Usual and Unusual Ways to Stop Snoring

March 24, 2009

What I’ll describe in below is a comprehensive list of all the standard medical, surgical, and over-the-counter options that you’ll hear and read about. If you see one that I’ve left out, please let me know and I’ll give you my opinion. Remember, many of these devices (with a few exceptions) only cover up the snoring, without treating the real cause. If you try a variety of these options to find no relief, it’s time to see your medical doctor or a sleep specialist for a formal evaluation and treatment. Not doing so can cost you more than your sleep. It can cause you to lose your life.

Medical Options For Snoring

Note: Many of the procedures below, although effective for snoring, are never 100 successful. Success rates range from 70% to 95%. There is also a small chance of relapse even if initially successful.

Continuous Positive Airway Pressure (CPAP): This option may be overkill, and you’ll need to pay for it out of pocket if you don’t officially have obstructive sleep apnea. But it does work, if you can get used to it.

Dental devices: There are multiple options with this type of treatment, with the formal mandibular advancement devices that are made by dentists. These devices pulls your tongue forward by pulling your lower jaw forward. There are many different models that all have various features that make it more likely to work depending on your anatomy. Different dentists have different preferences as well. A less expensive way to "test" whether or not these devices may work is to try one of the many over-the-counter (or over-the-internet) boil-and-bite models. These devices are softened in hot boiling water and the set as you softly clench down while simultaneously pushing your jaw forward.

Laser Assisted Uvulo-Palatplasty (LAUP): A laser is used to trim the free edge of the soft palate. It’s somewhat painful, and usually must be performed 2-3 times. It can be performed in the doctor’s office, and is relatively expensive.

Injection Snoreplasty: Any type of scarring agent (sodium tetradecyl sulfate, ethanol, etc.) can be injected just underneath the mucous membrane of the soft palate. Must be performed 2-3 times for maximum effectiveness, is less painful in general, and is the least expensive.

Pillar Procedure: Three thin woven braided polyester rods are inserted inside the muscle layer of the soft palate. It’s usually performed under local anesthesia and is one of the least painful. Typically, only one treatment is needed, and is most expensive.

Uvulopalatopharyngplasty (UPPP): Usually used for obstructive sleep apnea, but very effective for snoring. In general, it’s only about 40% successful for obstructive sleep apnea.

Some Unusual Ways to Stop Snoring

Note: All the options listed below, although not proven to help snorers on a consistent basis, have been reported to work at least some times in some people. Most of the reports are anecdotal, with no objective supportive data. One major problem is that if it works, it may only delay diagnosing and treating any underlying obstructive sleep apnea.

Tennis balls: For some people, staying off your back can make a big difference. The problem is staying on your back. The most common recommendation is to sew a sock filled with a tennis ball to the back of your pajamas. This method has mixed results, and in general, although it sounds great, doesn’t work that well. It just only annoys the snorer or they just sleep on top of it.

Sleep position devices: There are a number of gadgets and devices that prevents you from rolling onto your back. They range from triangular wedges to shirts filled with foam rods to prevent sleeping on your back. The only way to know whether or not they work is to try it. For some people, it can make a huge difference, even if you have obstructive sleep apnea. For many others, you may have a mixed response, or no response at all.

Side sleep position pillows: This one positions your arm above your head and somehow forces you to sleep on your side. Again, I’ve heard mixed responses from my patients. If you can sleep with your arm above your head for hours without it becoming numb, then this may work for you.

"Contour" pillows: This pillow works better if you prefer to sleep on your back. The lower end of this pillow is a bit higher than the middle part that the top of your head touches. This forces your head to be cocked back a bit, lifting up your chin somewhat, thereby opening up your airway somewhat. This the the same maneuver that you’re taught to do during CPR to open up the airway before you give mouth-to-mouth. Notice that after you fluff up your pillow you go to bed, the pillow height diminishes slowly, and by the end of the night, your chin is closer to your head, which closes your airway. Another option is to either roll up a towel into a "log" or get one of the Asian husk-filled pillows that are shaped like a roll. You’ll have to experiment to find the right height.

Diet and weight loss: This will help to various degrees for most people who are overweight, but what if you’re already thin? Also, since poor sleep leads to weight gain hormonally and metabolically, it can be very difficult to lose weight no natter how much you diet or exercise. For some, losing 10-15 pounds may help a great deal with your snoring, but chances are, it’ll return sooner or later as you get older.

Nasal dilator clips: Whether external (Breathe-Rite) or internal (Nozovent, Nasal Cones, or Breathewitheez), these work sometimes by pulling your soft flimsy nostrils apart, preventing nostril collapse when you inhale. During sleep, especially when your muscles relax, any degree of nasal congestion can aggravate higher vacuum pressures that can aggravate tongue collapse. Despite being touted to cure snoring, it only works about 10% of the time. Here’s one simple test to see if you should invest any money on these products: take both you index fingers and gently press on your skin, right next to your nostrils. Press gently and pull your cheeks apart on each side towards the outer corners of the eyes. This is called the Cottle maneuver.

Wind instruments: Playing any type of wind instrument (flute, clarinet, trumpet, etc.) can in theory promote throat and tongue muscle tone. Reports of success are anecdotal.

Playing the Didgeridoo: Various studies have suggested that playing this ancient Aborigine wind instrument can help relieve snoring. The mechanism in how it works is similar to any wind instrument.

Singing: The mechanical act of singing promotes profound throat muscle tone and control. Similar to all the wind instruments, prolonged periods of singing promotes relaxation, since exhalation is activated by your parasympathetic nervous system.

Tongue Exercises: Has been found to be helpful for some people, but needs continuous exercises.

Throat sprays: Various mixtures of herbs and natural ingredients are promoted for snoring, but a recent objective study showed that they were not helpful.

Acupuncture: No consistent evidence, but helps with stress and fatigue.

Bedpartner’s elbow: Works to wake you up to stop snoring, but never curative. This is called the "bruised rib syndrome".

Electronic devices that wake you up when you snore: More expensive than a bedpartner elbowing you in the ribs.

Ear plugs for the bedpartner: May help the bedpartner sleep, but not very effective for the very low-frequency snoring vibrations.

Sleeping in another room: Usually alleviates the problem, but bad for relationships, and not very helpful for "heroic" snorers where the sounds vibrate the bedroom walls 2-3 rooms down.

Written by Steven Park · Filed Under Articles | 5 Comments

Sleep Apnea – A Primer

April 1, 2008

Note: This is an edited transcription of a podcast recording

So what is obstructive sleep apnea? Apnea means a total cessation of breathing and this happens only when one is sleeping. So a person with sleep apnea can stop breathing from 10 to 50 to even over 100 times every hour with each episode lasting anywhere from 10 to 30 seconds. Using strict criteria, it is estimated that about 4% of men and 2% of women have this condition, but using looser criteria, it can be up to 25% in men and up to 9% in women. The scary statistic is that this condition is not diagnosed in about 80-90% of people who have it, so instead, they are being treated for the end result which can be diabetes, depression, high blood pressure, etc. It is also known that significant sleep apnea happens in about 35% of chronic snorers. It’s also important to note that you don’t need to snore to have sleep apnea, as well.

Some of the symptoms of sleep apnea include: snoring, depression or irritability, poor concentration, memory or focus problems, morning headaches, poor job performance, attention deficit disorder, and obesity. A recent study came out describing the number of car accidents in one year. It’s estimated that about 800,000 car accidents occur every year due to sleep apnea and of these, there are about 1,400 fatalities. In addition, it’s estimated that of all the commercial truck drivers in America, about 28% of them had this condition, and of this group, about one third of them have moderate to severe sleep apnea.

There are a number of medical conditions associated with sleep apnea, as well. It’s found that people with sleep apnea have up to a 50% incidence of high blood pressure and people with high blood pressure have about a 50% incidence of sleep apnea. Now the studies show that if you have had a heart attack, you are 23 times more likely to have sleep apnea and the reverse showed that if you have sleep apnea, you are about 1 ½ times as likely to have heart disease.

Another study looked at 200,000 charts retrospectively and found that patients on medicines for depression or high blood pressure were 18 times more likely to be eventually diagnosed with sleep apnea. So what they concluded was that many patients are being treated for the symptoms or complications of sleep apnea rather than the underlying cause itself.

I mentioned previously that attention deficit disorder was associated with sleep apnea. In an interesting study that came out in the Journal of Pediatrics, researchers recruited 78 children who were about to undergo a tonsillectomy for various reasons including recurrent infections or sleep apnea and compared them against 22 other children undergoing other types of surgical procedures. All these children underwent formal sleep studies and a battery of psychological tests including that for attention deficit disorder and found that 22 children, or 28% of the tonsillectomy group, were found to have ADHD by official psychiatric criteria. The control group only had 7% that were found to have sleep apnea. After surgery, one year later, 11 children or 50% of the children who originally had ADHD, no longer had by official criteria. Furthermore, after the surgery, the incidence of sleep apnea in the tonsillectomy group was equivalent to that in the control group.

I could go on and on about snoring and sleep apnea being associated with increased risk of children having memory, attention or cognitive skill problems, asthma, chronic cough, etc. but I’ll stop here. One more comment about adults and sleep apnea and ADHD: there was one study that looked at three adult patients with attention deficit disorder and sleep apnea and all three of these patients were on Ritalin. Two of these patients, after treatment for sleep apnea, were weaned off the Ritalin and the third selected weight loss and conservative regimen. This goes to show that sleep apnea and ADHD can co-exist in adults, as well.

Other medical conditions include heart disease, stroke, diabetes, erectile dysfunction and obesity, seizures, migraines, and even preeclampsia, which is a condition where pregnant women get high blood pressure at dangerous levels. All of these conditions have been associated with sleep apnea and to various degrees, respond to treatment.

So how do you diagnose sleep apnea? To diagnose sleep apnea, you have to undergo a formal sleep study, which is an overnight test where you go into a facility and they hook you up to all these monitors all over your body and they analyze all the different parameters like breathing, respirations, heart rate, brain waves, etc. while you sleep. This way they can calculate how many times you stop breathing every hour and how long for every episode. To officially get the diagnosis of obstructive sleep apnea, your apnea/hypopnea index, or the number of times you stop breathing totally or partially for greater than 10 seconds for each episode, has to be greater than 15 events every hour. Now, if you’re symptomatic – if you’re very sleepy or if you have any of the medical complications of sleep apnea such as depression, diabetes, high blood pressure, etc.—then your number can be down to 5.

One of the problems with these criteria for sleep apnea is that if you stop breathing for 9 seconds at a time and you stop breathing 50 times every hour, then officially you won’t have the diagnosis of sleep apnea and then you get into the realm of upper airway resistance syndrome, which I discussed in another article. If you snore only and don’t have any significant apnea or you’re otherwise asymptomatic, then you can elect to undergo snoring treatment, which I’ll talk about in a separate article. If you snore and have significant apneas, then treating the apneas will also treat the snoring, in general.

There are a number of conservative measures that are recommended to treat snoring and sleep apnea including weight loss, positional therapy, sleeping with the mouth closed as well as a number of different snoring treatments but there’s only so much one can do with this. First of all, it’s hard to lose weight because you’re so tired and it’s hard to exercise. In terms of trying to sleep on your side or on your back, you only have so much control over that when you’re sleeping. One note about snoring treatments: over-the-counter snoring treatments have been found to work sometimes but a recent controlled study which looked at three popular snore aids, including a nasodilator strip, an oral lubricant and a pillow. All were found objectively not to have any significant benefit. However, I have many patients who swear by these over-the-counter snore aids, but in my experience, it only works sometimes for some people but in general it doesn’t work most of the time.

If you’re found to have obstructive sleep apnea, the best way to treat this condition is via what’s called a Continuous Positive Airway Pressure machine, or CPAP. This is a small device that acts as an air pump which blows some positive gentle air pressure through your nose and it stents your airway open so you don’t stop breathing at night. When used effectively, it works. You wake up feeling much more refreshed, have much more energy and all the medical problems start to get better. One of the problems with CPAP, however, is that people just don’t like to use it, but with good counseling and proper follow-up from clinic staff and the equipment people that administer the device, many people can do well with this device.

However, there are certain people who just can’t use CPAP for other reasons despite trying different kinds of masks, headgear and devices. These people end up going to different devices, one of which is a mandibular advancement device, which are oral appliances that dentists make. They make an impression of your teeth and the bottom part, the mandible, the jaw bone slowly is pushed forward. The way this works is that it pulls the tongue forward, which is one of the reasons for sleep apnea, amongst many other reasons. Again, when applied properly and when patients use it, this device does work especially for snoring and for mild to moderate sleep apnea. But compliance is also a problem due to jaw pain, dry mouth, ear pain, headaches, and bite problems.

The last major option is surgery and this is a huge topic in itself and I will discuss this in detail in another article, but just to summarize, when considering doing surgery, people have to have failed trying CPAP, or at least consider the mandibular advancement device and reject it. One has to be really motivated. Secondly, there has to be some type of anatomic reason for the collapse so when I do the examination and do the endoscopy to look inside the airway passages, I have to see is some sort of obvious collapse to address it via surgical measures.

The first and most obvious area of obstruction is actually the nose. If your nose is stuffy for whatever reason—allergies, polyps, deviated septum, or anything else—that’s the first thing that I address, whether medically or surgically. This is because if you don’t breathe well through your nose, then everything else downstream is more prone to collapse. So once the nose is taken care of and if you still have sleep apnea, then you can try going back to the CPAP. Many people with stuffy noses can’t tolerate CPAP that well, but once that problem is corrected, a certain number of people can start using the CPAP more effectively. If you go further downstream, the other two major areas are at the palatal level and the tongue level. In our field (ear, nose, throat, head & neck surgery) we’ve been focusing too much on the palate because that’s typically where the snoring sounds are coming from, but that’s not the only area. If you don’t address the tongue, as well as the palate, then your success rates aren’t going to be that great.

Written by Steven Park · Filed Under Articles | 2 Comments