Snoring Treatment

Why Do We Snore?

Snoring is one of the conditions frequently sought for treatment in our country. The phenomenon we call loud snoring indicates facing a serious respiratory problem during sleep. In snoring, it is thought that the area where the air passes through the respiratory tract does not have enough clearance and is narrow. If air passage is forced, snoring occurs. Statistical studies show that there are snoring cases in between 10% and 30% of adults. In the majority of these individuals, snoring is what we call simple snoring, which does not pose a serious health problem. On average, severe snoring and sleep apnea are seen in 5 out of 100 people. This condition is called obstructive sleep apnea syndrome.

Cessation of Breathing During Sleep (Apnea) and the Emergence of Snoring

In children and adults, the muscles that normally keep the airway open contract, and the upper airway opens. If these muscles relax, a slight narrowing will occur in the upper airway. However, this situation does not cause a problem in air passage. But in the syndrome we call sleep apnea, this narrowing that occurs during sleep is at a serious level. This narrowing and difficulty in breathing send a message to the brain, and the respiratory effort begins to increase in this way. As a result of this chain reaction, an arousal reaction occurs in the brain. With arousal, the respiratory muscles will be activated, and the opening of the upper airway occurs. With this relief, the person falls back to sleep.

With a continuous strain in breathing and subsequent relief, this becomes a chronic condition. This causes the person to wake up constantly and not get a good night's sleep. If a person constantly wakes up at night like this, experiences breathing blockages, and wakes up the next day constantly feeling like they haven't had enough sleep, this condition is called "Obstructive Sleep Apnea Syndrome".

Types of Sleep Apnea:

• Obstructive Sleep Apnea: This type of apnea is the most common type. The muscles in the throat relax enough to close the area where air can pass.
• Central Sleep Apnea: In this type of apnea, the brain cannot send the correct signals to the muscles that control breathing. As a result, central sleep apnea occurs.

What Are the Symptoms?

Sleep apnea manifests itself with certain symptoms. We can list these as follows:

• Loud snoring
• Daytime sleepiness
• Waking up struggling to breathe
• Cessation of breathing during sleep
• Morning headaches
• Sore throat, dry mouth
• Waking up with shortness of breath

Causes of Sleep Apnea

Sleep apnea, which we call the obstructive type, is the type that occurs as a result of relaxation when the muscles in the throat close the area where air will pass. These muscles belong to the uvula, soft palate, tongue, and pharynx. If these muscles relax, the airway will narrow during breathing, and breathing will stop for a while. As a result, there will be a decrease in the amount of oxygen in the blood. The brain will sense this oxygen decrease and will try to reopen the airway by reducing the depth of sleep. With the decrease in sleep depth, some people experience one or two short, deep breaths, while in others, breathing is restarted with loud snoring and swallowing sounds.

This cessation of breathing can be repeated 2 to 30 times an hour at night. If such sleep apnea is present, it is not possible to go into deep sleep at all. Because the person spends all their effort trying to breathe. Consequently, they feel the need to sleep during the day. People experiencing sleep apnea are generally unaware of this situation. They fall under the illusion that they slept well.

Central sleep apnea, on the other hand, is a very rare type. It manifests itself when the brain cannot transmit the correct signals to the muscles that control breathing. Waking up occurs as a result of a decrease in oxygen and an increase in carbon dioxide in the blood. People experiencing central sleep apnea remember their waking periods more than those experiencing obstructive sleep apnea.

What Are the Risk Factors?

Risk Factors for Obstructive Sleep Apnea

• Narrow Structure of the Throat: In some people, the structure of the throat is congenitally narrow. This is one of the triggering factors in the emergence of sleep apnea.
• Excess Weight: A short and thick neck region will also cause the airway in the throat to narrow. As weight increases, the fat tissue around the neck and throat will also increase, so sleep apnea can occur severely. If a person's shirt collar size is more than 43 cm in men and more than 40 cm in women, they carry a risk of sleep apnea. However, this does not mean that sleep apnea will only be seen in obese people. Thin people can also have sleep apnea.
• Age Factor: The incidence of sleep apnea in adults is 2-3 times higher than in young people.
• Enlarged Tonsil and Adenoid Problems: If the tonsils are larger than normal and there is an adenoid problem, sleep apnea, which mostly occurs in children, can be seen. However, this condition can also be seen in some adults.
• Use of Alcohol, Sleep Medications, and Sedatives: The use of these substances causes the throat muscles to relax during sleep.
• Male Gender: Sleep apnea is twice as common in men as in women. However, it is also frequently seen in overweight women.

Risk Factors for Central Sleep Apnea:

• Diseases in the Muscle and Nervous System: Sleep apnea can be seen in nervous system diseases related to the spinal cord and brainstem, or in diseases that can affect the entire muscular system.
• Brain Strokes or Tumors: Such health problems can affect and disrupt the brain's function of regulating the respiratory rhythm.
• High Altitude: Being at an altitude higher than normal increases the risk of sleep apnea.

In both types, there is a risk of developing problems such as hypertension or heart failure. Since oxygen in the blood drops suddenly during apnea, blood pressure increases. This means strain on the cardiovascular system. Consequently, the risk of developing paralysis due to brain hemorrhage and heart failure arises. If a patient has heart disease, drops in oxygen caused by sleep apnea increase the risk of sudden death during sleep due to heart failure.

When Should You See a Doctor?

If the snoring is at a level that disturbs you or others, if there is difficulty breathing during sleep, if breathing pauses during sleep and this is witnessed, if there is daytime sleepiness at work, school, watching TV, on the bus, reading, etc., a specialist doctor should definitely be consulted.

Many people are not aware that snoring is a serious health problem. However, there is no rule that everyone experiencing sleep apnea will snore. If snoring is experienced very severely, if there are silences between snores, and if these occur especially in the supine position, it is also necessary to see a doctor.

Evaluation and Diagnosis of Sleep Apnea

Since how sleep apnea occurs and the problems it causes can be due to many reasons, separate evaluations by Ear, Nose, and Throat (ENT), Cardiology, Neurology, and Pulmonology specialists may be required. The evaluation process of the ENT specialist will primarily begin with an examination. During this examination, the specialist doctor will focus on shape changes that cause narrowing in the areas where air passes, starting from the nose down to the windpipe. Following this, a sleep study will be conducted, and the functions of the body during sleep will be recorded and examined.

The sleep study can be done at home or in a laboratory. In the sleep study, cables are connected to the body via a device, and many criteria such as respiratory and circulatory activities during sleep, airflow in the nose and mouth, brain waves, arm and leg movements, snoring sounds, and body positions are recorded. When the examination is over, the data starts to be evaluated in a computerized environment. In addition to this, the specialist doctor may request an X-ray to evaluate and measure the narrow area in the airway. This X-ray is called "cephalometry".

Problems Caused by Sleep Apnea

Sleep apnea brings along many health problems. These problems affect individuals quite badly both in terms of health and socially. To touch upon these health and social problems;

• Problems Created in Brain Activities: Problems such as forgetfulness, listlessness, fatigue, impotence issues, and waking up frequently at night to go to the toilet occur in people experiencing sleep apnea. Hyperactivity and attention deficit are frequently seen in children.
• Problems Occurring in the Cardiovascular System: A sudden drop in oxygen in the blood is seen during apnea. Along with this, blood pressure increases, and strains occur in the cardiovascular system. Hypertension is seen in at least half of those experiencing sleep apnea. This situation creates a risk of heart failure and brain hemorrhage. In those with heart disease, low oxygen along with sleep apnea can lead to consequences such as sudden death in sleep due to a heart attack.
• Problems Related to the Spouse: Severe snoring along with sleep apnea can cause major problems, especially for couples. The partner's inability to sleep and even wanting to sleep in another room creates a serious problem.
• Daytime Sleepiness: Since sleep is frequently interrupted in the middle of the night, it is not possible to fall into a deep sleep. In this case, daytime sleepiness occurs, and conditions such as irritability and weakness are observed. People experiencing sleep apnea are prone to sleeping constantly at work, school, watching TV, in classrooms, on the bus, and even in the car. People who experience sleep apnea and drive have a very high risk of having a traffic accident. The apnea condition in children generally causes situations such as failure at school.
• Medical Treatments That May Be Required for Other Reasons: Respiratory problems due to anesthesia may arise during surgeries that may be required for other reasons in people experiencing obstructive sleep apnea.

What Can Be Done Against Sleep Apnea?

If alcohol, sedatives, or sleeping pills are being used, they should be stopped. These substances cause the muscles in the throat to relax, affecting breathing in this way. If the person is overweight, they should resort to losing weight. In people with weight problems, losing weight helps regress the apnea. It is beneficial to sleep on the side or prone (face down). Sleeping on the back will cause the tongue and soft palate to sag backward. This is a factor that narrows the airway.

If one wants to prevent unknowingly getting into the supine position during sleep, placing a ping-pong ball or tennis ball in the pajama pants, at the waist area, can increase precaution. If there are nasal problems, these issues should be treated. Curvature in the nasal septum (septum deviation), lack of tension in the nasal wings, and allergic conditions are factors that make it difficult to breathe through the nose. Such situations are conditions that trigger apnea.

How is it Treated?

The condition that causes snoring, which we call sleep apnea, is generally not a condition that resolves spontaneously. Many methods can be used for treatment. The use of some devices to open the airway is common. However, surgery may be required in some cases.

Treatment in Obstructive Sleep Apnea:

• PAP Devices: A mask is placed over the nose, and the person sleeps with a device that applies pressure to the airway through this mask. This application has different types such as biPAP (bilevel positive airway pressure), CPAP (continuous positive airway pressure), and aPAP (automatic positive airway pressure).
• Surgical Procedures: The goal of the surgical method is to remove, tighten, or reduce the tissues that block the airway.
• Radiofrequency Surgery: In this method, which is mostly used to assist other surgical methods in sleep apnea, radio waves are applied to the back of the tongue and the parts of the soft palate intended to be tightened with the help of a special device. The effect occurring in the tongue and soft palate tissue will cause the palate to tighten and shrink at the base over time. A 6-week period is required for the effect to appear in each application, and several applications can be repeated at 3-month intervals.
• Pharyngoplasty Surgery: This procedure is generally performed under general anesthesia. During the surgery, the soft tissue, uvula, and tissues around the tonsils are reshaped. Along with these procedures, the tonsils are also often removed. The recovery time is about 4-6 weeks on average after the surgery. This type of surgery is the most frequently used method in the surgical treatment of sleep apnea.
• Surgeries Performed to Pull the Base of the Tongue Forward: This is a surgery performed to widen the airway by pulling forward a part of the jawbone connected to the tongue muscles and the hyoid bone in patients where the airway is blocked by the base of the tongue.
• Tracheotomy: This surgical treatment is used rarely, only when other methods provide no benefit and severe sleep apnea posing a life-threatening risk is observed. A cannula is inserted by opening a hole into the windpipe from the neck area. Breathing is provided through this cannula. While this hole can be closed during the day, it is opened while sleeping at night, allowing the air to go directly into the windpipe without passing through the obstructed throat area.
• Other Auxiliary Surgical Procedures: Apart from the treatment applications we have mentioned, there are other auxiliary applications. These include correcting the curvature in the nasal region (septum deviation), removing large tonsils and adenoids if any, surgical treatment for chronic sinusitis, and surgical applications to correct any structural disorder in the jaw if present. Such auxiliary applications provide support in treating sleep apnea.
• Oral Appliances: It is possible to pull the jaw and tongue forward with some dental appliances. This is another way to keep the airway open. However, such appliances are used only in mild cases of apnea. These prostheses must be worn in the mouth every night. These prostheses are custom-produced for each patient by taking the mold of the patient's teeth.