What is snoring and sleep apnea in the first place?

Snoring is more than just an irritating or funny problem.

Put simply, snoring is the noise produced by tissue that vibrates against the walls of the throat during sleep. The usual noise maker is the palate (roof of the mouth) and the uvula (the little flipper thing that hangs down from the end of the palate). Any tissue in the throat that is too long, thick, or floppy can cause the problem, however. The specific causes of this noise and the parts of the airway that can contribute to the problem are discussed in more detail elsewhere on this website.

It is important to know, however, that snoring is sometimes not only disruptive or annoying, but may also be a symptom of a more serious problem, called obstructive sleep apnea syndrome, or OSAS. This potentially dangerous problem occurs when the thick or floppy throat tissue not only vibrates against the walls of the throat, but also blocks off the throat repeatedly during sleep. These periods of blockage, called apnea, interfere with the depth and quality of sleep, and can lead to serious consequences. These include severe tiredness, heart and blood pressure problems, and others.

Sleep apnea can therefore be looked at as sort of an extreme form of snoring. This problem can worsen with age, weight gain, or hormonal changes. For example, many people with the problem relate a history of what started out as just occasional snoring at first; over a number of years this progressed to nightly, real annoying snoring, and later became frank sleep apnea. This change can be gradual and subtle. Since the change is not sudden, most people aren’t aware of how the condition has changed.

Rest assured (pun intended), however, that no matter how irritating or severe the problem is, it can be taken care of.

How common is this problem? Am I alone out there?

You are definitely not alone.

Everyone knows that snoring is a common problem, but you might be surprised to find out just how prevalent it is. Approximately 5% of females and 20% of males snore by age 25, and 40% of females and 60% of males snore by age 40. What is not as well known is that it doesn’t just have to be tolerated, but can also be treated quite effectively. New techniques are available which can reduce or eliminate simple snoring in the majority of people, and which generally often can be done under local anesthesia in the office.

So how common is sleep apnea? About as common as asthma in the adult population. Surprised? The prevalence of sleep apnea is estimated to be 9% for women and 24% for men between the ages of 30 and 60. Approximately 4% of men and 2% of women in that age range have full-blown obstructive sleep apnea syndrome with significant daytime sleepiness. It becomes even more common with aging, with 28-67% of elderly men and 20-54% of elderly women affected by sleep apnea. Recent studies have projected that between 7-18 million people in the US suffer from sleep apnea; 1.8-4 million of these have 15 or more obstructive breathing events every hour of sleep.

Definitions and terminology

Before continuing with our discussion, it is important to define a few common medical terms that may be referred to on this website:

q Polysomnogram (PSG): also known as a sleep study. An overnight evaluation during which you are hooked up to a variety of monitors during sleep. The gold standard PSG is performed in a sleep laboratory and is attended by a technologist who monitors the study continuously. This full PSG includes measurement of brain waves and eye movements through the closed eyelids to measure the depth of sleep, breathing effort, airflow, limb movements, oxygen levels, and other information. There are also a number of less involved or limited sleep studies that are used in some instances. For more information on sleep studies, click here.

q Apnea: lack of breathing for at least 10 seconds.

q Hypopnea: very shallow breathing for at least 10 seconds. Not quite apnea, as there is still some airflow, but the effects on the body are thought to be the same as if it were apnea.

q Respiratory Disturbance Index (RDI): the average number of apneas and hypopneas that occur during each hour of sleep, as determined during the sleep study.

q EDS: Excessive daytime somnolence

q OSA: Obstructive sleep apnea syndrome. The minimal criterion is an RDI >5. Therefore, up to five obstructions per hour of sleep is considered normal and not a cause for concern.

q OSAS: Obstructive Sleep Apnea Syndrome. The full-blown syndrome of OSAS with EDS.

q Pharynx: The throat, where all the action is.

So I make a little noise when I sleep. What’s the big deal?

It certainly must be a big problem to your bed partner, or you probably wouldn’t be wasting your time reading this in the first place! But even more importantly, you need to realize that it is also potentially a big deal to your body.

Sleep apnea is now recognized as a significant health problem, which can contribute to a variety of health problems, even death. Even relatively mild to moderate cases of sleep-disordered breathing may be associated with serious consequences, including strokes, heart attacks, angina (heart-related chest pain), heart rhythm disturbances, and high blood pressure. Read on for more details regarding these risks.

Effects on heart, blood pressure, and stroke risk

It is admittedly difficult to prove the exact relationship between sleep apnea and heart attack, stroke, and hypertension in any given person, especially since many people with sleep apnea also have other risk factors for them, such as smoking and obesity. In addition, a number of studies implicating sleep apnea have been criticized for having too few subjects or too short of follow-up, or inconsistent reporting methods.

Nevertheless, a number of good studies have demonstrated some sobering relationships. For example, sleep apneics have been found to have twice the prevalence of high blood pressure, three times the presence of coronary artery disease, and four times the incidence of stroke than does the rest of the U.S. population. Furthermore, significant snoring alone, even in the absence of sleep apnea, may be a health risk by itself. One such study concluded that snorers have four times the risk of heart attacks as nonsnorers, independent of weight or smoking.

These types of data suggest that sleep apnea can be deadly. Just how deadly it can be has been suggested by two other widely quoted studies. One of these studies followed almost 400 sleep apnea patients for eight years, and found that untreated apneics with more than 20 obstructive breathing events per hour of sleep had a death rate five times higher than untreated apneics with less than 20 events per hour. None of the patients who were adequately treated (with tracheostomy or nasal continuous positive airway pressure, or CPAP) died. Similar conclusions were reached other researchers who or five years followed 198 patients with sleep apnea, all of whom were treated conservatively—only by a regimen of weight loss. Eleven percent of the patients died, as compared to none in the comparison group who had tracheostomies, even though the patients with trachs had more severe apnea.

These relationships are being actively researched so that we can understand the link between sleep disordered breathing and health risks. One such project is the Sleep Heart Health Study. This extensive multicenter, multiyear study of the health risks and death rates of sleep apneics will be reported early in the year 2000, and will hopefully clarify the situation. Check this website periodically for updates, as Dr. Huntley will summarize this and other studies, as the results become available.

Effects of sleep deprivation

In addition to these major health problems, sleep apnea can also affect your quality of life in other ways, by causing morning headaches, memory loss, mood swings, and personality changes. Sleep apnea can lead to depression, impotence, disrupted sleep, and fatigue, and disruption of professional, family and social life.

One of the most frequent complaints made by people with sleep apnea is severe daytime sleepiness. This can include decreased concentration ability that results from the disrupted and fragmented sleep caused by the repeated episodes of airway collapse.

This sleepiness is not only bothersome, but can be extremely dangerous. Safety authorities are currently focusing on sleepiness as a significant cause of industrial and mass transportation accidents. For instance, it has been shown that people with sleep apnea have approximately seven times more automobile accidents than does the rest of the population. A landmark report reported in October of 1999 further documented just how much sleep apnea can seriously interfere with a person’s ability to function normally. In this study, it was found that people with even moderate levels of sleep apnea have reaction times as impaired as if their blood alcohol content was 0.08%, the legal limit in a number of states. In other words, a person with sleep apnea is likely to be so tired that he or she is as dangerous behind the steering wheel as a drunk driver is!

Because of the significance of this common problem, it is important for anyone with severe snoring to be thoroughly evaluated. It is hoped that this website is helpful in providing useful information regarding the workup and treatment of this health problem. It was written from the perspective of a physician with subspecialty training in the treatment of snoring and OSAS.

What therefore follows is a discussion of the prevalence of snoring and OSAS, its causes, consequences, risk factors, workup, and treatment—both medical and surgical. Please do not hesitate to contact Dr. Huntley for further information.

Where’s the noise coming from, anyway?

Snoring is a noise produced by the vibration of floppy tissues in a narrowed upper airway. The usual source is the palate, or the roof of the mouth. The typical frequency of snoring is in the 400-2000 hertz range, and it can frequently be as loud as 60-70 decibels. Note that the Occupational Safety and Health Administration (OSHA) recommends ear protection for continuous exposure to 70 dB or more for 7 hours!

Snoring implies that there is partial airway collapse during sleep, and the noise is produced by turbulent airflow with vibration of the soft palate (floppy part of the roof of the mouth), uvula (the little thing that dangles from the back of the soft palate), and tonsil regions. This obstruction can be worsened when snoring has gone untreated for a long time, as the resultant mechanical trauma causes swelling of the uvula and the development of thickened, floppy folds of tissue along the back wall of the throat. Nasal obstruction can also contribute to the problem.

Obstructive sleep apnea results when this partial airway obstruction becomes more complete. This airway narrowing can result from anywhere along the throat, and usually occurs at multiple levels, including the:

q Palate, uvula and /or tonsils

q Tongue base (the vertical portion of the tongue far down in the throat)

q Nose, including the septum (wall separating the nasal cavities), turbinates (shelf-like structures on the side walls of the nasal cavities that help direct the airflow), or nasal valves (nostril regions)

q Larynx (voice box); e.g., vocal cord paralysis, tumors, etc. (a very rare cause)

The most common sites of obstruction in patients with sleep apnea are the palate and tongue base levels. More details about these areas are presented elsewhere on this website.