is often worse when men have a neck circumference of 17 inches / 43 centimetres (or more) and women, 16 inches / 40 centimetres or more. ⁽¹¹⁾

During a medical consultation, a doctor may take measurements of a person’s neck, measuring the circumference to assess this possible risk factor. From there he or she will help to determine a safe amount of weight loss that needs to be achieved if necessary.

For many, adopting a more nutritious and healthy diet, and engaging in regular exercise can ‘kill two birds with one stone’ – helping one to lose excess weight while also alleviating snoring.

2. Sleeping position

Snoring is generally worse for a person who sleeps flat on their back. Drooping tissues in the upper airways, and the falling back of the tongue and soft palate of the mouth into the throat when in this position contribute to breathing obstruction and thus aggravate snoring.

As a potential remedy to this situation you might have read or heard about the age-old ‘tennis ball trick’ (sewing a tennis ball into the back of a snorer’s pyjama top) to help prevent them from comfortably sleeping on their back – although this may not work for everyone.

A snorer can try changing their sleeping position to help alleviate the frequency and severity of their snoring. A body pillow can be bought to help encourage sleeping on the side. Anti-snoring pillows are a thing too, and available for purchase. Some studies suggest that these pillows, which shift the position of the head, may help to alleviate snoring. ⁽¹²⁾

If adopting a new sleeping position is difficult, the torso can be raised slightly with an extra pillow. Alternatively, a person can use an additional pillow to prop up their head slightly as well.

3. Avoidance of certain substances

Alcohol and medications (including sleeping pills) that have a muscle relaxant effect should be limited or avoided altogether if one is a frequent snorer. Less frequent intake of alcohol (with a last drink being taken several hours before bedtime) and avoiding medications that result in the relaxation of the tongue and throat muscles can help to alleviate snoring. Some popular medications with this effect include tranquilisers like lorazepam (Ativan) or diazepam (Valium).

If these types of medications are necessary, it is a good idea to consult a medical doctor for alternative recommendations so as to avoid the development of unwanted side-effects like snoring. In contrast, there are some medications which may temporarily alleviate snoring while treating nasal congestion, such as use of antihistamines. It is however wise to use these only as directed by a doctor or pharmacist.

Some studies have also examined the potential impact of smoking in relation to habitual snoring. It is believed that irritation to the airways due to smoking can result in enough inflammation to cause upper airway narrowing. Some findings attribute smoking and exposure to smoke (even in ex-smokers) as risk factors for those prone to snoring in the general population. ⁽¹³⁾

4. Removal of certain allergens

Those suffering from nasal congestion-related illnesses and allergies may experience snoring at times, especially when exposed to certain irritants like dust, dust mites and pet dander or when managing a bout of sinusitis or the common cold.

If allergies are a possible irritant to the airways at night, a snorer can help things by ensuring that their bedroom is cleaned and dusted before bedtime. Surfaces, ceiling fans and linens should be kept clean to avoid exposure to irritants. Some may also find relief by keeping pets out of the bedroom.

If nasal congestion is caused by an illness, like flu, sinusitis or hay fever, stuffy noses can be rinsed with a saline solution (saline sprays) to try and alleviate snoring. Some find that a hot shower or bath before bedtime can also help in this regard. Inflammation and swelling of nasal tissues can be alleviated with the use of a humidifier. A doctor can also recommend certain medications to be used in the short-term.

5. A regular routine

Snorers can benefit from adhering to a regular bedtime and awakening schedule. The main reason for this is to try and ensure that a person gets an adequate amount of rest every night and does not become overtired.

If a person becomes overtired, he or she is capable of falling into a deep sleep at night. This results in the airway muscles relaxing more than they usually would, contributing to more frequent and louder snoring.

6. Hydration

Secretions (mucus) in the soft palate of the mouth and the nose tend to accumulate or become stickier in the airways as a person dehydrates. This can worsen things for a habitual snorer. It is thus a good idea to remain well-hydrated throughout the day to help ease away any potential for airway blockages or obstructions during sleep.

Over-the-counter options

There are a variety of products available over-the-counter that are marketed for snoring relief. A fair number of these products are a little ‘hit-and-miss’ – providing relief for some, but not for others. These include nasal lubricants (drops and sprays) and oral varieties (sprays, pills etc.). These products are not recognised cures for snoring, and as such should not be used with this expectation. Any relief experienced may be temporary or short-lived.

Lubricant sprays and drops target the upper airways, helping to lubricate the upper-pharyngeal structures. There have been numerous unpublished clinical studies assessing the efficacy of these products, with a fair majority determining little harm (i.e. few adverse reactions) in using the products for temporary relief. For some, these products may assist in alleviating the duration and intensity (volume) of snoring. For others, these products may merely help in providing relief in the intensity of their snoring.

Since the safety of the use of these products does not appear to be very well studied, it is a good idea to discuss any intention of using them with a medical doctor should a person have known medical concerns, like hypertension, along with a snoring habit. A doctor can clarify whether or not a product may be safe enough to try.

Oral dietary supplements are also widely available over-the-counter and marketed as snoring relievers. Many of these products contain ingredient combinations of herbs, melatonin and various enzymes. Supplements, in general, are not strictly regulated by the FDA (U.S. Food and Drug Administration). For this reason, it is wise to consult a medical doctor before trying any of these products, especially if a person is already under treatment for another medical condition. A doctor can recommend the safest possible ways to use these supplements and avoid any possible adverse side-effects (such as allergic reactions / hypersensitivity).

Chin straps are also a popular product on the shelves but have not shown much in the way of clinical anti-snoring success. Simply strapping on this facial band (which resembles a jaw retaining band) every night before bed may not have much effect on the frequency or volume of snoring ⁽¹⁴⁾ and can merely make a person more uncomfortable than anything else.

Some products on the market pose little harm in trying, but many may leave a person wondering just how on earth they’re supposed to get a good night’s rest ‘wearing that’! If snoring is bothersome but not related to a diagnosable medical condition, it’s not a bad idea to check-in with a family physician for a little advice.

A doctor will have the most up to date knowledge regarding products which may or may not be the most effective. As with any health condition, it makes sense to understand a direct cause for a physical problem before trying to treat it. In this way, it becomes a little easier to tackle it at the very root. Not everyone who snores does so for the exact same reason. Getting to the cause provides the best clue as to what may help to turn down the volume or reduce the frequency of snoring.

Medical treatment options

There are hundreds of devices available on the market that promise to be “the best remedy for snoring”. Not many are backed up by conclusive clinical research, however. Those that have been researched appear to have been clinically tested for efficacy in relation to snoring and OSA conditions combined.

If snoring is more severe (and does not respond well to basic lifestyle changes or over-the-counter remedies), treatment can involve the following:

1. Oral appliance therapy

Oral devices (including mandibular advancement splints / MAS which may help reposition the lower jaw forward, opening the nasal passages / airways) are made to fit over the teeth inside the mouth of a snorer. The device resembles an orthodontic retainer or sports mouth guard and is intended to be worn during sleep. The idea behind the use of such a product is that it may help to prevent a collapse of the airways and also hold the tongue in place, preventing it from falling slightly backwards. To some extent this has been found to be mildly effective for habitual snorers and those with milder OSA conditions. ⁽¹⁵⁾ A tongue-retaining device can have the same effect.

If a frequent snorer would like to try an oral device, it is best to consult a medical doctor who can recommend a dentist / dental surgeon who is able to assist with fitting this customised aid.

A dentist will conduct an evaluation of a person’s jaw, teeth, tongue and upper airways. An X-ray of the mouth may be recommended. Physical and digital impressions of a person’s teeth will be made to customise a device that will be most comfortable to wear. Any adjustments for additional comfort can be made at the first follow-up visit.

These oral devices are fairly light, portable (and easy to travel with) and simple to keep clean. Routine follow-up visits may be recommended as part of a long-term treatment plan to ensure the most optimum fit over time.

There are varieties available which are thermoplastic, and thus can be moulded by a patient – no dental evaluation or fitting is required. Many of these require a ‘boil-and-bite’ process whereby a mouthpiece is soaked in a little boiling water for a few minutes, softening the portions that come into contact with the teeth, and then placed inside the mouth to bite down on. These options may not be covered by medical health insurance.

Mouth guards / oral devices may not be the most comfortable snoring solution but can be reasonably effective. Some people experience a little jaw or facial discomfort due to the muscular tension experienced in order to use the device. Others may simply struggle with a gag reflex. If these are concerns, it should be discussed with a dentist /dental surgeon while having an oral device fitted. The best fitting devices are made to be micro-adjustable, making it easier to customise them for optimum comfort.

2. Nasal-dilating strips

Nasal-dilating strips (for use internally or externally) are another relatively inexpensive product that is considered harmless to use. These products have been shown to help improve nasal breathing somewhat and, as such, are considered potentially useful for alleviating a snoring habit.

Adhesive strips for external use (referred to as external nasal dilator strips / ENDS) are placed across the nose. The strips are thought to help dilate the nose (pulling the lateral nasal vestibule walls outwards), allowing for more air flow, thereby easing breathing through the airways. ENDS are FDA approved for temporary snoring relief as a result of transient causes (like nasal congestion) or minor structural abnormalities of the nose.

A direct clinical link, however, has not yet been conclusively proven. Of the studies conducted, many have had mixed findings with limited data (small population groupings). Some studies have noted a considerable reduction in snoring with the use of these strips. Others have merely noted a decrease in the frequency of snores (i.e. the number of snores per hour) during the night, but not necessarily in volume (loudness) – according to specific decibel measurements (snoring index). ⁽¹⁶⁾

For the most part, due to limited data, nasal dilators are not considered first line treatment options recommended by medical doctors even though the products are readily available for purchase.

Alternative products include internal nasal dilators (IND). The various product designs may differ somewhat, but mostly resemble plastic devices that can be placed into the nose. These dilators are held in place with the use of end tabs (little knobs) which press against the lateral nasal vestibule walls. Some products also make use of a biocompatible stainless-steel wire (in the form of a flexible looped spring) that provides outward pressure in the nasal vestibules for easier breathing. These are also FDA approved for temporary relief.

It is generally considered that there is little harm in trying one of these products, but if in doubt, it is not a bad idea to discuss their use in relation to snoring with a medical practitioner.

3. Surgical procedures

There are surgical options available for snoring that is severe and identified as being the result of nasal deformity, large / bulky adenoids or interference by the tonsils. Large tissue masses causing obstruction in the airway can thus be considered for surgical treatment. These elective procedures can be performed in stages in relation to the different sites of obstruction causing snoring.

A doctor will take a systematic approach and conduct a thorough examination (including imaging tests like a CT scan or anterior rhinoscope /endoscope analysis) in order to make an appropriate diagnosis. He or she will take into account just how great of an impact snoring is having on a person’s quality of life, as well as the effects on other household companions, during an evaluation.

The short-term and possible long-term benefits of surgical procedures will also be assessed. If surgical benefits outweigh non-surgical treatment options, a procedure may be considered.

Following a clinical evaluation, surgery (usually performed as an outpatient procedure) can be considered as part of a treatment plan involving multi-disciplinary management (i.e. non-surgical snoring relief options) to alleviate snoring.

Surgical procedures, however, are not normally considered to be cures for snoring. While they can offer some short-term relief, not all have been shown to demonstrate reliable long-term effects, with some patients experiencing a degree of obstruction again following a surgical procedure, and thus developing a snore once more.

A doctor will discuss all result expectations, potential risks and complications associated with any elective procedure (the most common being post-operative bleeding) being considered beforehand.

Some procedures which can be performed include:

1. Nasal reconstruction / obstruction correction:

• A septoplasty – This involves the correction / resection of septal deviation, straightening the nasal septum and leaving behind as much bone and cartilage as possible. Cartilage can be reshaped, recontoured and repositioned. Surgery is performed with a patient under either local or general anaesthetic.
• A functional endoscopic sinus surgery (FESS) – If a patient is affected by chronic sinusitis or nasal congestion with the effect being persistent snoring, this surgical procedure is an option, and helps to alleviate inflammatory infection. Nasal endoscopes are used to remove nasal masses causing obstruction and helping to restore normal function.
• A turbinate reduction – Nasal obstructions, like turbinate hypertrophy, can be corrected by surgically reducing the turbinate size. Turbinates are ridges of tissue along the inside walls of the nose, which project into the nasal passages. Inferior turbinates which become enlarged can sometimes block the free flow of air in the nose. Surgery (often a radiofrequency turbinate reduction / RFTR using radiofrequency heat to shrink tissues) can help to reduce airway resistance and retain the natural function of these tissue structures.

2. The removal of adenoids and tonsils:

• Adenotonsillectomy – Masses or clusters of lymphoid tissue (located in the back and sides of the throat / upper airways) are more commonly found in children and some adults who experience snoring. This procedure involves the removal of both the adenoids and tonsils (either partially or completely).

3. Corrections involving the mouth and palate:

• Uvulopalatopharyngoplasty (UPPP) – Structures in the mouth and pharynx (the cavity behind the mouth and nose which connects to the oesophagus) that cause or aggravate snoring can be removed with this procedure. The uvula and soft tissues in the pharynx are commonly extracted while a patient is under general anaesthesia. These tissues can also be tightened so as to help dilate or expand the airways for better air flow. Recovery can be lengthy, taking several weeks during which a patient will undergo guided pain management.
• Uvulopalatoplasty (UP) / Laser-assisted uvulopalatoplasty (LAUP) – An alternative to UPPP, this procedure opts to use laser beams or high-frequency radio waves to remove (shrink) the uvula or other soft tissues in the pharynx causing obstruction of airflow. Recovery time is a little shorter than that of a UPPP but can still take up to a few weeks.
• Soft palate implants – Snoring influenced by the soft palate can sometimes be alleviated with injections of synthetic (polyester) implants under local anaesthetic. Implants are injected beneath the mucous membrane lining the inside of the mouth (oral or palatal mucosa). These implants help to stiffen the membrane lining (via the body’s natural scarring response) preventing the collapsing of the soft palate and thus assisting in alleviating the vibration associated with snoring. Discomfort is relatively minimal, and recovery takes place over a short period of time. The cost of the implants can make this procedure a little on the expensive side.
• Radiofrequency ablation (RFA) of the soft palate – An alternative to soft palate implants, and a less expensive option which can be performed under a local anaesthetic involves the implantation of an electrode in the tissues of the soft palate. This emits radio waves that encourage a thickening of the tissues, and thereby enhance air flow through the upper airways.

Some procedures which are more commonly used in OSA treatment may be useful for severe cases of snoring. These can include:

• Genioglossus and hyoid advancement – This procedure helps to pull the tongue muscle (genioglossus) forward and attaches it to the central portion of the inside of the lower jaw. The surgery allows for the tongue to have more room in the mouth to relax while asleep, and thus prevent it from becoming a possible obstruction. Hyoid advancement (also referred to as hyoid suspension / hyoid myotomy) involves the pulling forward of the hyoid bone (the bone situated between the lower jaw and largest cartilage of the larynx that anchors the tongue) along with its muscle attachments (between the floor of the mouth and base of the tongue). This also helps to create more room for the airways and thus improve air flow stability.
• Maxillomandibular advancement (MMA) – This procedure is sometimes referred to as double jaw advancement or bimaxillary advancement and focuses on moving both the upper (maxilla) and lower (mandible) jaw forward. In this way the airways are enlarged allowing for better airflow in the palate and tongue areas of the mouth.

With surgical procedures to treat snoring being elective, a patient may not wish to go under the knife in an attempt to lessen or eradicate snoring. In this instance, should all other options fail, medicated nasal steroid sprays or allergy medications may prove useful for temporary relief, or a doctor may suggest CPAP, a standard treatment for OSA which involves the use of a nasal mask that delivers air pressure to the back of the throat during sleep.

References:

^{11. Harvard Medical School Special Report - Improving Sleep: A Guide to a Good Night's Rest. Breathing Disorders in Sleep: https://books.google.co.za/books?id=G8lL1ZhvZjIC&pg=PA27&dq#v=onepage&q&f=false [Accessed 21.02.2018]}

^{12. US National Library of Medicine - National Institutes of Health. September 2017. The effect on snoring of using a pillow to change the head position: https://www.ncbi.nlm.nih.gov/pubmed/28127672 [Accessed 21.02.2018]}

^{13. US National Library of Medicine - National Institutes of Health. October 2004. The influence of active and passive smoking on habitual snoring: https://www.ncbi.nlm.nih.gov/pubmed/15242843 [Accessed 21.02.2018]}

^{14. US National Library of Medicine - National Institutes of Health. August 2014. The Efficacy of a Chinstrap in Treating Sleep Disordered Breathing and Snoring: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4106943/ [Accessed 21.02.2018]}

^{15. US National Library of Medicine - National Institutes of Health. July 2017. Update on Oral Appliance Therapy for OSA: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5592194/ Accessed 21.02.2018]}

^{16. US National Library of Medicine - National Institutes of Health. December 2016. Nasal Dilators (Breathe Right Strips and NoZovent) for Snoring and OSA: A Systematic Review and Meta-Analysis: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5187471/ [Accessed 21.02.2018]}