Q: I snore. Loudly. It’s a real nuisance. My wife makes me sleep downstairs. My friends make me get my own room on road trips. But, other than a social problem, is it bad for me? I heard surgery hurts and doesn’t work. I don’t want one of those Darth Vader masks, either. Help.
A: Snoring is complicated. First of all, unless you snore and obstruct your breathing, your insurance company doesn’t care whether you have this problem or not. Snoring to them is a cosmetic issue. They don’t have the financial resources available to “fix” everyone covered by their policy that snores and doesn’t stop breathing. If you go to a center for a sleep study, just remember this; after you get all of the monitors attached, it’s hard to sleep.
If you snore and obstruct, meaning that you are trying to breathe and can’t, they care. But the work-up of apnea – the name for the act of stopping breathing – is a big deal.
Q: So, I do catch myself waking up, but those machines and that surgery are more than I want to do. I mean, this is just bad snoring, isn’t it? Snoring never killed anybody, right?
A: The initial symptoms of early apnea (besides daytime sleepiness, of course) are forgetfulness, difficulty concentrating, moodiness, and irritability. Once the apnea starts to be significant, you get things like poor work or school performance, morning headaches, and falling asleep driving. (Sleeping while driving is not conducive to health.)
P.S. Sleep deprived partners, angry with you for keeping them up with your snoring, are well known to cause bruised ribs. Ouch!
There are physiological effects as well. Upper airway obstruction causes a strain on your vascular system. This leads to elevation of blood pressure and cardiac effects such as heart failure, atrial fibrillation, and sudden cardiac death. Apnea can make you a much greater anesthetic risk, so having even a small operation can be risky. And your liver gets irritated, too.
Q: What are the first steps in fixing the issue?
A: First of all, what every patient needs to know is that ENT doctors are the most appropriate first step in snoring and apnea evaluation. That is because they are the most “in tune” with the anatomical variations that predispose a patient to airway issues, they have the best ways to evaluate the impact on the individual of structural problems, and they offer all of the options available for treatment (or know the people to refer you to for non-surgical and non-CPAP options.)
In some patients, especially the very young, the only thing blocking the airway could be large adenoids or really big tonsils. The mouth may be small and not have space for the tongue, which could be pushed back into the throat where it obstructs. The chin may be “weak”, not holding the tongue far enough forward.
Having a very long soft palate, especially when the uvula is enlarged as well, can act like a “cork”, blocking the airway. (I’ve seen people who just have a massive uvula as the sole reason for their problem.)
Having a large tongue, whether congenitally or because of disease, or having big lingual tonsils – the lymphoid tissue on the back of the tongue, can exacerbate apnea.
Nasal obstruction can be a big factor in nocturnal breathing problems. If your nose is congested or obstructed, your mouth hangs open, the tongue falls back, and snoring or apnea worsens. Nasal obstruction can be from a deviated nasal septum, enlarged nasal turbinates, nasal polyps, or just generalized from allergy or sinusitis.
The epiglottis rarely blocks the airway, except in laryngomalacia in the very, very young, or in acute illness – such as epiglottitis, a true medical emergency, or angioedema, usually from a drug side effect.
Your ENT physician has at their disposal fiber optic cameras through which they can inspect your airway, both sitting and supine if necessary, to properly assess the site of your obstruction. Once this area is identified as the site of the problem, a treatment plan can be made.
So, if you don’t want to snore, or have apnea, there are all sorts of things you have to consider. Are your problems bad enough to invest the time, money, and energy involved? Are you willing to risk the possibility that there are personal health consequences that you might be pretending don’t exist?
Surgery for easily diagnosed, major structurally abnormal physical findings can be a “home run”. Surgery can also be the last thing you would ever consider.
CPAP can be a lifesaver, with some patients not willing to leave the Sleep Center without the machine because it made them feel so much better. But the compliance with CPAP averages around 34%, meaning 3 out of 4 people who go home with the device, who were told the severity of their apnea merited the use of the machine, who were often told that they would die young without it, still chose not to use it.
Are you willing to go “outside of insurance” to try things like mandibular advancement appliances? Palate stiffening implants? New tongue base shrinking options? Even knowing that they might not work?