Snoring

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Overview
Snoring is the vibration of respiratory structures and the resulting sound, due to obstructed air movement during breathing while sleeping. The sound may be soft or loud and unpleasant. The structures are usually the uvula and soft palate. The irregular airflow is caused by a blockage, due to causes including:
 * Throat weakness causing the throat to close during sleep
 * Mispositioned jaw, often caused by tension in muscles
 * Fat gathering in and around the throat
 * Obstruction in the nasal passageway

Statistics on snoring are often contradictory, but at least 30% of adults and perhaps as many as 50% of people in some demographics snore. One survey of 5713 Italian 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.

Snoring is usually an involuntary act, but may also be produced voluntarily.

According to Dr. William C Dement, of the Stanford Sleep Center, anyone who snores and has daytime drowsiness should be evaluated for sleep disorders.

Societal Impact
Snoring is known to cause sleep deprivation to both the snorer and those who hear him/her, as well as knock-on effects: daytime drowsiness, irritability, lack of focus, decreased libido. It has also been suggested that it can cause significant psychological and social damage to sufferers.

Armstrong et al. at the Royal Infirmary of Edinburgh found that snoring strains interpersonal relationships, and concerns for its effects were often voiced above the medical malady. Patients also lamented the social embarrassment arising from complaints when they sleep outside their homes. Both business and holiday arrangements can be detrimentally affected.

While snoring may popularly be seen in some circles as a minor affliction, snorers can suffer severe impairment of lifestyle. The between-subjects trial by Armstrong et al. discovered a statistically significant improvement in marital relations after snoring was surgically corrected. This was confirmed by evidence from Gall et al., Cartwright and Knight and Fitzpatrick et al.

Differential Diagnosis of Causes of
In alphabetical order.


 * Aging
 * Alcohol abuse
 * Allergies
 * Bronchitis
 * Decreased lung volume
 * Deviated septum
 * Enlarged adenoids
 * Enlarged tongue
 * Enlarged tonsils
 * Eustachian tube infection
 * Gigantism
 * Hyperplasia of the tonsills
 * Hypothyroidism
 * Irritant inhalation
 * Loose side walls
 * Loss of general muscle tone
 * Nerve weakness
 * Obesity
 * Sedatives
 * Sensitivity to increased Co2 levels in the blood
 * Sleep apnea
 * Sinusitis
 * Small jaw
 * Small nasal valves
 * Smoke
 * Thick and long soft palate
 * Thickening of muscles in front of spinal column
 * Tonsillitis

Diagnosis
Ordinarily, snoring is recognised by a friend or partner who observes the patient sleeping. Besides the 'noise' of snoring, more complex conditions such as sleep apnea can be consistent with the symptom of snoring. A sleep study can identify such issues. Patients can also assess their own condition to determine the likelihood of such problems based on the severity of their sleeping disorder.

Treatment
Almost all treatment for snoring revolves around clearing the blockage in the breathing passage. This is the reason snorers are advised to lose weight (to stop fat from pressing on the throat), to stop smoking (smoking weakens and clogs the throat), and to sleep on their side (to prevent the tongue from blocking the throat).

It is important, when trying to treat snoring to first identify the cause of the snoring. The treatment modality can then be specifically targeted at the identified cause of snoring in the individual case. 

Other forms of treatment are also available:

Dental appliances
Specially made dental appliances such as a mandibular advancement splint, which advance the lower jaw slightly, and thereby pull the tongue forward, are a preferred mode of treatment for social snoring. Typically, a dentist specializing in sleep apnea dentistry is consulted. Such appliances have been proven to be effective in reducing snoring and sleep apnea, however side effects include the possibility that a patient's bite could be altered. Typical costs for such appliances would be between USD1000 to USD3000.

"Do it yourself" DIY dental appliances are also available, which cost around USD50 to USD200. These provide the same benefits if fitted correctly. A guide to the commercially available DIY splints is at (Commercial website). They are usually made from an EVA polymer, and are similar in appearance to protective mouth-guards worn for sports. One disadvantage of the cheaper devices compared to the professionally fitted devices is the difficulty in setting up the correct jaw position. An over-advanced jaw results in jaw joint pain, whilst an under-advanced jaw produces no therapeutic effect. The professionally fitted devices generally incorporate an adjustment mechanism so that jaw advancement can be easily increased or decreased after fitting. To adjust the "do it yourself" appliances it is necessary to reheat them and mold them again in the desired new position. Alternatively, given the low cost, a new appliance can be used to hold the jaw in the new position.

These DIY devices can be purchased at pharmacies in most countries (except the U.S.), or online (anywhere - though not legally in U.S.). In the U.S., the devices are considered class 2 medical devices and cannot be legally sold without a prescription. The FDA (Food and Drug Administration) has never made their reasons for this decision clear. Americans are, however, allowed to purchase these devices outside the US and import them for personal use. In Australia, manufacturers can obtain approval from the TGA (Therapeutic Goods Administration) allowing the devices to be sold via normal retail channels, without the involvement of a doctor.

Possible side effects of dental appliances include Temporomandibular joint disorder (TMJD). TMJD is an inflammation of the temperomandibular joint (jaw joint) which can be very painful and is sometimes, although very rarely, irreversible. There is no reliable way of knowing whether a person is at risk for TMJ before they start using a dental appliance.

Positive airway pressure
A Continuous Positive Airway Pressure (CPAP) machine is often used to control sleep apnea and the snoring associated with it. To keep the airway open, a shoebox-sized device pumps a controlled stream of air through a flexible hose to a mask worn over the nose, mouth, or both.

Surgery
Surgery is also available to correct social snoring. Some procedures, such as uvulopalatopharyngoplasty attempt to widen the airway by removing tissues in the back of the throat including the uvula and pharynx. These surgeries are quite invasive, and there are risks of adverse side effects. The most dangerous risk is that enough scar tissue could form within the throat as a result of the incisions to make the airway more narrow than it was prior to surgery, diminishing the airspace in the velopharnyx. Scarring is an individual trait. It is difficult for a surgeon to predict how much a person might be predisposed to scarring. Some patients have reported that they developed severe sleep apnea as a result of damage to their airway caused by pharnygeal surgeries. At the present time, the American Medical Association does not approve of the use of lasers to perform operations on the pharnyx or uvula.

Radiofrequency ablation (RFA) is a relatively new surgical treatment for snoring. This treatment applies radiofrequency energy and heat (between 77ºC to 85ºC) to the soft tissue at the back of the throat, such as the soft palate and uvula, causing scarring of the tissue beneath the skin. After healing, this results in stiffening of the treated area. The procedure takes less than one hour, is usually performed on an outpatient basis, and usually requires several treatment sessions. Discomfort and pain is usually minimal. Radiofrequency ablation is frequently effective in reducing the severity of snoring, but, often does not completely eliminate snoring. 

Positioning
Snoring can be reduced by changing position on the bed; Sleeping on the side is a possible solution, to avoid rolling back it is possible to place a pillow or a "ball" on the back; raising the head is also another option, useful both while lying on the back or for supporting the head while lying on the side .

Other treatments
Devices such as nose clips can dilate the nostrils and other devices can alter jaw mechanics to keep the jaw in an optimum position. Different aids and practices may work for different people. According to the British Medical Journal, playing the didgeridoo can also help, as it increases muscle usage in the throat. . However, snoring is a recognized medical problem and people who snore should always seek professional medical advice before relying on techniques which may mask symptoms (i.e. snoring) but not treat the underlying condition.

A large number of product manufacturers and vendors offer "non-surgical" snoring treatments which are promoted as "cures" or "treatment" for snoring. Some examples include 'throat lubricants', moulded pillows, accupressure devices and herbal sprays. Such products are frequently offered for sale on the Internet and are generally attractive as their low price (and the potential for avoiding a trip to the doctor) encourage people to "have a go" and try them to see if they work. Given the complexity of snoring, in general, such 'cures' are of little benefit.

However, snoring may be helped by using the Buteyko Method as Buteyko has been shown to reduce the volume of air automatically breathed by 31% within three months of starting a course.[PMID 9887897] Since snoring is the sound of a person breathing forcefully through narrowed airways, when breathing is done with less force, as is likely to happen by using the Buteyko Method, then the snoring sound is likely to decrease.