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Snoring and Its-management (Part 1/2): A Review

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Abstract and Figures

In-this-study ‘snoring’ was considered under-the-umbrella of sleep-disordered-breathing. The-article reflects concise-background-information, selected via document-analysis, on: Snoring (definitions, types, causes, prevalence, and effects, including: (i) acoustic-disturbance (noise-pollution) and resulted sleep- deprivation, and relationship-problems; and (ii) health-effects, due-to Upper Airway-obstruction); and Snoring-management (treatments and remedies), including the-concept of anti-snoring chin-strap-device. Although, snoring is amedical- issue, this-review, primarily-targeted, non-medics – product-designers, in-particular; also, it was not intended to-be fully-comprehensive, and, hence, should-be-considered for illustrative-purpose. Nevertheless, theauthor trusts, this-review, provided a-contribution (in its-small-way) to the-body of knowledge, on the-subjectmatter. Moreover, the-study constituted an-important-step, toward deeper-understanding, of snoring, and itsmanagement- options, alongside with their-limitations, in-the preparation for the-design of an-anti-snoring-device (Part 2/2). Finally, further-research-areas were recommended, on: (1) country-wise-survey on snoring-prevalence; (2) perceptions on snoring; (3) anti- snoring-treatments and remedies, available, and their-cost implications; and (4) the-design of anti-snoring-device (for-example uncomplicated chin-strap-device), to-offer an-affordablesolution, to untapped-local-population of snorers. Keywords: OSA; sleep-disordered-breathing; anti-snoring-devices; anti-snoring-surgery.
The-anatomy of the upper-airway (Kuna & Remmers, 2000). Factors, causing UA-obstruction, in-patients with sleep-disordered-breathing, are: (1) Skeletal-factors (Verin et al., 2002; Sforza et al., 2000; Gunn et al., 2000); (2) Soft-tissue-factors (Schwab et al., 2003; Schellenberg et al., 2000; Deegan & McNicholas, 1995). For-example, the-pharynx, in-UA, has a-collapsiblestructure, due to the-lack of bony-formation. Both; passive-mechanical and active-neural factors contribute to itspatency and collapsibility (Izci et al., 2006); (3) Combining skeletal-factors and obesity (Douglas, 2002; Tangugsorn et al., 2000); and (4) Other-factors, such-as: oedema, nasal-obstruction, and respiratory-controlinstability; as-well-as active/passive-smoking (Pae et al., 2005; Franklin et al., 2004). UA-patency depends on many-factors, including, but not limited to: (1) Mechanical factors: Lung-volume (Fogel et al., 2003; Stanchina et al., 2003); Body-position and gravity (Isono et al., 2004; 2002); Breathing-route (e.g., nasal, oral, or both)(Fitzpatrick et al., 2003); Surface-adhesive-forces and fluid-elasticity of the-mucosa (Kirkness et al., 2003); The-vascular-tone of the-blood-vessels (Wasicko et al., 1990); (2) Gender differences as regards upper airway (Jordan et al., 2005; Shahar et al., 2003; Liu et al., 2003; Rowley et al., 2002; Kamal, 2002; Malhotra et al., 2002; O'Connor et al., 2000; Huang et al., 1998); (3) the balance between dilating and collapsing forces (Kuna & Remmers, 2000); and (4) Upper airway compliance and collapsibility (Schneider et al., 1986) among-other-factors. Heavy-snoring is a-result in sleep-related upper-airway narrowing, which leads to-respiratory flowlimitation. The-narrower the UA becomes, the-greater the-vibration, and the-louder the-snoring. The-soft-tissues of the-pharynx, including the-tonsils, soft-palate, uvula, tongue, and the-lateral pharyngeal-walls, in the-adult, are important in influencing airway-size (Schwab et al., 2003; Schellenberg et al., 2000; Deegan & McNicholas, 1995; Schwab et al., 1995; 1993). Constriction or narrowing, of UA, can happen for many-reasons, such-as: cartilage-deformities, in the-nose or nasal-structure. The-most common-cause, however, is a-tongue-muscle, which relaxes too-much, during sleep, and allows the-tongue to-be-sucked-back, into the-airway, with eachbreath. On-the-other-hand, there is no single-cause for snoring; Cote (1988), for-instance, includes conditions, such-as: sleep-related-loss of muscle-tone, in the-tissues supplied by the-glosso-pharyngeal-nerve; anatomicalobstruction of nasal-passages; large-tonsils; large-tongue; a retrognathic-mandible; allergies; and certainmedical-conditions. For-example, asthma, can-potentially cause a-shrinking, of the-air-passages, which can-leadto-snoring. Besides, snoring can-be-accredited to-one, or more, of the-following: (1) Obesity, that has caused fat to-gather in and around-the-throat. For-example, Fogel et al. (2003); Deegan & McNicholas (1996); Mortimore et al. (1998); and Davies & Stradling (1990) stated, that anthropomorphic measurements, such-as upper-bodyobesity, neck-circumference, and waist-hip-ratio (WHR) are better-predictors, of sleep-disordered-breathing, including snoring, than BMI; (2) Obstructive-sleep-apnea (OSA); (3) Sleep-deprivation; (4) Relaxants, such-as: alcohol or other-drugs, relaxing throat-muscles; (5) Sleeping on one's back, which may-result in the-tonguedropping to-the-back of the-mouth; (6) Mis-positioned-jaw, frequently caused by tension in the-muscles (Mayo Clinic, 2015); (7) throat-weakness, causing the-throat-to-close, during-sleep. Throat loses muscle-tone, but does
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Snoring and Its-management (Part 1/2): A Review
Diana Starovoytova
School of Engineering, Moi University P. O. Box 3900, Eldoret, Kenya
Abstract
In-this-study ‘snoring’ was considered under-the-umbrella of sleep-disordered-breathing. The-article reflects
concise-background-information, selected via document-analysis, on: Snoring (definitions, types, causes,
prevalence, and effects, including: (i) acoustic-disturbance (noise-pollution) and resulted sleep- deprivation, and
relationship-problems; and (ii) health-effects, due-to Upper Airway-obstruction); and Snoring-management
(treatments and remedies), including the-concept of anti-snoring chin-strap-device. Although, snoring is a-
medical-issue, this-review, primarily-targeted, non-medics product-designers, in-particular; also, it was not
intended to-be fully-comprehensive, and, hence, should-be-considered for illustrative-purpose. Nevertheless, the-
author trusts, this-review, provided a-contribution (in its-small-way) to the-body of knowledge, on the-subject-
matter. Moreover, the-study constituted an-important-step, toward deeper-understanding, of snoring, and its-
management-options, alongside with their-limitations, in-the preparation for the-design of an-anti-snoring-device
(Part 2/2). Finally, further-research-areas were recommended, on: (1) country-wise-survey on snoring-prevalence;
(2) perceptions on snoring; (3) anti- snoring-treatments and remedies, available, and their-cost implications; and
(4) the-design of anti-snoring-device (for-example uncomplicated chin-strap-device), to-offer an-affordable-
solution, to untapped-local-population of snorers.
Keywords: OSA; sleep-disordered-breathing; anti-snoring-devices; anti-snoring-surgery.
1. Introduction.
The-term ‘sleep-disordered-breathing’ is commonly-used, to-describe the-full-range of breathing-problems,
during sleep, in-which, not enough-air reaches the-lungs (hypopnea and apnea)--a-common-condition in the-
middle-aged adult-population. All-airflow-disruption, which lasts two-complete respiratory-cycles, is called
apnea, while the-hypopnea is identified as the-partial-obstruction of more than 50% of the-air-flow (Rangel et al.,
2012). According to Izci et al. (2006), the-impact of sleep-disordered-breathing on society, health-care, and
affected-individuals, is considerable. In-this-study ‘snoring was considered under-the umbrella of sleep-
disordered-breathing.
2. Snoring.
2.1. Definitions.
According to MedTerms™ Medical-Dictionary, snoring is:
A rough rattling noise made on inspiration during sleep by vibration of the soft palate (the back of the
roof of the mouth) and the uvula (the prominent structure dangling down at the back of the mouth). On
inspiration, air on its way to the lungs travels by the tongue, the soft palate, the uvula, and the tonsils.
When a person is awake, the muscles in the back of the throat tighten to hold these structures in place
and prevent them from collapsing and vibrating in the airway. During sleep, the soft palate and uvula
may vibrate causing the sounds of snoring.
The-Webster-Dictionary, provided shorter-definition, of snoring, as: ‘The action or sound of breathing
during sleep with harsh, snorting noises caused by vibration of the soft palate’.
In the-Cambridge-English-Dictionary, no definition for snoring, is provided; a-verb ‘snore’[snɔr, snoʊr],
however, is defined as: ’to make loud noises as you breathe while you are sleeping’.
Simply put, snoring occurs when a-collapse, blockage, or restriction, to-the-upper-airway, obstructs air-
movement (through the-back of the-mouth, throat, or nose), during breathing, while sleeping. The-sound
(snoring) is created by the-vibration of the-affected-soft-tissues. In-some-cases, the-sound may-be soft, but in
most-cases, it can-be loud and unpleasant, for their bed-partners.
2.2. Predisposing factors/ Causes.
It-is beneficial to-look at the-mechanism of snoring, first. Generally-speaking, snoring is the-result of the-
relaxation of the-uvula and soft-palate, and, subsequent, partial-blockage the-airway, resulting in-irregular-
airflow and vibrations (Chokroverty, 2007). During the-stage when the-muscles go into deep relaxation, they
become completely-loose, and incapable of movement. For-example, with open-mouth-snorers, the-muscles, in
the-jaw, and the-chin, tends to-drop-down, leaving the-mouth hanging-open. Besides, the-tongue, and other-soft-
tissues, in the-throat, also tend-to-fall-back, blocking the-airways, and causing the-typical snoring-sounds, to-
emerge. Snoring is simply the-sound of resistance and turbulence, in the-upper-airway.
The-upper-airway (UA) is a-very-complex-structure, which plays vital-roles for respiratory, digestive, and
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phonatory-functions (Kuna & Remmers, 2000; Remmers et al., 1978). It consists of the-nasal-airway, the-
pharynx, the-larynx, and the-trachea (Ayappa & Rapoport, 2003; Kuna & Remmers, 2000). Figure 1 shows the-
anatomy of the-UA.
Ayappa & Rapoport (2003); Douglas (2002); and Kuna & Remmers (2000) indicated, that the-pharynx is
the-main-site of airflow-obstruction, during-sleep, due-to-lack of bony and cartilaginous-support. According to
Isono et al. (2003); Schwab et al. (2003); Isono et al. (1997); and Schwab et al. (1995; 1993), however, the-
most-common-sites, of obstruction, are: the-retropalatal (in-almost 100% at the-retropalatal airway), and
retroglossal-regions (in 50% of the-patients, at the-level of oropharynx); obstruction may-also-occur in the-
hypopharyngeal-airway (Hudgel, 1998).
Figure 1: The-anatomy of the upper-airway (Kuna & Remmers, 2000).
Factors, causing UA-obstruction, in-patients with sleep-disordered-breathing, are: (1) Skeletal-factors
(Verin et al., 2002; Sforza et al., 2000; Gunn et al., 2000); (2) Soft-tissue-factors (Schwab et al., 2003;
Schellenberg et al., 2000; Deegan & McNicholas, 1995). For-example, the-pharynx, in-UA, has a-collapsible-
structure, due to the-lack of bony-formation. Both; passive-mechanical and active-neural factors contribute to its-
patency and collapsibility (Izci et al., 2006); (3) Combining skeletal-factors and obesity (Douglas, 2002;
Tangugsorn et al., 2000); and (4) Other-factors, such-as: oedema, nasal-obstruction, and respiratory-control-
instability; as-well-as active/passive-smoking (Pae et al., 2005; Franklin et al., 2004).
UA-patency depends on many-factors, including, but not limited to: (1) Mechanical factors: Lung-volume
(Fogel et al., 2003; Stanchina et al., 2003); Body-position and gravity (Isono et al., 2004; 2002); Breathing-route
(e.g., nasal, oral, or both)(Fitzpatrick et al., 2003); Surface-adhesive-forces and fluid-elasticity of the-mucosa
(Kirkness et al., 2003); The-vascular-tone of the-blood-vessels (Wasicko et al., 1990); (2) Gender differences as
regards upper airway (Jordan et al., 2005; Shahar et al., 2003; Liu et al., 2003; Rowley et al., 2002; Kamal,
2002; Malhotra et al., 2002; O’Connor et al., 2000; Huang et al., 1998); (3) the balance between dilating and
collapsing forces (Kuna & Remmers, 2000); and (4) Upper airway compliance and collapsibility (Schneider et
al., 1986) among-other-factors.
Heavy-snoring is a-result in sleep-related upper-airway narrowing, which leads to-respiratory flow-
limitation. The-narrower the UA becomes, the-greater the-vibration, and the-louder the-snoring. The-soft-tissues
of the-pharynx, including the-tonsils, soft-palate, uvula, tongue, and the-lateral pharyngeal-walls, in the-adult,
are important in influencing airway-size (Schwab et al., 2003; Schellenberg et al., 2000; Deegan & McNicholas,
1995; Schwab et al., 1995; 1993). Constriction or narrowing, of UA, can happen for many-reasons, such-as:
cartilage-deformities, in the-nose or nasal-structure. The-most common-cause, however, is a-tongue-muscle,
which relaxes too-much, during sleep, and allows the-tongue to-be-sucked-back, into the-airway, with each-
breath.
On-the-other-hand, there is no single-cause for snoring; Cote (1988), for-instance, includes conditions,
such-as: sleep-related-loss of muscle-tone, in the-tissues supplied by the-glosso-pharyngeal-nerve; anatomical-
obstruction of nasal-passages; large-tonsils; large-tongue; a retrognathic-mandible; allergies; and certain-
medical-conditions. For-example, asthma, can-potentially cause a-shrinking, of the-air-passages, which can-lead-
to-snoring. Besides, snoring can-be-accredited to-one, or more, of the-following: (1) Obesity, that has caused fat
to-gather in and around-the-throat. For-example, Fogel et al. (2003); Deegan & McNicholas (1996); Mortimore
et al. (1998); and Davies & Stradling (1990) stated, that anthropomorphic measurements, such-as upper-body-
obesity, neck-circumference, and waist- hip-ratio (WHR) are better-predictors, of sleep-disordered-breathing,
including snoring, than BMI; (2) Obstructive-sleep-apnea (OSA); (3) Sleep-deprivation; (4) Relaxants, such-as:
alcohol or other-drugs, relaxing throat-muscles; (5) Sleeping on one’s back, which may-result in the-tongue-
dropping to-the-back of the-mouth; (6) Mis-positioned-jaw, frequently caused by tension in the-muscles (Mayo
Clinic, 2015); (7) throat-weakness, causing the-throat-to-close, during-sleep. Throat loses muscle-tone, but does
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not completely-collapse. Throat-tissues (mainly uvula and soft-palate) rattle and produce the-noise of snoring,
while breathing-effort increases; and (8) A-muscular-tonus-change, in the-UA-region, results in a-failure of
maintaining the-proper-pace for the-airflow, especially in the-deepest-stages of sleep, is an-important-cause of
snoring, in-adults (Rangel et al., 2012).
Moreover, UA-obstruction can-be-caused by: anatomic-deviations, tumors, polyps, large-adenoids and
tonsils, large-uvula, or a-long-soft-palate (Pataka & Riha, 2013; Arias et al., 2005).
To-summarize, the-ability of UA-muscles to-act, in-response to-different-conditions, is reduced, during-
sleep. This-ability includes changes in-UA-muscle dilator-activity and related-changes, in the-mechanics, and
reflex-activity of the-muscles. Thus, sleep-related-changes, in-UA, are the-key-factors, for understanding the-
mechanism of UA-obstruction. Presently, sleep-disordered-breathing, including snoring, is considered to-result
from a-combination of the-anatomical UA-predisposition and the-changes in-reflex-activity of the-muscles,
during-sleep (Izci et al., 2006).
1.3. Types.
As-mentioned earlier, snoring is associated with breathing-abnormalities, during-sleep. Snoring is a-sign of
partial-UA-obstruction, occurring during, most-commonly, via oral-breathing; however, in-some-people, it can-
occur during-both; oral, and nasal-breathing, or, exclusively, during nasal-breathing (Hsia et al., 2014). Besides,
snoring can-happen in any-part of the-UA, such-as: the-nose, the-soft-palate; the-back of the-tongue; and the-
back of the-throat.
Primary/simple-snoring is defined-as loud aspiratory-sounds, in-sleep, without apnoea or hypoventilation
(American-Academy of Sleep-Medicine, 2001), which occurs due to-turbulent-air-flow, through a-narrow
oropharyngeal or nasopharyngeal-space (Bradley & Floras, 2009). Habitual-snoring is a-chronic-condition,
which may-be-described as snoring ‘almost-every-night’, or ‘every-night, per-week’ (Young et al., 2001; 1993).
All-snorers have UA-obstruction (characterized by increased respiratory-effort), and most-habitual-snorers have
complete-episodes of UA-obstruction, during-sleep (American-Academy of Sleep-Medicine, 2001;
Guilleminault et al., 1976). Snoring generally-arises in the-supineposition, but habitual-snoring occurs in all-
body-postures (Guilleminault & Abad, 2004; Bassiri & Guilleminault, 2000).
Inflammation and trauma, which are caused by snoring, and other-respiratory-events, may play a-role in
the-progression of sleep-disordered-breathing (Izci et al., 2006), transforming primary, or habitual snoring, to
much-more-serious-condition, known as Sleep-Apnea. Sleep-Apnea, a-severe-form of sleep disordered-breathing,
is characterized by recurrent-episodes of complete (apnoea), or partial UA-obstruction (hypopnoea), at the-
pharyngeal- level, during-sleep, resulting in cortical-arousal, and oxygen-de-saturation (American-Academy of
Sleep-Medicine, 2001), with sleep-disturbance, and transient-rises in blood-pressure (BP) (Davies et al, 2000).
Each-pauses, in- breathing, or periods of shallow-breathing, can-last for a-few-seconds to-several-minutes, and
they happen many-times, a-night. In the-most-common form, this follows loud-snoring. There may-be a-choking
or snorting-sound, as breathing resumes (NHLBI, 2012). There are 3 of sleep apnea: obstructive (OSA); central
(CSA); and a-combination of the two, called mixed. OSA is the-most common form, accounting for 84% (De
Backer, 2013; NHLBI, 2012), and CSA for less than 1%, and 15% of cases, are mixed (Morgenthaler et al.,
2006).
When breathing is paused, carbon-dioxide builds up, in the-bloodstream. Chemo-receptors, in the-blood-
stream, note the-high carbon-dioxide-levels, which, often, lead to-a-loud-gasp, or snort. The-brain is signaled, to-
wake the-person, sleeping, and breathe-in air. Breathing, normally, will-restore oxygen-levels, and the-person
will fall-asleep, again (AASM Task Force, 1999).
1.4. The-Prevalence.
It has-been-estimated, that roughly 30-50%, of the U.S.A.-population, snore, and almost 1/3 of them, suffers
from OSA (Aston-Acton-Q., 2013; Jovanovic & NightLase, 2011). Epidemiological-studies indicate that, the-
prevalence of OSA affects at least 9% of the-adult-male, and 4% of the-adult female-population (Pracharktam et
al., 1994). Besides, in a-sample of 1500 Israeli-factory-workers, 3% had OSA-symptoms. Almost 82 to 95% of
OSA-cases are middle-aged men (Marklund et al., 2001). According to Katsantonis, 45% of adults snore, at-
least-occasionally, and 25% are habitual-snorers. Ten to twenty-million-adults have OSA (4% of males and 2%
of females). Besides, children can-also suffer from OSA (usually caused by enlargement of tonsils and adenoids)
(Katsantonis, nd).
One-survey, of 5,713 American-residents, identified habitual-snoring in 24% of men and 13.8% of women,
rising to 60% of men and 40% of women aged 60 to 65 years; this suggests an-increased susceptibility to-
snoring as age-increases (Lugaresi et al., 1983). Jennum & Sjol (1992), in their-study, in a-Danish-population,
identified, that habitual-snoring was 19.1%, in-males, and 7.9%, in-females. Young et al. (1993) in a-study of
602 employees, between 30 and 60 years of age, reported, that 52% of women and 64% of men, were habitual-
snores. Although the-estimated-ratio of male/female has-been-reported as 8 to 10:1 in-sleep-laboratories
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(Redline et al., 1994; Guilleminault et al., 1995; 1988), in population-based studies this-ratio is 2 to 4:1 (Bixler
et al., 2001; Young et al., 1993). Women tend to-start to-snore, during-pregnancy and again later-in-life
(Chervin 2000; Franklin et al., 2000; Edwards et al., 2002; Loube et al., 1996), with an-increased-prevalence
after-menopause (Bixler et al., 2001). The-predominance of sleep-disordered-breathing, in men, rather than
women, decreases-with increasing- age, and after age 50, the occurrence of sleep-disordered-breathing is similar,
between males and females (Tishler et al, 2003).
The-prevalence of snoring, and OSA, increases with age, and this-proportion peaks between the-ages of 50
to 60 years (Ohayon et al., 1997; Young et al., 1993). Duran and his-colleagues (2001) found, that habitual-
snoring occurred in 46% of men, and 25% of women, with a- significant-trend to-increase with age, among
2,148 subjects, aged 30-70 years old, in Spain. In-the-UK, an-interview of 2,894 women and 2,078 men, aged
15-100 years old, reported that 47.7% of males, and 33.6% of females, snored. This-percentage increased to 97%,
in a-patient-group with suspected-sleep-apnoea (Whyte et al., 1989).
Sleep-disordered-breathing is usually considered a-disease of middle-aged-adults, between 30 and 65 years-
old (Stradling & Crosby, 1991), but studies have-also-shown that sleep-disordered breathing is very-common in
the- elderly, over 65 years-old (Young et al., 2002b; Bixler et al., 2001; 1998). An-increased BMI, a-reduction in
UA-muscle-tone, thinning of the-facial bones, and loss of teeth, that can manifest, with-age, may all predispose
to sleep-disordered-breathing.
In-addition, Bearpark et al (1995), study on 294 men, aged 40-65 years old, found that 81% snored, for
more-than 10% of the-night, and 22% for more-than-half the-night.
Besides, some-studies also-have shown, that risk-factors, for sleep-disordered-breathing, do vary, among-
different-ethnic-groups. Craniofacial-bony-structure is a-relatively important-risk-factor, for sleep-disordered-
breathing, in-people with Chinese, and other-Far-Eastern-origin (Lam et al., 2005). Moreover, Li and colleagues
observed that Asian-men, with OSA, have more severe-OSAHS and less-obesity, than Caucasian. OSAHS,
among Asian-groups, appears to-be-related to-different craniofacial-morphology (the-cranial-base-dimensions
were significantly-decreased) than that associated with OSAHS, in Caucasians (Li et al., 2000). Furthermore,
African-descendants face a-higher-risk for OSA, than any-other ethnic-group, in the-U. S. A. Other-groups, at
increased-risk, include Pacific-Islanders, and Mexicans. Besides, people, with a-family-history of OSA, are at
increased-risk of developing the-condition (Grandner et al., 2013).
In-summary, there are more male-snorers; snoring also-tends to-increase with-age; large-share of habitual-
snorers will become sufferers from OSA, particularly those with family-history of the-condition; while risk-
factors, for sleep-disordered-breathing, do vary, among-different-ethnic-groups.
1.5. Effects.
The-potential-effects of snoring can-be-grouped as: (1) acoustic-disturbance (noise-pollution) and resulted sleep-
deprivation, and relationship-problems; and (2) health-effects, due to UA-obstruction.
1.5.1. Acoustic-disturbance (noise-pollution), and resulted sleep-deprivation.
Many-snorers are, usually, not aware of their-snoring; Their-bed-partners (if any), or family-members, or
roommates, or, even, neighbors, may notice and complain/report, to the-snorers, very-loud, roaring, unrelenting,
highly-unpleasant, annoying, irritating, intrusive, and, at-times, interrupted-snoring, associated-with choking or
gasps. This often-occurs in a-crescendo-pattern, with the-loudest-noises, occurring at the-very-end, and then the-
snorer immediately fall-back to-sleep, which is not the-case for their-partners.
Loud-intrusive-snoring results in sleep-interruptions, and sleep-fragmentation, affecting bed-partners and
other-family-members. Sleep-needs do vary, from person-to-person, and they also-change, throughout the-life-
cycle. Most-adults, however, need 7-8 hours of sleep, each-night (Dreher et al., 2009). Snoring can deprive a-
spouse/partner of sleep, which can not only lead-to arguments, and lost-patience, but a-spouse/partner also
experience terrible-physical and psychological-effects, of sleep-deprivation, such-as fatigue, daytime-sleepiness,
clumsiness, or weight-loss, or weight-gain (Sharma & Kavuru, 2010). Sleep-deprivation is a-serious-issue,
which can-be just as-harmful, to the-human-body, as starvation, or dehydration (Luboshitzky et al., 2002).
As-a-result, many-couples sleep-apart, because of snoring (Izci et al., 2005), some have severe-marital-
conflicts, some, even, divorce. For-example, Fitzpatrick et al. (1993); Gall et al. (1993); and Armstrong et al.
(1999) and Cartwright & Knight (1987) discovered a-statistically-significant-improvement in marital-relations,
after snoring was surgically-corrected.
Besides, there-are several-adverse-effects of sleep-deprivation on the-human-body, such-as: Lower-
metabolism; it-has-been demonstrated, that the-metabolic-activity, of the-human-brain, decreases, considerably,
after 24 hours of sustained-wakefulness (Spiegel et al., 1999); Increased-appetite (Taheri et al., 2004); Risk of
type 2 Diabetes (Renee et al., 2010; Kendzerska et al., 2014), and of Dementia (American-Academy of
Neurology, 2014); Change in brain-activity (National-Sleep-Foundation (2006); High-blood-pressure (Miguel-
Angel et al., 2013); Stroke (Barbé et al., 2012); and Heart-failure (Somers et al., 2008; 2011), among-others.
Moreover, sleep-deprivation results in a-decrease of body-temperature, a-decrease in immune-system-
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function, as-measured by white-blood-cell-count, and a-decrease in the-release of growth-hormone. Sleep-
deprivation can-also-cause increased heart-rate-variability. Moreover, sleep is paramount, for human-nervous-
system, to-work-well. Sleep-deprivation makes a-person drowsy, and unable-to-concentrate, the-next-day. It-also
leads to-impairment of memory, and physical-performance. If sleep-deprivation continues, hallucinations, and
mood-swings, may-develop (Somers, 2011).
In-addition, sleep-depravation can result in excessive-daytime-sleepiness, due to-sleep-fragmentation
(Lindberg et al., 1998; Martin et al., 1996), sometimes in-embarrassing or hazardous-situations (Dawjee, 2007).
Daytime-Sleepiness, generally-occurs in monotonous-situations, such-as: watching TV, or films; sitting as a-
passenger, in a-car; attending meetings or conferences; eating; working, for a-long-time, with computers, or,
even, while-driving (Guilleminault & Abad, 2004; Douglas, 2002; Bassiri & Guilleminault, 2000). Other-effects
are: daily-fatigue; lethargy; lack of energy; insomnia; depressed-mood (Chervin, 2000), and impaired-
concentration/less-mental-alertness, which has a-major-effect on reaction-time, memory, judgment, and
cognitive-performance of tasks, requiring dexterity and alertness (Bassiri & Guilleminault, 2000; Cheshire et al.,
1992), such-as driving, or operating-machinery.
In-addition, Douglas (2002); and Bassiri & Guilleminault (2000) documented complains of repeated-
morning-headache. Besides, it-can-cause emotional-problems, such-as: personality-changes, mood-disturbance,
and depression (Wells et al., 2004; Bassiri & Guilleminault, 2000). Moreover, sexual-dysfunction (decreased-
libido and/or impotence) (Bassiri & Guilleminault, 2000; Whyte et al., 1989), and irritation/aggression is
common (Dawjee, 2007).
Sufficient-amount of ‘quality’ sleep is, therefore, paramount, for both; physical-survival, and proper-
functionality, of a-person.
1.5.2. Health-effects, due to UA-obstruction.
According to Verin et al. (2002), researchers have-shown, that snoring-is the-most important-symptom
connected-with the-obstructive-sleep-apnea (OSA) syndrome.
OSA-sufferers will characteristically fall-asleep, experience a-UA-airway-blockage, exhibit loud-snoring,
stop-breathing, experience a-drop in-blood-oxygen-levels, attempt to-breathe, arouse, gasp for air, breathe for a-
few-seconds, and fall-back-to-sleep. The-Respiratory- Disturbance-Index (RDI) is a- measure of the-number of
OSA-events, occurring, per-hour of sleep. An-index, of fewer than five-episodes, per-hour, is considered normal;
10-20 episodes, per-hour, is mild; 20-40 is moderate, while more than 40 is regarded-as severe (Ivanhoe &
Attanasio, 2001).
OSA is among the-most-common and most-dangerous-types of sleep-breading-disorders. OSA sufferers
never get a ‘good-night-sleep’, because repeated-arousals deprive them of REM(deep-sleep-stage), leading-to
chronic-daytime-exhaustion, and long-term cardiovascular-stress. People, with sleep-disordered breathing,
including snoring, often-suffer from un-refreshing-sleep; irrespective of how-many-hours they actually-sleep
(Young et al., 1993). For-example, 18-31% of snorers, diagnosed with OSA, reported that their-sleep was-
interrupted, by an-awareness of choking, or breathlessness (Bassiri & Guilleminault, 2000; Whyte et al., 1989).
The-short-term-consequences of UA-obstruction, during-sleep, include: arousals, sleep-fragmentation,
intermittent-hypoxemia, and hypercapnia, and nocturnal-blood-pressure-surges. The-long-term complications of
OSA are important, and may contribute to-mortality: hypertension, cardiovascular, and cerebra-vascular-diseases.
Some-neurobehavioral-morbidities, such-as daytime-sleepiness and impaired cognitive-function, are also-linked-
with OSA, and may-contribute to-motor-vehicle-crashes and work-related-accidents, in untreated-patients, with
OSA (Young et al., 2002a).
Snoring is also a-sign of different-disorders, such-as: pre-eclampsia; and foetal-growth-restriction (Franklin
et al., 2000), Diabetes; Gastroesophageal-Reflux-Disease (GERD); and Polycystic-Ovary Syndrome (PCOS)
(Guilleminault et al., 2000), among-others. Besides, sore-throat, dry-mouth, and drooling, are frequent-
consequences of snoring and mouth-breathing, during-sleep (Guilleminault & Abad, 2004).
It has-been-reported, that the-association between sleep-disordered-breathing and hypertension (Moller et al,
2003; Peppard et al., 2000; Nieto et al., 2000, Bixler et al., 2000); Ischaemic-heart-disease (Davies et al., 2000;
Veale et al., 2000); Cardiovascular-complications (Ryan et al., 2005; Svatikova, 2005; Lavie, 2003).
Endothelial-dysfunction, and oxidative-stress, are also reported, to-be-associated-with cardiovascular-disease, in
the later-life of pre-eclamptic-women (Duley, 2003; Longo et al., 2003; Roberts & Lain, 2002); Endothelial-
dysfunction (Nieto et al., 2004); and atrial-fibrillation (Gami et al., 2004). Moreover, Lavie et al (2005) and
Marin et al (2005) stated, that the-risk of mortality increases, in untreated snorers, with moderate or severe-forms,
of sleep-disordered-breathing. If left-untreated, OSA will increase hypoxemia, which-will, in-turn, result in
pulmonary-vascular-constriction and increase pulmonary-arterial-pressure. This-sequence of events can result in
a-marked-increase in the-load, on the- right-side of the-heart, which can ultimately-cause right-ventricular-
hypertrophy and failure (Cote, 1988). The-National-Sleep-Foundation reports, that 70% of all-congestive-heart-
failure and 60% of all-strokes is directly-related to a-sleep-disorder.
Decreased-libido and impotence is common, among-patients, with OSA; 33-36 % of patients, with-OSA,
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reported sexual-dysfunction, either decreased-libido, or impotence (Bassiri & Guilleminault, 2000; Whyte et al.,
1989). Approximately 50% of patients, with OSA, complain of repeated-morning-headache. There is also a-
‘chicken-egg’ scenario, in that the-researchers found that not only does asthma create bad-sleep, but that bad-
sleep can worsen an-asthmatic’s breathing (Douglas, 2002; Bassiri & Guilleminault, 2000; Guilleminault et al.,
1976). There-is also strong-evidence for an-association between OSA and cardiovascular-diseases, with
hypertension. This-association occurs, possibly, due to-increased-sympathetic-activity, or atherogenesis (or both),
as free-radical-production, occurs in-OSA, as a-consequence of the-cyclic de-oxygenation/re-oxygenation.
Multiple-studies reveal a-positive-correlation, between loud-snoring and risk of heart-attack (about 34% higher-
chance) and stroke (about 67% higher-chance) (BBC News, 2008). In-addition, sleep-disordered breathing-
related motor-vehicle-crashes and work-accidents, in untreated/undiagnosed-patients, are possible-causes of
increased-mortality-rate (Young et al., 2002a).
Moreover, a-2012-study has-shown, that hypoxia (an-inadequate-supply of oxygen) that characterizes
sleep-apnea promotes angiogenesis, which increase vascular and tumor-growth, which in-turn, results in a 4.8
times higher-incidence of cancer-mortality (Nieto et al., 2012; Yan-fang & Yu-ping, 2009). Other-studies
associate loud ‘snoring’ with the-development of carotid-artery-atherosclerosis (Lee et al., 2008). Amatoury et al.
(2006) demonstrated, that snoring-vibrations are transmitted to the-carotid-artery; this can potentially-lead-to
atherosclerotic-plaque-rupture and, as a-result, ischemic-stroke.
Besides, studies report an-association between severe-apnea and psychological-problems. The-risk for
depression rises with increasing-severity of sleep-apnea. Sleep-related breathing-disorders can also-worsen
nightmares and post-traumatic stress-disorder. It-has-been also-revealed, that people, with OSA, show tissue-loss,
in-brain-regions, that help store memory, thus linking OSA with memory-loss. Using magnetic resonance
imaging (MRI), the-scientists also-discovered, that people, with sleep apnea, have ‘mammillary-bodiesthat are
about 20% smaller, particularly on the-left-side. One of the-key-investigators hypothesized, that repeated-drops
in oxygen, lead to the-brain-injury (Chang & Kezirian, 2013).
In-a-nutshell, sleep-disordered-breathing is not only associated with sleep-disturbance, but also with an-
increased-risk of many-serious-conditions, such-as: hypertension, cardiovascular, and cerebra-vascular-diseases;
as-well-as some-neurobehavioral-morbidities, with potential-risk of increased-mortality. According to Izci et al.
(2006) ‘the-impact of sleep-disordered-breathing on affected-individuals, society, and health-care, at-large, is
considerable’.
2. Treatments and remedies.
According-to Katsantonis, sophistication of options, in snoring-management, ranges from simple life-style-
changes, ‘over the-counter’-devices and medication, dental-appliances, Continuous-Positive Air-Pressure (CPAP)
machine, to minimally-invasive-procedures, and lastly, radical-surgery.
2.1. Behavioral or Lifestyle-Modifications.
Behavioral or Lifestyle-Modifications are usually-advised, as a-first-step to-treat snoring and OSA, of any-
severity. These-include: (1) losing-weight, if one is overweight; (2) not drinking alcohol, particularly few-hours,
before going to-bed; (3) giving-up smoking, if one smokes; (4) exercising-regularly this can-help-strengthen
neck-muscles, which may help prevent the-airways-narrowing; (5) sleeping position--trying to-sleep on the-side,
and not on the-back; and (6) improving sleep-hygiene i.e., a-regular sleep-wake-schedule (Guilleminault & Abad,
2004; Scottish-Intercollegiate-Guidelines-Network, 2003; Douglas, 2002).
It-is also advisable to-keep the-bedroom air-moist (for-example via using a-humidifier). The-membranes, of
the-nose and throat, are, normally, very-sensitive, when exposed to-dry air and, often, dry-air irritates the-
membranes, which, in-turn, causes narrowing of air-passages. Besides, throat-exercises, to-strengthen the-
muscles, has proven to-be an-effective-way (for some-people), to-reduce-snoring, gradually. For-example,
curling the-tongue, repeatedly, and pronouncing each-vowel (a-e-i-o-u), for a-few-times, a-day, loudly, can
strengthen the-upper-respiratory-tract-muscles, and, thus, reduce snoring. It-is recommended practicing-these-
exercises, for 20-30 minutes, a-day. In-addition, singing-exercises, were-also-proposed, for reduction of snoring,
for-example, Irumee et al. (2008) pointed-out, that professional singers seldom-snore, but Valbuza et al. (2008)
stated, that ‘there have been no medical-studies to-fully-link the- two’. More-recently Hilton et al. (2013),
pointed-out, that singing can, indeed, improve the-tone and strength of pharyngeal-muscles, a-group of muscles,
near the-soft-palate and upper-throat. They also revealed, that daily-singing-exercise, for 3 months, significantly-
reduced the-severity, frequency, and loudness, of snoring, in-participants. Moreover, Puhan et al (2006), also
advocating playing the ‘didgeridoo’ (Australian-musical-instrument); their-study, performed to-evaluate the-
effectiveness of this-instrument, published in the-British-Medical-Journal, found, that regular-playing of a-
didgeridoo, was an-effective treatment for reducing both; daytime-sleepiness, and snoring, in-participants with
moderate-OSA.
If lifestyle-changes, however, do not help, there are a-number of anti-snoring-devices, to-consider, in-order-
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to-reduce snoring.
2.2. Anti-snoring-devices.
A-variety of anti-snoring-devices are, currently, offered; these can-be classified, by-type, as: (1) Oral/Dental-
Appliances: Custom-made and Non-custom-made; Mandibular-Advancement-Devices (MADs); and Tongue-
retaining-Devices (TRD); (2) Nasal-Devices (External-Nasal-Dilators; and Other Nasal-Devices); (3) Position-
Control-Devices (e.g., anti-snore-pillows); (4) Chin-Straps; (5) Tongue-stabilizing-Devices; and (6) Positive-
Airway-Pressure (PAP) Therapy-Devices, among-others. Majority of them are so-called: ‘over the-counter’-
devices. The-phrase ‘over-the-counter’ meaning here: ‘available without a-prescription, or clinical-guidance’
(CDRH, 2004). Selected-devices were highlighted in the-following-sub-sections.
(a) Continuous Positive Air Pressure (CPAP/BIPAP) is the-use of a-constant-stream of pressurized-air, to-
maintain airway-integrity, and prevent OSA (Tan et al., 2002). Basically, CPAP is a-mechanical-device,
consisting of a-flow-generator, a-flexible-air-tube, and a-nasal, or oro-nasal-mask (see, for-example, Scottish-
Intercollegiate-Guidelines Network, 2003; Douglas, 2002; and Sullivan et al., 1981). CPAP-machine functions
by forcing-air into-the-airways, through a-nasal-mask, preventing tissue, in-the-throat, from collapsing, and
cutting-off air, and, therefore, oxygen-supply. The-standard CPAP-machine delivers a-fixed, constant-flow of air.
Variations of CPAP include: (1) Autotitrating positive airway pressure (APAP) devices automatically-respond
to-changes in-the-sleeper’s breathing-patterns, by adjusting and varying the-air-pressure-flow, throughout the-
night. Some-patients find this makes CPAP easier-to-tolerate; and (2) Bilevel positive airway pressure (BPAP)
systems deliver two-different-pressures, a-higher-one, for inhalation (breathing-in) and a-lower-one, for
exhalation (breathing-out).
Patients, with the-mild to moderate-forms of sleep-disordered-breathing, who are not sleepy, often cannot
tolerate CPAP-treatment, or simply refuse it, altogether, due to its-cumbersome-nature (Giles et al., 2006;
McArdle et al., 1999). A-large-number of patients refuse CPAP due its-side-effects (e.g., Cranio-facial-changes
(Tsuda et al., 2010), nasal-congestion and irritation, rhinitis, nasal-bridge-sores, discomfort, claustrophobia,
conjunctivitis, and noise) (Giles et al., 2006); and also, due to-discomfort, and, sometimes, for psychological-
reasons. Such-problems may-be improved, by using chin-straps-devices, or full-face-masks, heated-
humidification, and local-treatments (moisturizers or corticosteroids) (Scottish-Intercollegiate-Guidelines-
Network, 2003; Douglas, 2002). In-addition, the-equipment is rather-expensive (prices of suppliers range USD 1,
000-2,000, or, even-more (Ballard, 2008).
A-more-common and widely-used-approach, for the-management of OSA, is the-use of oral/dental-
appliances, to-reposition the-mandible, in a-forward, and downward-location (Johnston et al., 2002; Tan et al.,
2002; Rose et al., 2002).
(b) Oral/Dental-Appliances (OAs) are placed in the-mouth, during-sleep, to-prevent UA-obstruction. OAs-
function by increasing UA-size, and preventing the-collapse of the-tongue and the-soft-tissue, behind the-throat,
by: (1) repositioning the-mandible, tongue, soft-palate, and uvula; (2) stabilizing the-mandible, tongue, and
hyoid-bone; and (3) increasing the-muscle-tone-activity of the-tongue (Lowe, 2000). All-OAs fall into 2
categories: tongue-retaining-appliances, and mandibular-repositioning/advancing-device (MRS/MAD), which is
most-commonly-used in-clinics. Disadvantages of Dental/oral Devices: Dental devices are not as-effective, as
CPAP-therapy. The-cost of these-devices tends to-be-high. Side-effects, associated with dental-devices include:
(1) Nighttime pain, dry-lips, tooth-discomfort, and excessive-salivation. In-general, these-side-effects are mild,
although, over-the-long-term, they cause nearly-half of patients to-stop using dental-devices. Devices, made of
softer-materials, may produce fewer-side-effects; (2) Permanent-changes, in the-position of the-teeth, or jaw, and
bite-alignment, can occur, with long-term-use. Teeth-shift, both; temporary and permanent, is well-documented;
(3) Users of dental-devices should-regularly visit a-health-professional, to-check the-devices and make-
adjustments (if needed); (4) Many of these-devices cannot be used if the-person has poor-dental-health and
dental-hygiene (for-example: people with several-missing-teeth, dentures, etc.); and (5) In a-small-number of
patients, the-treatment may-worsen apnea (Chan et al., 2007). In-addition, the-most-reported-side-effects of the-
devices, are: initial or persistent-discomfort, excessive-salivation, dryness of the mouth, and long-term-effects of
temporo-mandibular-joint-discomfort, possible-dental-damage, bite-change, and periodontal-disease (Ferguson
et al., 2006; Izci et al., 2005; Engleman et al., 2002; Mehta et al., 2001; Lowe, 2000).
(c) On-the-other-hand, if snoring is, mainly, coming from one’s-nose, they may-benefit-from using nasal-
strips, or nasal-dilators. With open-mouth-snorers, chin-straps, or a-vestibular-shield, could-be of help. Chin-
straps are one of the-simplest anti-snoring-devices. A-chin-strap-device includes a-chin-cup, side-straps, and
rear-straps. The-chin-strap is used to-support a-snorer’s lower-jaw, upwards jaw (the-chin, and forwards the-
mandibula, and the-base-tongue), during-sleep, and substantially-close the-person’s mouth. A-vestibular-shield is
a-plastic-device that looks-similar to a-gum-shield. It fits inside the-mouth, and blocks the- flow of air. This-
forces one to-breathe, through the-nose, which may-prevent one, from opening the-mouth and snoring.
(d) Besides, if snoring is, mainly, due to the-base of the-tongue-vibration, a-mandibular advancement-
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device (MAD) may-be recommended. A-MAD is similar to a-vestibular-shield, but it-is designed to-push one’s
jaw and tongue, forward.
(e) Orthopedic-pillows are the-least-intrusive-option, for reducing snoring. These-pillows are designed to-
support the- head and neck, in a-way, that-ensures the-jaw stays-open and slightly forward. This-helps keep the-
airways as unrestricted, as-possible, and, in-turn, can lead to a-small-reduction, in-snoring. For-example, the-
pillow may provide contouring, graded-cushioning, and/or head/neck-configuration, to-promote jaw-closure.
(f) Moreover, a-lip-adhesive, or lip-seal, may-be-used (including one or more, of the-following: a-lip-gel,
to- adhere, or stick-lips-together; butterfly-closure; mouth-block; and/or gaffer-tape. With a-chin-strap, for-
example, lip seal can-be used.
The-cost, of anti-snoring-devices, ranges from USD 30 to USD150. Anti-snoring-mouthpieces, which are
made by dentists, however, may cost over USD 1,000. Besides, most-snoring-devices are not expected to-last for
more-than 1 year, also they do not work with-denture-users (Ballard, 2008).
Moreover, there is a-limited evidence on which-type of device is more-effective, so the-choice will-be-
down to one-s type of snoring, as-well-as their-personal-preference.
1.3. Medication
Pharmacotherapy is a-potentially-attractive-alternative, for treatment of sleep-disordered-breathing. Medication,
however, cannot, directly, treat the-symptoms of snoring, but it can-be-used to-help-treat some of the-
underlying-causes. For-example, if allergic-rhinitis (nasal-irritation and swelling) is causing one’s snoring, an-
antihistamine nasal-spray may-help relieve these-symptoms. If snoring is as a-result of having a-blocked-nose, a-
short-course of nasal-decongestants might help. Other-specific-examples include: (1) Modafinil (Provigil), a
central-nervous-system-stimulant (also-used to-treat narcolepsy), may marginally-improve alertness, in-snorers
and their-partners (Kingshott et al., 2001). The-drug was approved, by-the-FDA, as the-first-drug to-treat the-
sleepiness, associated-with OSA. However, modanifil is meant to-be-used in-combination-with standard apnea-
treatments, such-as CPAP. Modafinil can cause rare, but serious, side-effects, such-as life-threatening rash; and
(2) Thyroid-hormone, which may help OSA, in those with low-thyroid-levels (hypothyroidism).
It-is very-important to-note, on the-use on sedatives; some-snorers may assume them beneficial. Sedatives,
narcotics, antidepressants, and anti-anxiety-drugs, however, can actually, worsen the-breathing disturbances, and
arousal-conditions, that occur, with OSA. These-substances cause the-soft-tissues, in-the-throat, to-over-relax
and sag, increasingly-diminishing the-body’s ability to-inhale. Apnea-sufferers should never use sleeping-pills or
tranquilizers (Ballard, 2008).
To-sum-up, according-to Izci et al. (2006) ‘So-far, there are no drugs, which usefully decrease sleep-
disordered-breathing’ and according-to Smith et al. (2002): ‘the role of pharmacotherapy for sleep-disordered
breathing remains controversial’.
1.5. Surgery.
Surgery, for snoring, is usually regarded-as a-last-resort, when all-other-treatment-options have-been-tried, with
no success. Generally, surgical-procedures are attempted to-modify the-retropalatal-pharynx, the-retrolingual-
pharynx, or both (Sher, 2002), and directly, or, indirectly, focused-on increasing the-pharyngeal airway-size.
Anti-snoring Surgical-Procedures are categorized-as (Raynov et al., 2015): (1) Intranasal-operation; (2)
UPPP (uvulo-palato-pharyngoplasty); (3) Laser-assisted uvulo-palato-plasty (LAUP); (4) Laser-midline
glossectomy (LMG); (5) Adenotonsillectomy; (6) Tracheotomy; (7) Radiofrequency-Ablation; (8) Pillar
Procedure; (9) Injection-Snoreplasty; (10) Palatal-Stiffening; and (11) Other-Surgical-Procedures. Selected-
surgical-procedures were highlighted, below.
Tracheostomy used to-be the-only-treatment, for OSA. Tracheostomy is the-first-effective surgical-
procedure, for the-treatment of OSA, which is aimed to-bypass the-site of UA-closure. It-is quite-uncomplicated;
a-surgeon makes an-opening, through the-neck, into the-windpipe, and inserts a-tube. It-is almost 100%
successful, but it requires a rather-large-size-opening, in the-throat, which produces a-number of medical and
psychological-problems, associated-with recovery (Thatcher & Maisel, 2003; Partinen & Guilleminault 1990).
Today, this-operation is performed very-rarely, due-to-significant medical and psychological-morbidity; usually
only if OSA is life-threatening (Friedman & Schalch, 2007).
Uvulopalatopharyngoplasty (UPPP) is used when it-is been-confirmed, that-soft-tissue in one’s mouth
(excluding the-tongue) is responsible for snoring. UPPP is a-commonly-performed-procedure that enlarges the-
retropalatal-airway, by removal of the-tonsils, along with-portions of the-anterior and posterior-tonsillar pillars,
and the-free-margin of the soft-palate, including the-uvula (American-Sleep-Disorders Association, 1996). This
is an-operation, done with a-general-anesthetic. According-to Kezirian et al. (2013), and Franklin et al. (2009),
UPPP is among the-most-painful-treatments for OSA, and recovery takes several-weeks. The-procedure also-has
a-number of potentially-serious-complications, including: Infections; Impaired-function, in the-soft-palate and
muscles of the throat (called velopharyngeal-insufficiency), which can make-it-difficult to-keep liquids out of
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the-airway; Mucus in the-throat; Changes in voice-frequency; Swallowing-problems; Removing of uvula, can
also-affect the-ability to- pronounce certain-sounds; Regurgitation, of fluids, through the-nose or mouth;
Impaired-sense of smell; and Failure and recurrence of OSA. UPPP is also associated-with significant post-
operative-mortality and morbidity (Izci et al., 2006).
Laser-assisted-uvulopalatoplasty (LAUP) is a-similar, to-UPPP, procedure, but done with a-laser, which
burns away the-uvula and some of the-soft-palate. This stiffens the-soft-palate, to-reduce it vibration. An-
electrode is put into the-roof of the-mouth, and radiofrequency-waves are sent into soft-palate, through the-
electrode. It-is done with a-local-anesthetic. So-far, the-procedure achieved very-limited-efficacy (Izci et al.,
2006). With LAUP, throat-dryness, after-surgery, and throat-narrowing, and scarring, have-been reported.
Besides, in a-minority of patients, snoring becomes worse, afterward. In-this-regard, the-American-Academy of
Sleep-Medicine (AASM), stated, that LAUP is not routinely-recommended as treatment, for OSA. According to
the AASM, this-surgery, generally, does not help improve symptoms, and may actually worsen the-condition.
Soft-palate-implants: These are implants, injected into soft-palate, which stiffen it. This should-reduce it
vibration. This is also-done with a-local-anesthetic. NICE (2007) stated that there are no safety-concerns, over
the-use of soft-palate-implants; however, there-is limited-evidence about whether they are an-effective long-
term-treatment.
Radiofrequency-ablation (RFA) of the-soft-palate is an-alternative-treatment to soft-palate-implants.
However, evidence as to their-long-term-effectiveness is limited.
Another palate-tightening-treatment is the-Pillar-implant-system, where small-plastic-rods are inserted in
the-palate, causing it to-become-firm and reduce-vibration.
Other-surgical-procedures may-be-appropriate, to-correct facial-abnormalities, or obstructions, that cause
OSA. They may-be used alone, or in combination-with each-other, or with UPPP. Most are invasive, and, hence,
reserved for patients with severe-OSA, who fail-to-respond-to, or comply-with CPAP. Overall, there is limited-
evidence as to their-effectiveness, in treating OSA. These-procedures include: Maxillomandibular-advancement
(MMA), which moves the-upper (maxilla) or lower (mandible) jawbone forward. MMA was found by Bettega et
al. (2000), as not beneficial, for most-patients with sleep-apnoea; Genioglossus (tongue-advancement), in which
an-opening is cut, where the-tongue-joins the-jawbone, and the area is pulled-forward; Genioplasty, which is
plastic surgery on the-chin; Hyoid-advancement-surgery, in which the-movable-bone, underneath the-chin is
moved forward, pulling the-tongue-muscle along with it; and Surgery for nasal-obstructions (such as a-deviated-
septum), that contribute to-snoring and other-symptoms of OSA (Caples et al., 2010; Epstein et al., 2009;
Sundaram et al., 2005). These-treatments are considered less-invasive, than other-surgical-procedures; they
can-be-done under local- anesthetic; do not involve cutting, and stitching; little, if any, down-time; and little-post
operational-pain, afterwards. However, these-therapies may still cost thousands of dollars, without providing a-
long-term solution, as one may-need to-go-back, for more.
Overall, jaw and UA-surgeries may-be beneficial, in-selected-patients, with primary-snoring, or mild-OSA
(Izci et al., 2006). The-use of surgery, however, is rather-limited, due to-their-high-cost, invasiveness,
irreversibility, post-operative-swelling, pain, discomfort, and long-recovery-period. Besides, according-to Izci et
al. (2006), the-role of surgery, in treating OSA is still-poorly-understood, and there is significant-disagreement,
as regards its-use as a-treatment. Both; snoring, and OSA, are cause for several-health-issues, and are,
potentially-life-threatening (Mannarino et al., 2012). Still, most-patients are unwilling to-treat these, due to-
multiple-side-effects, unsuccessful-non-surgical and surgical-treatments, and uncomfortable-procedures
(Lindman et al., 2001).
On-the-other-hand, most of the-above-procedures are not available in-Kenya, moreover, ‘medical-tourism’
expenses, to-undertake such-procedures and operations, even, within-Africa (say, in-Egypt, or South-Africa),
currently, is not covered by the-NHIF (National-Health-Insurance-Fund), Kenya.
4. Conclusion and Recommendations.
Not only sleep, but enough-sleep, and ‘quality’-sleep, is absolutely-essential, for a-person’s physical- survival,
health, wellbeing, and for maintaining their optimal-emotional and social-functioning.
Although many-people consider snoring as rather-normal, and absolutely-harmless,snoring can, actually,
indicate serious-underlying-medical-condition(s). Besides, left-untreated, habitual-snoring can-develop into
more-serious-condition, named OSA. Sleep-disordered-breathing, including OSA and snoring, is not only
associated with sleep-deprivation, but also-with an-increased-risk of many-serious-conditions, such-as:
hypertension; cardiovascular and cerebra-vascular-diseases; as-well-as some-neuro-behavioral-morbidities, with
potential-risk of increased-mortality. Snoring, hence, should not be ignored.
On-the-other-hand, at the-local-context, currently, there is a-very-limited (if any) attention, given to-snoring,
as a-phenomena, as a-medical-condition, and also as a-research-subject. This-review, however, have illustrated,
that snoring has-been-linked not only-to OSA, but also to: diabetes, stroke, heart-failure, cancer, dementia, and
many-more. More-importantly, snoring can also be a-symptom of an-underlying-health-condition, which may-
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lead to-further health-complications. Left-untreated, complications from snoring, disrupted-breathing, and sleep-
deprivation, can, even, lead to-lethal health-problems, as-well-as occupational and driving-accidents.
Sleep-disordered-breathing, including snoring, is considered to-result from a-combination of the-anatomical
UA-predisposition and the-changes in-reflex-activity, of the-muscles, during-sleep. Many-different-treatments
and remedies, are offered, globally, however, most of them are yet to-be available, in-Kenya. Besides, even when
they become available, for them, to-be covered by NHIF, Kenya, the-snoring, and its-potential-dangers, should-
be-taken with all-seriousness, it is rightfully-deserve.
For-a-developing-country, like Kenya, limited-awareness on the-ill-effects of snoring, lack of treatment-
options, available, and high-cost of treatments, abroad, are additional-barriers, or excuses, for not treating and
largely-disregarding, snoring. The-author believes, this-concise-review will play a-role (in its-small-way) in
increasing-awareness on the-subject-matter.
Finally, the-current-study recommended to-conduct further-research on: (i) country-wise-survey on snoring-
prevalence; (ii) perceptions on snoring; (iii) anti-snoring-treatments and remedies, available, and their-cost
implications; and (iv) the-design of anti-snoring-device (for-example uncomplicated chin-strap-device), to-offer
an-affordable-solution, to untapped-local-population of snorers.
5. Acknowledgment.
The-author is thankful to Research-Assistants, MIT, SOE, MU--Wanjala, Andrew and Munyae, John, for their-
valuable-contribution, during document-analysis.
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Introduction: Finally the dentist has awaken to the fact that by being a health professional, he has as primary function to take good care of the welfare of patients. In face of this challenge, the dentist starts to understand his role in the treatment of snoring and of obstructive sleep apnea and hypopnea. Objective: The current paper has the purpose of discussing the role of this professional in the diagnosis and treatment of these diseases, most specifically of the therapy involving inter-occlusal devices, emphasizing the importance of multidisciplinarity in the reestablishment of the quality of life of the patient.
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Objectives: To assess the effectiveness of regular singing exercises in reducing symptoms of snoring and sleep apnoea. Methods: A prospective single blinded randomised controlled trial was conducted in the otolaryngology department of a UK teaching hospital (Exeter). 127 adult patients with a history of simple snoring or sleep apnoea were recruited. 93 patients completed the study. Patients were excluded because of severe sleep apnoea (apnoea index > 40), or morbid obesity (BMI > 40). The study group completed a self-guided treatment programme of singing exercises contained on a 3CD box set, performed for 20 minutes daily. Outcome measures included the Epworth Sleepiness Scale, the SF-36 generic quality of life assessment tool, visual analogue scales (VAS range 0 - 10) of snoring loudness and frequency, and visual analogue scale of compliance (for intervention group). Results: The Epworth scale improved significantly in the experimental group compared to the control group (difference −2.5 units; 95% CI −3.8 to −1.1; p = 0.000). Frequency of snoring reduced significantly in the experimental group (difference −1.5; 95% CI −2.6 to −0.4; p = 0.01), and loudness of snoring showed a trend to improvement which was non-significant (difference −0.8; 95% CI −1.7 to 0.1; p = 0.08). Compliance with exercises was good; median 6.6 (quartiles = 4.1, 8.3). Conclusions: Improving the tone and strength of pharyngeal muscles with a 3 months programme of daily singing exercises reduces the severity, frequency and loudness of snoring, and improves symptoms of mild to moderate sleep apnoea.
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Study Objectives: Previous studies in both awake and sleeping humans have demonstrated that lung-volume changes substantially affect upper-airway size and pharyngeal resistance and, thus, may influence pharyngeal patency. We sought to systematically investigate the isolated effects of lung-volume changes on pharyngeal collapsibility and mechanics and genioglossus muscle activation during stable non-rapid eye movement sleep. We hypothesized that lower lung volumes would lead to increased pharyngeal collapsibility, airflow resistance, and, in compensation, augmented genioglossus muscle activation. Design: Nineteen normal individuals (age, 30.4 +/- 0.5 years; body mass index,: 24.5 +/- 0.4 kg/m(2)) were studied during stable non-rapid eye movement sleep in a rigid head-out shell equipped with a variable positive/negative pressure attachment for manipulations of extrathoracic pressure and, thus, lung volume. Setting: Sleep physiology laboratory Participants: Normal healthy volunteers Interventions: N/A Measurements and Results: We measured change in end-expiratory lung volume (EELV)(magnetometers), genioglossus electromyogram (GGEMG) (intramuscular electrodes), pharyngeal pressure, and collapsibility of the pharynx in response to a brief pulse of negative pressure (-8 to -15 cm H20) under the following conditions: (1) baseline, (2) increased EELV (+1 liter), and (3) decreased EELV (46 liter). Reduced lung volumes led to increased inspiratory airflow resistance (7.54 +/- 2.80 cm H20.L-1.s-1 vs 4.53 +/- 1.05 cm H20.L-1.s-1, mean +/- SEM, P = 0.02) and increased genioglossus muscle activation (GGEMG peak 14.6% +/- 1.5% of maximum vs 8.6% +/- 1.5% of maximum, maximumP = 0.001) compared to baseline. The pharynx was also more collapsible at low lung volumes (4.3 +/- 0.5 cm H20 vs 5.4 +/- 0.6 cm H20, P = 0.04). Conclusions: We conclude that upper-airway muscles respond to changes in lung volumes but not adequately to prevent increased collapsibility. These results suggest that lung volume has an important influence on pharyngeal patency during non-rapid eye movement sleep in normal individuals.
Chapter
Oral appliances are an established treatment option for snoring and mild obstructive sleep apneaa-hypopnea (OSAH). Oral appliance therapy is a noninvasive, reversible approach to treatment. Oral appliances appear to work by increasing upper airway space, stabilizing the anterior position of the mandible, advancing the tongue or soft palate, or both, and possibly by changing upper airway muscle activity. Randomized, controlled trials of oral appliance therapy have shown a good efficacy in patients with mild to moderate OSAH and in some patients with more severe OSAH. In most of the studies, patients preferred the oral appliance over continuous positive airway pressure (CPAP), although CPAP was more effective in reducing the apneaa-hypopnea index (AHI).
Article
In this study, we hypothesized that anatomic abnormalities of the oropharynx, particularly narrowing of the airway by the lateral pharyngeal walls, tonsils, and tongue, would be associated with an increased likelihood for obstructive apnea among patients presenting to a sleep disorders center. To test this hypothesis, we used data from a cohort of 420 patients presenting to the Penn Center for Sleep Disorders. Associations between individual variables in the clinical evaluation model and sleep apnea as defined by a re-spiratory disturbance index greater than or equal to 15 events per hour were characterized by odds ratios (ORs) with 95% confidence intervals (CIs). Multivariable logistic regression was used to simultaneously estimate ORs for multiple variables and to control for other relevant patient characteristics. Results showed that narrowing of the airway by the lateral pharyngeal walls (OR 5 2.5; 95% CI, 1.6‐3.9) had the highest association with obstructive sleep apnea (OSA) followed by tonsillar enlargement (OR 5 2.0; 95% CI, 1.0‐3.8), enlargement of the uvula (OR 5 1.9; 95% CI, 1.2‐2.9), and tongue enlargement (OR 5 1.8; 95% CI, 1.0‐3.1). Low-lying palate, retrognathia, and overjet were not found to be significantly associated with OSA. Controlling for BMI and neck circumference, only lateral narrowing and enlargement of the tonsils maintained their significant (OR 5 2.0 and 2.6, respectively). A subgroup analysis examining differences between male and female subjects showed that no oropharyngeal risk factor achieved significance in women while lateral narrowing was the sole independent risk factor in men. These findings suggest that enlargement of the oropharyngeal soft tissue structures, particularly the lateral pharyngeal walls, is associated with an increased likelihood of OSA among patients presenting to sleep disorders centers.