Snoring is common and easy to write off as a harmless habit and something that a partner complains about, not neccesarily something about which to see a doctor.However snoring can also be the most obvious sign of obstructive sleep apnoea (OSA), a condition that affects breathing during sleep and has significant consequences for long term health if left untreated. This guide explains how doctors may distinguish between simple snoring from sleep apnoea and why that difference matters, and what the current evidence based guidelines are about treatment, from lifestyle changes through to surgery.
Why is it Important to Not Just Live with Snoring?
Snoring occurs when air struggles to move past relaxed or narrow tissue in the nose and throat causing the throat to vibrate. In many people, it is just noise, however in others this narrowing goes further causing partial,or complete blockages or obstructions of the airway during sleep. This is called obstructive sleep apnoea (OSA). OSA affects a substantial number of adults and children worldwide. If obstructive sleep apnoea is left untreated in adults, there is a high risk of high blood pressure, heart attack, stroke, heart failure, type II diabetes and driving related accidents due to drowsiness. This is why the first step for any one with significant snoring is not necessarily treatment, it should be proper assessment to assess whether sleep apnoea is present or not.
How is Sleep Apnoea Actually Diagnosed?
To diagnose sleep apnoea with certainty a sleep study is required. This can be done via an “ in laboratory”(hospital) sleep study, which is considered the gold standard and most acurate sleep study monitoring brain activity, breathing, oxygen levels and other parameters overnight.
A home sleep study which is a simplified test done in your own bed is appropriate for adults with a clear uncomplicated pattern of symptoms suggesting obstructive sleep apnoea. The guidelines specify that in clinic sleep studies rather than a home sleep studies are preferred for people with significant heart or lung disease, possible respiratory muscle weakness, suspected lower overnight breathing, hyperventilation or a history of stroke or severe insomnia since a home test is less reliable in these situations.
If a home sleep study result comes back as negative or inconclusive or technically inadequate, the guidelines recommend that a laboratory sleep study be performed rather than assuming the result is accurate.
A key take away from this is that if you snore and there is any suspicion of obstructive sleep apnoea, a formal sleep study not guesswork is the evidence based way to assess what is occurring.
Non-Surgical Treatment Options for Snoring and Sleep Apnoea
Once OSA is confirmed guidelines are clear that most people should start with non-surgical treatment before surgical intervention is considered.
Weight management. The guidelines give a strong recommendation that all overweight and obese patients diagnosed with OSA be encouraged to lose weight as excess weight is a major contributing factor to airway narrowing during sleep.
CPAP. Continuous positive airway pressure (CPAP) is a machine that gently keeps the airway open with a steady flow of air through a mask is recommended as initial first line therapy for patients diagnosed with certain levels of obstructive sleep apnoea. This is based on the strong evidence of effectiveness. CPAP is found to be more effective than oral devices such as mandibular advancement splints at improving oxygen levels during sleep and its effectiveness tends to increase with the severity of a person’s obstructive sleep apnoea. CPAP is not always easy to use long term, however there are other alternatives should a patient not cope with the use of CPAP.
Mandibular advancement splints. Are appliances for people who prefer not to use CPAP who cannot tolerate it. Mandibular advancement appliances may be useful. These are custom made mouthguard type devices that push the lower jaw forward during sleep to help open the airway. The current guidelines support the use of mandibular advancement splints although the evidence for them is not as strong as in CPAP. The most commonly reported side effects are jaw related such as jaw joint discomfort and jaw movement. These mandibular advancement splints may be fabricated by a Dentist or Orthodontist.
Positional therapy and other measures. For some patients obstructive sleep apnoea occurs mainly when sleeping on their back. Positional therapy devices or techniques that encourage sleeping on your side can be very helpful in this group of patients. It is generally considered as an adjunctive treatment rather than a primary treatment of obstructive sleep apnoea.
When is surgery considered for snoring and obstructive sleep apnoea. Surgery is not the first option in most cases of obstructive sleep apnoea in adults. There are clear guideline defined roles for surgery in selected patients. The guidelines state that adults with obstructive sleep apnoea can be referred to an ENT Surgeon for consideration of upper airway surgery if:
CPAP has not been adequately tolerated or used consistently despite appropriate attempts or for the person who prefers not to use CPAP and there is an identifiable anatomical structural abnormality in the upper airway that may be suitable for surgical correction.
Referral for weight loss is also advised ,when appropriate.
Surgical options that may be discussed depending on the individual patient include soft palate and throat procedures such as uvulopalatopharyngoplasty and related techniques to address obstruction of the level of the palate and throat. Nasal surgery to improve nasal airflow through the nose, which can help improve tolerance for CPAP and hypoglossal nerve stimulation. This is an implanted device that stimulates the nerve controlling tongue movement to keep the airway open during sleep.
Maxilla/ mandibular advancement surgery (jaw surgery). This involves repositioning of the upper and lower jaws forward to increase the airway and is usually reserved for more severe cases of obstructive sleep apnoea.
Which of these surgical options (if any) is appropriate depends entirely on where in the airway the obstruction occurs which is typically assessed with a combination of examination, fibreoptic endoscopy of the airway and sometimes further imaging or sleep endoscopy. The severity of OSA is an important guide as to the likelihood of a successful outcome postoperatively.
What this means for you, putting the guidelines together, an evidence based path through snoring and suspect sleep apnoea is:
- Assessment of snoring and any daytime tiredness, witnessed breathing pauses, gasping and morning headaches warrants a proper evaluation.
- Obtain a sleep study. Diagnosis should be based on objective testing. Polysomnography or a home based sleep study not just symptoms.
- Start with non-surgical treatment, weight management where relevant and CPAP as first line therapy with a mandibular advancement device is a well supported alternative.
- Consider surgical referral if necessary. If CPAP Is not tolerated or is not effective enough or is not preferred, and especially if there an anatomical cause that could be addressed surgically.
Frequently Asked Questions About Snoring and Sleep Apnoea
Does snoring always mean I have sleep apnoea?
No. Many people snore without having sleep apnoea, however loud frequent snoring especially combined with witnessed pauses, gasping for daytime sleepiness should be properly assessed since guidelines recommend a sleep study rather than assumptions either way.
Can a Question or App Diagnose Sleep Apnoea?
No. Current guidelines specifically recommend against relying on symptom check lists or prediction tools alone. A formal sleep study in lab or at home is needed for an accurate diagnosis.
Is CPAP the Only Treatment for Sleep Apnoea?
No. CPAP is recommended first line treatment based on strong evidence for certain levels of obstructive sleep apnoea, however mandibular advancement splints are well supported alternatives for people who prefer them, experience side effects or cannot tolerate CPAP. Surgical options may be available in adults in suitable cases.
When Would Surgery be Considered for Sleep Apnoea?
A surgical referral is generally considered when CPAP is not well tolerated or effective, when a patient prefers not to use CPAP, or when there is a specific anatomical airway problem that surgery could address.
Is Surgery Guaranteed to Fix Sleep Apnoea
Not in adults.But it is effective at reducing the severity of OSA and may cure select cases.
