Snoring

What Is Snoring and How Does It Occur?

Snoring is the sound produced by the vibration of the soft tissues in the upper airway during sleep. It is not a disease but a clinical indicator that there is some degree of narrowing in the airway. This narrowing may occur at the soft palate, the uvula, the tonsils, the base of the tongue or the pharyngeal wall.

In terms of physical principle: as air passes through a narrow channel during inhalation, the pressure along the channel wall drops (the Bernoulli principle). The flexible palatal and pharyngeal tissues are drawn closer together by this pressure difference, the airflow makes these soft tissues vibrate, and the classic snoring sound emerges.

An important distinction: simple snoring (primary snoring) is a condition that does not disrupt sleep architecture or oxygen levels. Obstructive sleep apnoea (OSA), on the other hand, is the complete collapse of the tissues that stops the airflow. On the surface, both sound like snoring; but their clinical consequences are very different. For this reason, in persistent, loud or irregular snoring, the distinction between these two conditions is made with an objective sleep study.

When Should Snoring Be Evaluated?

Not every instance of snoring is a medical problem; however, an ENT evaluation is needed if any of the following features are present:

• Snoring that recurs regularly every night
• Loud, noisy snoring that disturbs a partner’s sleep
• Pauses in breathing described by a partner, or snoring that begins with a gasp
• Waking with a sensation of choking
• Daytime sleepiness, waking unrefreshed, morning headaches
• Difficulty concentrating, a decline in daytime performance
• Coexisting hypertension, atrial fibrillation or type 2 diabetes
• Drowsiness while driving
• Noisy snoring in a child together with mouth breathing and restless sleep at night
• A marked increase in neck circumference, weight gain
• A history of nasal trauma, persistent congestion

Causes and Risk Factors

There are usually several factors present together underlying snoring.

Anatomical causes

• Nose: septal deviation, turbinate hypertrophy, nasal polyps, allergic rhinitis, a history of nasal trauma
• Tonsils: enlarged tonsils, particularly in children and young adults
• Adenoids: the most common cause in children
• Soft palate and uvula: a long, thick or lax structure
• Base of the tongue: a large and posteriorly positioned tongue
• Jaw structure: a retruded (retrognathic) or small (micrognathic) lower jaw, a narrow upper jaw

Functional and lifestyle factors

• Excess weight and especially an increased neck circumference (the most powerful modifiable risk factor)
• Advancing age (a reduction in muscle tone)
• Male sex, post-menopausal women
• Sleeping on the back
• Alcohol (especially before bedtime)
• Smoking
• Sedatives, sleeping pills, muscle relaxants
• Reflux (irritating the airway at night)
• Endocrine conditions such as hypothyroidism and acromegaly

In children

A very large proportion of snoring in children is based on enlarged adenoids and tonsils. In addition, allergic rhinitis, mouth breathing and a narrow upper-jaw structure may accompany it.

Symptoms: Simple Snoring or Apnoea?

Clinical clues help to distinguish the two, but only a sleep study provides the definitive distinction.

In favour of simple (primary) snoring:

• Regular, rhythmic snoring, with no breathing pauses described
• Waking refreshed in the daytime
• No marked daytime sleepiness
• No accompanying blood-pressure, rhythm or metabolic disease

In favour of obstructive sleep apnoea:

• Irregular, noisy snoring that “chokes and then restarts”
• Witnessed pauses in breathing
• Waking with a sensation of choking
• Excessive daytime sleepiness, microsleeps
• Morning headache, dry mouth
• Frequent night-time urination
• Treatment-resistant hypertension
• Complaints of impaired attention and memory

Because of this clinical suspicion, snoring on its own should always be evaluated.

The Diagnostic Process

The fundamental approach in evaluating snoring is to look not only at the sound but at the patient as a whole.

1. Detailed history. The duration, frequency and character of the snoring, a partner’s account, daytime sleepiness, weight changes, alcohol and smoking, chronic illnesses and medications.
2. Sleep questionnaires. The level of apnoea risk assessed with tools such as the Epworth Sleepiness Scale and STOP-BANG.
3. ENT examination.
   • Nose: septum, turbinates, polyps, allergic findings
   • Mouth and throat: tonsil size, soft-palate length, uvular structure, Mallampati score, tongue position, floor of the mouth
   • Jaw and facial structure: retrognathia, jaw asymmetry, dental occlusion
4. Nasal endoscopy. The nasopharynx, base of the tongue and hypopharynx are clearly visualised.
5. Drug-induced sleep endoscopy (DISE). Under light sedation, the level at which the patient obstructs in a sleep-like state is observed with an endoscope. It is the most valuable tool for surgical planning.
6. Polysomnography (PSG). If apnoea is suspected, this is a fully equipped sleep study performed in a sleep laboratory. The AHI (Apnoea-Hypopnoea Index), oxygen levels, sleep stages and accompanying findings are recorded. This study allows “simple snoring” to be clearly distinguished from “sleep apnoea”.
7. Home portable sleep study. This may be an alternative in selected patients.

Across the snoring–apnoea spectrum, it is not correct to make a surgical decision without a PSG result.

Treatment Approaches: From Conservative to Surgical

Treatment is personalised according to the level of obstruction, the AHI value, weight and any accompanying illnesses.

1. Lifestyle modifications

In most cases of simple snoring this is the first step and usually the one that makes the difference:

• Weight loss — reducing the fatty tissue around the neck markedly lowers the severity of snoring
• Stopping sleeping on the back (this can be very effective in positional snoring)
• Avoiding alcohol before bedtime
• Stopping smoking
• Elevation of the head of the bed and treatment of reflux
• Adequate, regular sleep and sleep hygiene
• Medical treatment of allergic rhinitis and nasal congestion (steroid spray, saline rinses)

2. Positional and device therapies

• Positional devices: belt, vest or pillow systems that prevent sleeping on the back
• Mandibular advancement appliances: dentist-made, intraoral devices that move the lower jaw forward and open the airway. They are preferred in cases of mild-to-moderate apnoea and predominant snoring.
• CPAP / APAP / BiPAP devices: the gold-standard treatment for moderate-to-severe sleep apnoea. Snoring on its own is not an indication for these devices; they are considered if apnoea accompanies it.

3. Surgical treatment (an ENT perspective)

Surgery is planned after the level of obstruction has been determined with sleep endoscopy and is generally planned as a multilevel procedure. It is not a single standard operation but a combination tailored to the individual.

Procedures directed at the nose

• Septoplasty (correction of septal deviation)
• Turbinate radiofrequency / partial turbinoplasty
• FESS (when accompanied by sinus disease or polyps)

Nasal surgery on its own may not completely eliminate snoring; however, it markedly reduces it and improves CPAP tolerance. It is often part of a multilevel plan.

The soft-palate and uvular region

• Classic or modified UPPP (uvulopalatopharyngoplasty)
• Soft-palate radiofrequency — less invasive, with effectiveness achieved through follow-up sessions
• Plasma-assisted techniques
• Palatal implants in selected cases
• Pharyngoplasty variants (such as expansion sphincter pharyngoplasty)

Tonsil surgery

In young adults and children with enlarged tonsils, tonsillectomy is often very effective even on its own.

Tongue-base surgery

• Tongue-base radiofrequency
• Hypoglossal nerve stimulation (in selected patients with severe apnoea who cannot tolerate CPAP and meet certain criteria)
• Tongue-base reduction techniques

Orthognathic (jaw) surgery

• Maxillomandibular advancement (MMA): comprehensive surgery in which the lower and upper jaws are moved forward together. It is considered in severe apnoea with advanced jaw retrusion or that does not respond to other treatments.
• Genioglossus advancement (GA): moving the attachment point of the tongue base forward.

Paediatric patients

In paediatric snoring, adenoidectomy ± tonsillectomy is the most common surgery worldwide and is, in the great majority of cases, highly rewarding. The approach of “the child will grow out of snoring” is not correct, because a neglected condition can have an adverse effect on growth, development and behaviour.

Process and Recovery

Although it varies according to the procedure, the typical course is:

• Nasal surgery: marked improvement in 3–7 days, settling of the result over 4–6 weeks.
• Soft-palate / uvular radiofrequency: a few days of sore throat, return to work within 1 week, the result becoming apparent over 4–6 weeks.
• Classic UPPP: 10–14 days of marked sore throat and difficulty swallowing; plenty of fluids, soft foods, pain control and hydration are critical.
• Tonsil surgery: 7–14 days of pain and difficulty swallowing, with marked recovery at 2 weeks.
• Multilevel operations: a recovery process of between 2 and 4 weeks.
• Orthognathic surgery (MMA): recovery over 45–60 days; it requires advanced planning and multidisciplinary follow-up.

Practical advice:

• Plenty of fluids and soft, warm foods
• Avoiding acidic, spicy and hard foods during the first weeks
• Staying away from smoking and alcohol
• Not skipping the follow-up appointments on the recommended dates
• Regular use of saline / spray treatments

Quality of Life and Long-Term Follow-Up

Snoring that is correctly evaluated and treated provides much more than a reduction in the sound alone:

• A marked improvement in the quality of life of a partner and family
• Deeper, uninterrupted sleep
• Greater concentration and energy during the day
• A reduction in morning headaches
• Easier management of blood-pressure and metabolic parameters (where apnoea is also present)

In long-term follow-up:

• A follow-up sleep study after surgery (especially if apnoea was present) is important.
• If weight, alcohol, smoking and sedative use rise again over the years, snoring may also return.
• Control of accompanying conditions such as allergic rhinitis, reflux and hypothyroidism should be maintained.
• Annual ENT / sleep-centre follow-up is recommended.

Common Misconceptions

Mistaken beliefs about snoring that are frequently encountered in the clinic:

• “Snoring is natural; everyone snores.” Occasional, mild snoring really is common; however, loud snoring that recurs every night or witnessed breathing pauses cannot be regarded as normal.
• “Only overweight men snore.” Women snore markedly, especially after the menopause; snoring is possible in slim individuals for anatomical reasons.
• “I don’t snore; only my partner hears it.” Patients often do not hear their own snoring; for this reason the observation of a partner or family members is very valuable. An audio recording made with a smartphone app can also be helpful.
• “It can be fixed with a single operation.” In most patients snoring is a multilevel problem; an intervention at a single site may not provide a complete solution.
• “My child will grow out of it.” A “watch and wait” approach to paediatric snoring is generally mistaken; a neglected condition can adversely affect growth, behaviour and facial and jaw development.
• “If I have nasal surgery my snoring will stop.” Nasal surgery often contributes, but if there is obstruction at the pharynx, palate or tongue base, it may not be a solution on its own.

Practical Tips for Partners and Family

Some practical suggestions may be valuable for those close to a person who snores:

• Regular observation is important: knowing whether the breathing stops, how many seconds it lasts and how often it recurs is very valuable when attending an appointment.
• A phone audio recording: a recording made in the sleep environment over one or two nights makes it easier both for the patient to be convinced and for the doctor to make a preliminary evaluation.
• Is sleeping on the back a trigger? If snoring decreases when lying on the side, the positional component is strong; even this simple piece of information helps to guide treatment.
• Observing alcohol and sedatives: if snoring increases markedly on the nights these substances are taken, this should be shared with the doctor.
• Weight change: the relationship between a weight gain over recent months and an increase in the severity of snoring should be considered.

When Should a Specialist Be Consulted?

If any of the following situations is present, an ENT specialist should be consulted for an evaluation of snoring:

• Loud snoring that recurs every night
• Pauses in breathing witnessed by a partner
• Waking with a sensation of choking
• Excessive daytime sleepiness, waking unrefreshed, morning headaches
• Drowsiness while driving or at a desk
• Treatment-resistant hypertension, atrial fibrillation, a heart-rhythm problem
• Snoring together with obesity and a large neck circumference
• Persistent loud snoring, mouth breathing, restless sleep at night and a decline in school performance in a child
• A return of complaints after previous apnoea / snoring surgery

Snoring is not “a detail a family accepts with a laugh” but a warning signal from the upper airway. An evaluation carried out at the right time makes it possible — sometimes with simple lifestyle advice, sometimes with an oral appliance or a personalised surgical plan — to manage both the sound problem and any underlying sleep apnoea safely.