Snoring is a sound produced by vibration of the soft tissues of the upper airway during sleep and is indicative of increased upper airway resistance. Studies estimate that 45% of men and 30% of women snore on a regular basis. It can affect not only the snorer’s sleep but also the sleep of a spouse or other family members nearby. In fact, snoring causes many couples to sleep in separate rooms and often places strain on marriages and relationships. Recent evidence suggests that snoring may even cause thickening of the carotid arteries over time and potentially increase risk of stroke.

Snoring also may be a sign of a more serious health condition known as obstructive sleep apnea (OSA), characterized by a repetitive stopping or slowing of breathing that can occur hundreds of times through the night. Most patients who snore should receive a comprehensive sleep evaluation, by a trained physician, that often includes sleep testing either done in the home or sleep laboratory.

1) Palatal stiffening procedures

  • Palatial Implants: – Palatal implant therapy, also known as the Pillar procedure, involves the placement of three polyester implants into the soft palate under local anesthesia in the office. The implants, in conjunction with the body’s scarring response, result in stiffening of the palate, and subsequently, less vibration and flutter that causes snoring. Potential benefits of this method include ease of application, minimal discomfort, fast recovery and potentially more long-term benefit. Complications are rare but include implant extrusion requiring replacement. The primary drawback for many patients considering this option is the relatively high cost of the implants.
  • Injection Snoreplasty: – In this method, also done under local anesthesia in the office, a chemical is injected into the soft palate. The subsequent inflammation and scar tissue stiffen the palate, therefore decreasing vibration and snoring. The most commonly used agent is Sodium tetradecyl sulfate which has been used in the treatment of varicose veins. Injection snoreplasty has the advantage of lower cost than other methods but is associated with more pain and recovery time. Some patients may also require additional injection treatments to achieve optimal results.
  • Radiofrequency: – Radiofrequency treatment, also an office-based procedure performed under local anesthesia, uses heat to stiffen portions of the soft palate. Multiple treatment sessions may be required to achieve the desired results. Discomfort and recovery are generally less than injection snoreplasty but more than palatal implants. Cost of radiofrequency also usually falls in between the other two options.

2) Tonsillectomy/Adenoidectomy

Enlarged tonsils and adenoids are a common cause of snoring and sleep disruption in children. The tonsils are clusters of lymphoid tissue in the back of the throat while the adenoids are a similar mound of tissue in the back of the nose. Although less commonly a problem in adults, some adults can receive excellent resolution of snoring through removal of enlarged tonsils and/or adenoids.

As opposed to the above office-based procedures, tonsillectomy/adenoidectomy is an outpatient surgery performed in the operating room under general anesthesia. Most patients require a recovery time at home of approximately one week but may continue to experience a sore throat for two weeks. The most common complication is bleeding, often occurring over a week after the surgery. Serious bleeding is rare.

3) Nasal Surgery

Increased nasal congestion has been shown to cause or contribute to snoring. Nasal obstruction may result from many causes, including allergies, polyps, septal deviation and turbinate hypertrophy. Medical treatment options, such as a nasal steroid spray or allergy management may be helpful in some patients. Structural problems, such as a deviated septum, often benefit from surgical treatment.

One surgical option, known as radiofrequency turbinate reduction (RFTR), can often be performed in the office setting under local anesthesia. RFTR uses radiofrequency heat to shrink swollen tissues in each side of the nose. Other nasal surgeries, including septoplasty and polyp removal, are usually performed in the operating room under general anesthesia. In select patients, treatment of nasal congestion can result in improvement or resolution of snoring.

What else should I know?

There are also other available treatments such as oral appliances, nasal devices, positional therapy and a variety of over-the-counter products. Careful patient and procedure selection is critical to successful management of snoring. Talk to your ear, nose and throat doctor for a complete evaluation and to learn what treatment may be best for you.

© 2016 American Academy of Otolaryngology – Head and Neck Surgery

Tonsils and adenoids are the body’s first line of defense as part of the immune system. They “sample” bacteria and viruses that enter the body through the mouth or nose, but they sometimes become infected. At times, they become more of a liability than an asset and may even cause airway obstruction or repeated bacterial infections. Your ear, nose and throat (ENT) specialist can suggest the best treatment options.

What are tonsils and adenoids?

Tonsils and adenoids are similar to the lymph nodes or “glands” found in the neck, groin and armpits. Tonsils are the two round lumps in the back of the throat. Adenoids are high in the throat behind the nose and the roof of the mouth (soft palate) and are not visible through the mouth or nose without special instruments.

What affects tonsils and adenoids?

The two most common problems affecting the tonsils and adenoids are recurrent infections of the nose and throat, and significant enlargement that causes nasal obstruction and/or breathing, swallowing and sleep problems.

Abscesses around the tonsils, chronic tonsillitis and infections of small pockets within the tonsils that produce foul-smelling white deposits can also affect the tonsils and adenoids, making them sore and swollen. Cancers of the tonsil, while uncommon, require early diagnosis and aggressive treatment.

When should I see a doctor?

You should see your doctor when you or your child experience the common symptoms of infected or enlarged tonsils or adenoids.

Your physician will ask about problems of the ear, nose and throat and examine the head and neck. He or she may use a small mirror or a flexible lighted instrument to see these areas.

Other methods used to check tonsils and adenoids are:

  • Medical history
  • Physical examination
  • Throat cultures/Strep tests – helpful in determining infections in the throat
  • X-rays – helpful in determining the size and shape of the adenoids
  • Blood tests – helpful in diagnosing infections such as mononucleosis
  • Sleep study, or polysomnogram – helpful in determining whether sleep disturbance is occurring because of large tonsils and adenoids.

Tonsillitis and its symptoms

Tonsillitis is an infection of the tonsils. One sign is swelling of the tonsils. Other symptoms are:

  • Redder than normal tonsils
  • A white or yellow coating on the tonsils
  • A slight voice change due to swelling
  • Sore throat, sometimes accompanied by ear pain
  • Uncomfortable or painful swallowing
  • Swollen lymph nodes (glands) in the neck
  • Fever
  • Bad breath

Enlarged tonsils and/or adenoids and their symptoms

If your or your child’s adenoids are enlarged, it may be hard to breathe through the nose. If the tonsils and adenoids are enlarged, breathing during sleep may be disturbed. Other signs of adenoid and or tonsil enlargement are:

  • Breathing through the mouth instead of the nose most of the time
  • Nose sounds “blocked” when the person speaks
  • Chronic runny nose
  • Noisy breathing during the day
  • Recurrent ear infections
  • Snoring at night
  • Restlessness during sleep, pauses in breathing for a few seconds at night (may indicate sleep apnea).

How are tonsil and adenoid diseases treated?

Bacterial infections of the tonsils, especially those caused by streptococcus, are first treated with antibiotics. Removal of the tonsils (tonsillectomy) and/or adenoids (adenoidectomy) may be recommended if there are recurrent infections despite antibiotic therapy, and/or difficulty breathing due to enlarged tonsils and/or adenoids. Such obstruction to breathing causes snoring and disturbed sleep that leads to daytime sleepiness, and may even cause behavioral or school performance problems in some children.

Chronic infections of the adenoids can affect other areas such as the eustachian tube – the passage between the back of the nose and the inside of the ear. This can lead to frequent ear infections and buildup of fluid in the middle ear that may cause temporary hearing loss. Studies also find that removal of the adenoids may help some children with chronic earaches accompanied by fluid in the middle ear (otitis media with effusion).

In adults, the possibility of cancer or a tumor may be another reason for removing the tonsils and adenoids. In some patients, especially those with infectious mononucleosis, severe enlargement may obstruct the airway. For those patients, treatment with steroids (e.g., prednisone) is sometimes helpful.

How to prepare for surgery

Children

  • Talk to your child about his/her feelings and provide strong reassurance and support
  • Encourage the idea that the procedure will make him/her healthier.
  • Be with your child as much as possible before and after the surgery.
  • Tell him/her to expect a sore throat after surgery, and that medicines will be used to help the soreness.
  • Reassure your child that the operation does not remove any important parts of the body, and that he/she will not look any different afterward.
  • It may be helpful to talk about the surgery with a friend who has had a tonsillectomy or adenoidectomy.
  • Your otolaryngologist can answer questions about the surgical procedure.

Adults and children

For at least two weeks before any surgery, the patient should refrain from taking aspirin or other medications containing aspirin. (WARNING: Children should never be given aspirin because of the risk of developing Reye’s syndrome). Your doctor may ask to you to stop taking other medications that may interfere with clotting.

  • Tell your surgeon if the patient or patient’s family has had any problems with anesthesia or clotting of blood. If the patient is taking medications, has sickle cell anemia, has a bleeding disorder, is pregnant, or has concerns about the transfusion of blood, the surgeon should be informed.
  • A blood test may be required prior to surgery.
  • •A visit to the primary care doctor may be needed to make sure the patient is in good health at surgery.
  • You will be given specific instructions on when to stop eating food and drinking liquids before surgery. These instructions are extremely important, as anything in the stomach may be vomited when anesthesia is induced.

When the patient arrives at the hospital or surgery center, the anesthesiologist and nursing staff may meet with the patient and family to review the patient’s history. The patient will then be taken to the operating room and given an anesthetic. Intravenous fluids are usually given during and after surgery.

After the operation, the patient will be taken to the recovery area. Recovery room staff will observe the patient closely until discharge. Every patient is unique, and recovery time may vary.

Your ENT specialist will provide you with the details of pre-operative and post-operative care and answer your questions.

After surgery

There are several post-operative problems that may arise. These include swallowing problems, vomiting, fever, throat pain and ear pain. Occasionally, bleeding from the mouth or nose may occur after surgery. If the patient has any bleeding, your surgeon should be notified immediately. It is also important to drink liquids after surgery to avoid dehydration.

Any questions or concerns you have should be discussed openly with your surgeon.

© 2016 American Academy of Otolaryngology – Head and Neck Surgery

Obstructive sleep apnea (OSA) is a serious health condition characterized by a repetitive stopping or slowing of breathing that can occur hundreds of times during the night. This often leads to poor quality sleep and excessive daytime sleepiness. Risks of untreated sleep apnea include high blood pressure, stroke, heart disease and motor vehicle accidents. It is estimated that 1 in 5 Americans have at least mild OSA.

A variety of surgical and non-surgical options are available for the treatment of snoring and sleep apnea. Medical options include positive pressure (i.e. CPAP), oral appliances and weight loss. Many of these treatment options depend on regular, long-term adherence to be effective. In patients having difficulty with other treatments, surgical procedures for the nose and throat can be a beneficial alternative. Surgical therapy can also be effective when used as an adjunct to improve tolerance and success with CPAP or an oral appliance.

Surgical Treatments

Nose

Increased nasal congestion has been shown to cause or contribute to snoring, disrupted sleep and even sleep apnea. It is also a leading cause of failure of medical treatments for OSA, such as CPAP or an oral appliance. Nasal obstruction may result from many causes including allergies, polyps, deviated septum, enlarged adenoids and enlarged turbinates.

Medical treatment options, such as a nasal steroid spray or allergy management, may be helpful in some patients. Structural problems, such as a deviated septum, often benefit from surgical treatment. One surgical option, known as radiofrequency turbinate reduction (RFTR), can be performed in the office under local anesthesia. RFTR uses radiofrequency to shrink swollen tissues in each side of the nose.

Upper throat (palate, tonsils, uvula)

In many patients with OSA, airway narrowing and collapse occurs in the area of the soft palate (back part of the roof of the mouth), tonsils and uvula. The specific type and combination of procedures that are indicated depend on each individual’s unique anatomy and pattern of collapse. Therefore the procedure selection and surgical plan must be customized to each patient. In general, these procedures aim to enlarge and stabilize the airway in the upper portion of the throat.

The surgery is performed in an operating room under general anesthesia, either as an outpatient or with an overnight hospital stay. The recovery varies depending on the patient and the specific procedures performed. Many patients return to school/work in approximately one week and return to normal diet and activity at two weeks. Throat discomfort, particularly with swallowing, is common in the first two weeks and usually managed with medications for pain and inflammation. Risks include bleeding, swallowing problems and anesthesia complications, although serious complications are uncommon.

The tonsils and adenoids may be the sole cause of snoring and sleep apnea in some patients, particularly children. In children and in select adults with OSA and enlarged tonsils/adenoids, tonsillectomy/adenoidectomy alone can provide excellent resolution of snoring, sleep apnea and associated symptoms.

Lower throat (back of tongue and upper part of voice box)

The lower part of the throat is also a common area of airway collapse in patients with OSA. The tongue base may be larger than normal, especially in obese patients, contributing to blockage in this area. The tongue may also collapse backward during sleep as the muscles of the throat relax, particularly when some patients sleep on their back. The epiglottis, or upper part of the voice box, may also collapse and contribute to airway obstruction.

Multiple procedures are available to reduce the size of the tongue base or advance it forward out of the airway. Other procedures aim to advance and stabilize the hyoid bone which is connected to the tongue base and epiglottis. A more recent technology involves implantation of a pacemaker for the tongue (“hypoglossal nerve stimulator”) which stimulates forward contraction of the tongue during sleep. As with palatal surgery, the most appropriate type of procedure varies from one individual to another, and is primarily determined by each patient’s anatomy and pattern of obstruction.

The procedures are done under general anesthesia, often with overnight hospital observation. Recovery and risks vary depending on the procedure(s) performed, but are generally similar to procedures in the upper throat.

Skeletal procedures

For the most part, the above procedures involve surgical enlargement and stabilization inside the airway. For some patients, particularly those with developmental or structural changes of the jaw or other facial bones, surgical or orthodontic procedures on the bones of the face, jaw or hard palate (roof of the mouth) may be beneficial.

Orthodontic procedures to widen the palate (palatal or maxillary expansion) may be useful treatment options in some pediatric patients. Maxillomandibular advancement surgery includes a number of procedures designed to move the upper jaw (maxilla) and/or lower jaw (mandible) forward, thus opening the upper and/or lower airway, respectively. Although full maxillomandibular advancement surgery can provide effective enlargement and stabilization of the airway, the potential benefits must be cautiously weighed against the potential increased risks of complications, longer recovery and changes in the cosmetic appearance of the face.

What should I know before considering surgery?

Surgery is an effective and safe treatment option for many patients with snoring and sleep apnea, particularly those who are unable to use or tolerate CPAP. Proper patient and procedure selection is critical to successful surgical management of obstructive sleep apnea. Talk to your ear, nose and throat doctor for a complete evaluation and to learn what treatment may be best for you.

© 2016 American Academy of Otolaryngology – Head and Neck Surgery

Overview of Sleep Disordered Breathing

Sleep-disordered breathing (SDB) is a general term for breathing difficulties occurring during sleep. SDB can range from frequent loud snoring to Obstructive Sleep Apnea (OSA) a condition involving repeated episodes of partial or complete blockage of the airway during sleep. When a child’s breathing is disrupted during sleep, the body perceives this as a choking phenomenon. The heart rate slows, blood pressure rises, the brain is aroused and sleep is disrupted. Oxygen levels in the blood can also drop.

Approximately 10 percent of children snore regularly and about 2-4 % of the pediatric population has OSA. Recent studies indicate that mild SDB or snoring may cause many of the same problems as OSA in children.

Could my child have Obstructive Sleep Apnea?

The most obvious symptom of sleep disordered breathing is loud snoring that is present on most nights. The snoring can be interrupted by complete blockage of breathing with gasping and snorting noises and associated with awakenings from sleep. Due to a lack of good quality sleep, a child with sleep disordered breathing may be irritable, sleepy during the day or have difficulty concentrating in school. Busy or hyperactive behavior may also be observed. Bed-wetting is also frequently seen in children with sleep apnea.

A common physical cause of airway narrowing contributing to SDB is enlarged tonsils and adenoids. Overweight children are at increased risk for SDB because fat deposits around the neck and throat can also narrow the airway. Children with abnormalities involving the lower jaw or tongue or neuromuscular deficits such or cerebral palsy have a higher risk of developing sleep disordered breathing.

Potential consequences of untreated pediatric sleep disordered breathing

  • Social: Loud snoring can become a significant social problem if a child shares a room with siblings or at sleepovers and summer camp.
  • Behavior and learning: Children with SDB may become moody, inattentive and disruptive both at home and at school. Sleep disordered breathing can also be a contributing factor to attention deficit disorders in some children.
  • Enuresis: SDB can cause increased nighttime urine production, which may lead to bedwetting.
  • Growth: Children with SDB may not produce enough growth hormone, resulting in abnormally slow growth and development.
  • Obesity: SBD may cause the body to have increased resistance to insulin or daytime fatigue with decreases in physical activity. These factors can contribute to obesity.
  • Cardiovascular: OSA can be associated with an increased risk of high blood pressure or other heart and lung problems.

How is sleep apnea diagnosed?

Sleep disordered breathing in children should be considered if frequent loud snoring, gasping, snorting and thrashing in bed or unexplained bedwetting is observed. Behavioral symptoms can include changes in mood, misbehavior and poor school performance. Not every child with academic or behavioral issues will have SDB, but if a child snores loudly on a regular basis and is experiencing mood, behavior or school performance problems, sleep disordered breathing should be considered. If you notice that your child has any of those symptoms, have them checked by an otolaryngologist (ear, nose and throat doctor). Sometimes physicians will make a diagnosis of sleep disordered breathing based on history and physical examination. In other cases, such as in children suspected of having severe OSA due to craniofacial syndromes, morbid obesity or neuromuscular disorders or for children less than 3 years of age, additional testing such as a sleep test may be recommended.

The sleep study or polysomnography (PSG) is an objective test for sleep disordered breathing. Wires are attached to the head and body to monitor brain waves, muscle tension, eye movement, breathing and the level of oxygen in the blood. The test is not painful and is generally performed in a sleep laboratory or hospital. Sleep tests can occasionally produce inaccurate results, especially in children. Borderline or normal sleep test results may still result in a diagnosis of SDB based on parental observations and clinical evaluation.

Treatment for sleep disordered breathing

Enlarged tonsils and adenoids are a common cause for SDB. Surgical removal of the tonsils and adenoids (T&A) is generally considered the first line treatment for pediatric sleep disordered breathing if the symptoms are significant and the tonsils and adenoids are enlarged. Of the over 500,000 pediatric T&A procedures performed in the U.S. each year, the majority are currently being done to treat sleep disordered breathing. Many children with sleep apnea show both short and long-term improvement in their sleep and behavior after T&A.

Not every child with snoring should undergo T&A as the procedure does have risks. Potential problems can include anesthesia or airway complications, bleeding, infection and problems with speech and swallowing. If the SDB symptoms are mild or intermittent, academic performance and behavior is not an issue, the tonsils are small, or the child is near puberty (tonsils and adenoids often shrink at puberty), it may be recommended that a child with SDB be watched conservatively and treated surgically only if symptoms worsen.

Recent studies have shown that some children have persistent sleep disordered breathing after T&A. A post-operative PSG may be necessary after surgical intervention, especially in children with persistent symptoms or increased risk factors for persistent apnea after T&A such as obesity, craniofacial anomalies or neuromuscular problems. Additional treatments such as weight loss, the use of Continuous Positive Airway Pressure (CPAP) or additional surgical procedures may sometimes be required.

© 2016 American Academy of Otolaryngology – Head and Neck Surgery

Today in the United States, studies estimate that 34% of U.S. adults are overweight and an additional 31% (approximately 60 million) are obese. Combined, approximately 127 million Americans are overweight or obese. Some 42 years ago, 13% of Americans were obese, and in 1980 15% were considered obese.

Alarmingly, the number of children who are overweight or obese has doubled in the last two decades as well. Currently, more than 15% of 6- to 11-year-olds and more than 15% of 12- to 19-year-olds are considered overweight or obese.

What is the difference between designated “obese” versus “overweight”?

Unfortunately, the words overweight and obese are often interchanged. There is a difference:

  • Overweight: Anyone with a body mass index (BMI) (a ratio between your height and weight) of 25 or above (e.g., someone who is 5-foot-4 and 145 pounds) is considered overweight.
  • Obesity: Anyone with a BMI of 30 or above (e.g., someone who is 5-foot-4 and 175 pounds) is considered obese.
  • Morbid obesity: Anyone with a BMI of 40 or above (e.g., someone who is 5-foot-4 and 233 pounds) is considered morbidly obese. “Morbid” is a medical term indicating that the risk of obesity related illness is increased dramatically at this degree of obesity.

Obesity can present significant health risks to the young child. Diseases are being seen in obese children that were once thought to be adult diseases. Many experts in the study of children’s health suggest that a dysfunctional metabolism, or failure of the body to change food calories to energy, precedes the onset of disease. Consequently, these children are at risk for Type II diabetes, fatty liver, elevated cholesterol, SCFE (a major hip disorder), menstrual irregularities, sleep apnea and irregular metabolism. Additionally, there are psychological consequences; obese children are subject to depression, loss of self-esteem and isolation from their peers.

Pediatric obesity and otolaryngic problems

Otolaryngologists, or ear, nose and throat specialists, diagnose and treat some of the most common children’s disorders. They also treat ear, nose and throat conditions that are common in obese children, such as:

Sleep apnea

Children with sleep apnea literally stop breathing repeatedly during their sleep, often for a minute or longer, usually ten to 60 times during a single night. Sleep apnea can be caused by either complete obstruction of the airway (obstructive apnea) or partial obstruction (obstructive hypopnea – or slow, shallow breathing), both of which can wake one up. There are three types of sleep apnea – obstructive, central and mixed. Of these, obstructive sleep apnea (OSA) is the most common. Otolaryngologists have pioneered the treatment for sleep apnea; research shows that one to three percent of children have this disorder, often between the age of two-to-five years old.

Enlarged tonsils, which block the airway, are usually the key factor leading to this condition. Extra weight in obese children and adults can also interfere with the ability of the chest and abdomen to fully expand during breathing, hindering the intake of air and increasing the risk of sleep apnea.

The American Academy of Pediatrics has identified obstructive sleep apnea syndrome (OSAS) as a common condition in childhood that results in severe complications if left untreated. Among the potential consequences of untreated pediatric sleep apnea are growth failure; learning, attention, and behavior problems; and cardio-vascular complications. Because sleep apnea is rarely diagnosed, pediatricians now recommend that all children be regularly screened for snoring.

Middle ear infections

Acute otitis media (AOM) and chronic ear infections account for 15 to 30 million visits to the doctor each year in the U.S. In fact, ear infections are the most common reason why an American child sees a doctor. Furthermore, the incidence of AOM has been rising over the past decades. Although there is no proven medical link between middle ear infections and pediatric obesity there may be a behavioral association between the two conditions. Some studies have found that when a child is rubbing or massaging the infected ear the parent often responds by offering the child food or snacks for comfort.

When a child does have an ear infection the first line of treatment is often a regimen of antibiotics. When antibiotics are not effective, the ear, nose and throat specialist might recommend a bilateral myringotomy with pressure equalizing tube placement (BMT), a minor surgical procedure. This surgery involves the placement of small tubes in the eardrum of both ears. The benefit is to drain the fluid buildup behind the eardrum and to keep the pressure in the ear the same as it is in the exterior of the ear. This will reduce the chances of any new infections and may correct any hearing loss caused by the fluid buildup.

Postoperative vomiting (POV) is a common problem after bilateral myringotomy surgery. The overall incidence is 35 percent, and usually occurs on the first postoperative day, but can occur up to seven days later. Several factors are known to affect the incidence of POV, including age, type of surgery, postoperative care, medications, co-existing diseases, past history of POV, and anesthetic management. Obesity, gastroparesis, female gender, motion sickness, pre-op anxiety, opioid analgesics and the duration of anesthetic all increase the incidence of POV. POV interferes with oral medication and intake, delays return to normal activity and increases length of hospital stay. It remains one of the most common causes of unplanned postoperative hospital admissions.

Tonsillectomies

A child’s tonsils are removed because they are either chronically infected or, as in most cases, enlarged, leading to obstructive sleep apnea. There are several surgical procedures utilized by ear, nose and throat specialists to remove the tonsils, ranging from use of a scalpel to a wand that emits energy that shrinks the tonsils.

Research conducted by otolaryngologists found that morbid obesity was a contributing factor for requiring an overnight hospital admission for a child undergoing removal of enlarged tonsils. Most children who were diagnosed as obese with sleep apnea required a next-day physician follow-up.

A study from the University of Texas found that morbidly obese patients have a significant increase of additional medical disorders following tonsillectomy and adenoidectomy for obstructive sleep apnea or sleep-disordered breathing when compared to moderately obese or overweight patients undergoing this procedure for the same diagnosis. On average they have longer hospital stays, a greater need for intensive care and a higher incidence of the need for apnea treatment of continuous positive airway pressure upon discharge from the hospital. The study found that although the morbidly obese group had a greater degree of sleep apnea, they did benefit from the procedure in regards to snoring, apneic spells and daytime somnolence.

What you can do

If your child has a weight problem, contract your pediatrician or family physician to discuss the weight’s effect on your child’s health, especially prior to treatment decisions. Second, ask your physician about lifestyle and diet changes that will reduce your child’s weight to a healthy standard.

© 2016 American Academy of Otolaryngology – Head and Neck Surgery

Insight into sleeping disorders and sleep apnea

Forty-five percent of normal adults snore at least occasionally and 25 percent are habitual snorers. Problem snoring is more frequent in males and overweight people and usually worsens with age. Snoring may be an indication of obstructed breathing and should not be taken lightly. An otolaryngologist can help you to determine where the anatomic source of your snoring may be, and offer solutions for this noisy and often embarrassing behavior.

What causes snoring?

The noisy sounds of snoring occur when there is an obstruction to the free flow of air through the passages at the back of the mouth and nose. This area is the collapsible part of the airway where the tongue and upper throat meet the soft palate and uvula. Snoring occurs when these structures strike each other and vibrate during breathing.

In children, snoring may be a sign of problems with the tonsils and adenoids. A chronically snoring child should be examined by an otolaryngologist, who may recommend a tonsillectomy and adenoidectomy to return the child to full health.

People who snore may suffer from:

  • Poor muscle tone in the tongue and throat: When muscles are too relaxed, the tongue falls backwards into the airway or the throat muscles draw in from the sides into the airway. Some relaxation is natural during deep sleep, but may become a problem if exacerbated by alcohol or drugs that cause sleepiness
  • Excessive bulkiness of throat tissue: Children with large tonsils and adenoids often snore. Overweight people may have excess soft tissue in the neck that can lead to airway narrowing. Cysts or tumors are rare causes of airway narrowing.
  • Long soft palate and/or uvula: A long palate narrows the opening from the nose into the throat. The excessive length of the soft palate and/or uvula acts as a noisy flutter valve during relaxed breathing.
  • Obstructed nasal airways: A stuffy or blocked nose requires extra effort to pull air through it. This creates an exaggerated vacuum in the throat that pulls together the floppy tissues of the throat, and snoring results. So snoring may only occur during the hay fever season or with a cold or sinus infection. Also, deformities of the nose or nasal septum, such as a deviated septum (a deformity of the wall that separates one nostril from the other) can cause such an obstruction.

Why is snoring serious?

Socially
Snoring can make the snorer an object of ridicule and can cause the bed partner to experience sleepless nights and fatigue.

Medically
It disturbs sleeping patterns and deprives the snorer of adequate rest. It may be a sign of obstructive sleep apnea (OSA), which can lead to serious, long-term health problems.

What is obstructive sleep apnea?

Snoring may be a sign of a more serious condition known as obstructive sleep apnea (OSA). OSA is characterized by multiple episodes of breathing pauses greater than 10 seconds at a time, due to upper airway narrowing or collapse. This results in lower amounts of oxygen in the blood, which causes the heart to work harder. It also causes disruption of the natural sleep cycle, which makes people feel poorly rested despite adequate time in bed. Apnea patients may experience 30 to 300 such events per night.

The immediate effect of sleep apnea is that the snorer must sleep lightly and keep the throat muscles tense in order to keep airflow to the lungs. Because the snorer does not get a good rest, he or she may be sleepy during the day, which impairs job performance and makes him or her a hazardous driver or equipment operator. Untreated obstructive sleep apnea increases the risk of developing heart attacks, strokes, diabetes and many other medical problems.

How is heavy snoring evaluated?

Heavy snorers should seek medical advice to ensure that sleep apnea is not a problem. Heavy snorers include people who snore constantly in any position or who negatively impact a bed partner’s sleep. An otolaryngologist will provide a thorough examination of the nose, mouth, throat, palate and neck, often using a fiberoptic scope. An examination can reveal if the snoring is caused by nasal allergy, infection, nasal obstruction or enlargement of tonsils and adenoids. A sleep study in a laboratory or at home may be necessary to determine if snoring is due to OSA.

All snorers with any of the following symptoms should be evaluated for possible obstructive sleep apnea:

  • Witnessed episodes of breath pauses or apnea during sleep
  • Daytime sleepiness or fatigue
  • High blood pressure
  • Heart disease
  • History of a stroke

What treatments are available?

Treatment depends on the diagnosis and level(s) of upper airway narrowing. In some cases, more than one area may be involved.

Snoring or OSA may respond to various treatments offered by many otolaryngologist – head and neck surgeons:

  • Obstructive sleep apnea is most often treated with a device that opens the airway with a small amount of positive pressure. This pressure is delivered via a nasal mask worn during sleep. This treatment is called CPAP; it is currently the initial treatment of choice for patients with OSA.
  • Uvulopalatopharyngoplasty (UPPP) is surgery for treating snoring and obstructive sleep apnea. It removes excess soft palate tissue and opens the airway. In addition, the remaining tissue stiffens as it heals, thereby minimizing tissue vibration. The size of the air passage may be further enlarged when a tonsillectomy is added to the procedure.
  • Thermal ablation procedures reduce tissue bulk in the nasal turbinates, tongue base and/or soft palate. These procedures are used for both snoring and OSA. Different methods of thermal ablation include bipolar cautery, laser and radiofrequency. These procedures may be done in the operating room or during an office visit. Several treatments may be required.
  • Methods to increase the stiffness of the soft palate without removing tissue include injecting an irritating substance that causes stiffness in the injected area near the uvula. Another method is inserting stiffening rods (Pillar implants) into the soft palate.
  • Genioglossus and hyoid advancement is a surgical procedure for the treatment of sleep apnea. It prevents collapse of the lower throat and pulls the tongue muscles forward, thereby opening the obstructed airway.
  • A custom-fit oral appliance, which repositions the lower jaw forward, may also be considered for certain patients with snoring/ OSA. This should be fitted by an otolaryngologist, dentist or oral surgeon with expertise in sleep dentistry.
  • In some patients, significant weight loss can also improve snoring and OSA.

Do you recommend the use of over-the-counter devices?

There is no specific device recommended. More than 300 devices are registered in the U.S. Patent and Trademark Office as cures for snoring. Different methods include products that help a person avoid sleeping on their back, since snoring is often worse in that position. Some devices open nasal air passages; others have been designed to condition a person not to snore by producing unpleasant stimuli when snoring occurs. While a person may find a product that works for him or her, underlying poor sleep quality may remain.

Self-help for the light snorer

Adults who suffer from mild or occasional snoring should try the following self-help remedies:

  • Adopt a healthy and athletic lifestyle to develop good muscle tone and lose weight.
  • Avoid tranquilizers, sleeping pills and antihistamines before bedtime.
  • Avoid alcohol for at least four hours and heavy meals or snacks for three hours before retiring.
  • Establish regular sleeping patterns.
  • Sleep on your side rather than your back.
  • Elevate the head of your bed four inches.

© 2016 American Academy of Otolaryngology – Head and Neck Surgery