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Managing disturbing snoring with palatal implants: a pilot study.

OBJECTIVE: To evaluate the safety and efficacy of polyethylene terephthalate implants in the soft palate to modify disturbing snoring. DESIGN: Interventional study, before-after trial. SETTING: Referral center, institutional practice, hospitalized care. PATIENTS: Twelve consecutive patients with disturbing snoring and an apnea-hypopnea index less than 15 per hour and a body mass index of 30 or less were recruited. One patient with no adverse effects was lost to follow-up. Extrusion of implants occurred in 2 patients. Complete data in 9 patients were available for analysis. INTERVENTION: Polyethylene terephthalate implants were inserted in the soft palate. MAIN OUTCOME MEASURES: Safety of the procedure and evaluation of the loudness of snoring by bed partners using a visual analog scale. RESULTS: There were no complications of infection or bleeding. Extrusion of implants occurred in 2 patients with no clinical sequelae. The mean (SD) loudness of snoring at baseline, as assessed by bed partners using a visual analog scale of 0 to 100, was 79 (17.2). This significantly decreased to 48 (20.4) at 3 months (Wilcoxon signed rank test, P =.008). Daytime sleepiness as measured with the Epworth Sleepiness Scale also decreased from an average score of 8.9 at baseline to 5.7 at 3 months (P =.007). There were no significant changes in the apnea-hypopnea index and body mass index from baseline to 3 months' follow-up. CONCLUSIONS: Polyethylene terephthalate implants in the soft palate are safe. Snoring decreased significantly at 3 months after surgery. Polyethylene terephthalate implants in the soft palate should be further explored as a treatment for snoring.

Adult↗

The effects of nasal dilation on snoring and obstructive sleep apnea.

The effects of nasal valve dilation on snoring and obstructed breathing were studied in 11 patients with habitual snoring and/or obstructive sleep apnea. The anterior part of the nose, the valve region, was dilated by means of a plastic device. Ten patients underwent polysomnographic investigation including pulse oximetry and measurement of snoring noise with and without the nasal dilator in a randomized manner. Snoring, nocturnal arousals, and daytime hypersomnolence were rated by the patient and partner on a questionnaire before and after a 10-day treatment period with the dilator. The nasal airflow, as assessed by rhinomanometry when awake in the sitting position, increased by 18% (range, 5.5% to 45%) when the nasal dilator was used. The frequency and severity of obstructed breathing decreased significantly with the nasal dilator. The apnea index with and without the nasal dilator was 6.4 (range, 1.3 to 15) and 18 (range, 1.8 to 60), respectively. The mean decrease of the apnea index was 47%. The overnight minimum arterial oxygen saturation (with and without the nasal dilator was 84% (range, 76% to 88%) and 78% (range, 68% to 89%), respectively. There was a substantial decrease in snoring noise (number of epochs with Leq values, equal energy level, above 55 or 60 dB) with the dilator in all patients who presented with snoring noise above these levels during the control night. No subjective effects on arousal frequency or daytime hypersomnolence were reported. Four of 11 patients were positive to continue using the nasal dilator.

Adult↗

Improved nasal breathing reduces snoring and morning tiredness. A 6-month follow-up study.

BACKGROUND: Dilation of the nasal valve region can increase the ability to breathe through the nose and reduce the negative intrathoracic pressure required for inspiration. Vibrations of the palate and soft tissues of the throat, which generate snoring sounds, can be prevented when patients inhale less heavily. OBJECTIVES: To evaluate the effect a nostril dilator has on patient snoring and tiredness in the morning and to determine how many patients would continue to use the device for half a year. DESIGN: For 6 months, 42 men who were heavy snorers graded their average tiredness in the morning and the patient's sleeping partner graded the average snoring using a visual analog scale from 0 to 100. SETTING: All patients were examined at the Department of Otorhinolaryngology, Central Hospital, in Skövde, Sweden. RESULTS: When the nostril dilator was used there was a significant decrease in snoring after both 1- and 6-month reports. There was a significant correlation between diminution of snoring and less tiredness in patients in the morning. The compliance was good since 60% of patients continued to use the device during the 6-month test period. CONCLUSIONS: This study illustrates the benefits that reducing nasal airway resistance during sleep has on snoring and morning tiredness in patients.

Adult↗

Reduced neurocognition in children who snore.

Obstructive sleep apnea syndrome (OSAS) has been associated with reduced neurocognitive performance in children, but the underlying etiology is unclear. The aim of this study was to evaluate the relationship between hypoxemia, respiratory arousals, and neurocognitive performance in snoring children referred for adenotonsillectomy. Thirteen snoring children who were referred for evaluation regarding the need for adenotonsillectomy to a children's hospital otolaryngology/respiratory department underwent detailed neurocognitive and polysomnographic (PSG) evaluation. PSGs were evaluated for respiratory abnormalities and compared with 13 nonsnoring control children of similar age who were studied in the same manner. The snoring children had an obstructive respiratory disturbance index within normal range (mean obstructive apnea/hypopnea index, 0.6/hr). Despite this, several domains of neurocognitive function were reduced in the snoring group. These included mean verbal IQ scores (snorers 92.6 vs. nonsnorers 110.2, P < 0.001), mean global IQ scores (snorers 96.7 vs. nonsnorers 110.2, P < 0.005), mean selective attention scores (snorers 46.4 vs. nonsnorers 11.8, P < 0.001), mean sustained attention scores (snorers 8.0 vs. nonsnorers 2.2, P = 0.001), and mean memory index (snorers 95.2 vs. nonsnorers 112.1, P = 0.001). There was a direct relationship between number of mild oxygen desaturations of > or = 3%, obstructive hypopneas with > or = 3% oxygen desaturations, and respiratory arousals and severity of neurocognitive deficits, with the greatest effect being on memory scores. The disruption of sleep in snoring children produced by relatively mild changes in oxygen saturation or by increases in respiratory arousals may have a greater effect on neurocognitive function than hitherto appreciated. A possible explanation for these neurocognitive deficits may be the combination of the chronicity of sleep disruption secondary to snoring which is occurring at a time of rapid neurological development in the first decade of life. Future studies need to confirm the reversal of these relatively mild neurocognitive decrements post adenotonsillectomy.

Analysis of Variance↗

Comparison of blood pressure measurements in children with and without habitual snoring.

Higher or similar systolic and/or diastolic blood pressure has been recorded in children with sleep apnea compared to subjects with primary snoring or in those with primary snoring compared to controls. To investigate the association between blood pressure and habitual snoring, we studied children in four randomly selected schools in central Greece. A symptom questionnaire was answered by parents, and children's weight, height, and blood pressure were measured. Seven hundred and sixty children (4-14 years old; 352 female) were recruited. Fifty of 760 (6.6%) participants were snoring more than 3 nights/week (habitual snorers). Mean (+/- SD) systolic blood pressure was 106.9 (+/-10.6) mmHg in habitual snorers vs. 107 (+/- 12) in nonhabitual snorers (P > 0.05). Mean diastolic blood pressure was 61.9 (+/- 7.6) in the former vs. 61.8 (+/- 6.8) in the latter (P > 0.05). While age, gender, and body mass index were significant predictors of systolic blood pressure in a general linear model, snoring was not. Similarly, that gender and body mass index but not snoring were significant predictors of diastolic blood pressure. In a community sample of children, habitual snorers do not have higher morning systolic or diastolic blood pressure than nonhabitual snorers.

Adolescent↗

Snoring and atherosclerotic manifestations in a 70-year-old population.

A number of studies have demonstrated an association between habitual snoring and ischemic heart disease like angina pectoris, myocardial infarction and ischemic changes on the electrocardiography (ECG). Control for the influence of potential confounders has been inadequate. To further elucidate the issue we examined the association between self-assessed snoring and the relation to atherosclerotic manifestations. 804 70-year-old males and females were classified according to snoring habits. Alcohol and tobacco consumption, blood pressure, body mass index, social group, plasma lipids (triglycerides, cholesterol, high density lipoprotein), fasting blood glucose, glucose tolerance test, plasma epinephrine and norepinephrine were determined. Presence of angina pectoris, claudication intermittens, use of nitroglycerine were questioned, a resting ECG and a distal arterial pressure by use of doppler technique in the lower limbs were determined. Distal atherosclerotic manifestations was defined as complaints of claudication intermittens, pulselessness in one or more foot arteries or a foot/arm systolic pressure ratio < 0.90. ECG changes were classified in accordance to standard criteria (Minnesota codes) into positive ECG signs (Q/OS waves, S-T depressions, T-wave inversion or flattering or left bundle branch block) and definitive myocardial infarction. Snoring showed a weak positive correlation to positive ECG signs and definitive myocardial infarction, but after adjustments for the above confounders, no association was found between snoring and atherosclerotic manifestations. We conclude that, in a 70-year-old population, self-reported snoring is not associated with atherosclerotic manifestations.

Aged↗

[Snoring as an sign of sleep disorders in 11- to 15-year-old school children--initial results of a Vienna epidemiologic study].

INTRODUCTION: The prevalence of snoring was evaluated in school children between 11 and 15 years of age. In addition to items reported by parents, children were asked to answer a questionnaire in order to receive information about the children's potential complaints, life style and school performance. METHOD: The study was performed in 21 randomly selected schools in the Vienna area. 1434 school children were interviewed by a questionnaire (mean age 12.5 years, median 13 years, 676 girls vs. 699 boys). The questionnaire consisted of 45 multiple-choice questions about the socioeconomic status, possible sleep disorders and signs or symptoms of obstructive sleep apneas (OSA). The questionnaire completed by parents was also used to calculate the Brouillette-Score from the items snoring, obstructed breaths and apneas. RESULTS: 5.2% (74/1434) of children and 6.9% (86/1259) of parents or caregivers reported about snoring (frequently or very frequently). There were no sex differences for the children's and the parents' questionnaire. None of the children had a clearly positive result (hint of OSA) from the Brouillette-Score whereas "suspicious OSA" was observed in 3.2% (40/1259). When frequent and very frequent snorers were compared with the other children, more mouth breathing during sleep (p < 0.00001), mouth dryness (p < 0.00005), headache (p < 0.0005), cigarette exposition at home (p < 0.001), smoking (p < 0.005), daytime naps (p < 0.005), crying out of sleep (p < 0.01), daytime tiredness (p < 0.05) und a higher body mass index (p < 0.05) could be observed in this group, in addition to the items reported by the parents. CONCLUSION: The prevalence of snoring is lower in our study than in other studies. No statistically significant sex differences were observed, both in the parents' and the children's questionnaire. In our study snoring seems to be a sign or symptom of different sleep disorders, and not only of OSA. A statistically significant correlation between snoring and anamnestic hints of sleep disorders underlines the need to ask concerned children themselves for observations potentially associated with sleep disorders. Results of the Brouillette-Score could not be used to identify sleep disorders in our study.

Adolescent↗

Snoring, hypertension and Type 2 diabetes in obesity. Protection by physical activity.

Sleep-related breathing disorders are recognized as major health problems in obesity. They are involved in both hypertension and Type 2 diabetes, through mechanisms possibly related to increased sympathetic tone. We studied the association of habitual snoring with diabetes, hypertension, weight cycling and physical activity in a large Italian database of treatment-seeking obese subjects. Clinical and behavioral data were assessed by standardized questionnaires. Consecutive data of 1890 obese patients were analyzed [average body mass index (BMI), 38.2 kg/m2, median age: 46 yr, 78% females], from 25 obesity Italian centers, with low prevalence of clinical manifestations of cardiovascular disease. Habitual snoring was reported in 56% of the cases, and was associated with day-time sleepiness. The prevalence increased with obesity class and waist circumference, and was positively associated with weight cycling and weight gain since the age of 20, and smoking. Regular physical activity had a protective effect. Snoring was associated with diabetes and hypertension at univariate analysis, but in multivariate analysis an independent effect was only observed for hypertension. After adjustment for age, gender and BMI, physical activity maintained an independent, protective effect on both snoring (odds ratio 0.65, 95% confidence interval 0.49-0.84; p=0.001), diabetes (0.50, 0.30-0.86; p=0.011) and hypertension (0.71, 0.53-0.95; p=0.023). We conclude that in treatment-seeking, obese subjects with low prevalence of cardiovascular disease, snoring independently increases the risk of hypertension, whereas physical activity exerts a protection on both snoring and complications. These data underline the importance of lifestyle interventions to limit the burden of obesity and associated diseases.

Adult↗

Snoring and sleep disturbance among children from an orthodontic setting.

Studies of snoring and sleep disturbance in the United States have been predominantly in clinic-based settings of children suspected to have obstructive sleep apnea hypopnea syndrome. Therefore, the purposes of this study were to utilize an orthodontic setting in which healthy children were seen regularly to study the prevalence of snoring and sleep disturbance among 405 children aged 6 to 17 years of age and to identify specific sleep behavior patterns associated with the increased odds of snoring. A sleep behavior questionnaire was administered to the child's parent or guardian. The questionnaire responses were analyzed using chi(2) analysis, and factor analysis was used to extract meaningful domains. The selected domains were used later in a logistic model to calculate the odds of snoring. The results indicated that 17% of the children habitually snored. The odds of snoring were approximately three times greater among mouth breathers and children who slept with their head tipped back and 1.5 times greater among those with morning headaches and frequent coughs and colds. In conclusion, snorers have significantly more sleep behavior problems than do non-snorers.

Adolescent↗

Habitual snoring and obstructive sleep apnea syndrome in children: effects of early tonsil surgery.

Habitual snoring and obstructive sleep apnea syndrome (OSA) in children are important in determining disturbed sleep, daytime symptoms and haemodynamic modifications. Moreover, chronic snoring is often associated with enlarged tonsils and adenoids. We studied 60 children (mean age 42.2 months) with habitual snoring, defined as a positive answer to the question 'does the child snore every night', by nocturnal or diurnal polysomnography in order to evaluate breathing disorders and choose surgical correction of upper airway stenosis. In more than half the children habitual (every night) snoring begin before the first year of life and is associated with obstructive apneas. Both nocturnal and, with some limits, diurnal recordings may be a good tool for diagnosis of sleep-related upper airway obstruction. Early adenomonotonsillectomy, in mild to moderate form and in children before 4 years of age, and adenotonsillectomy in the others seems to show a clinical and polysomnographic resolution of snoring and OSA during a short-term follow up.

Adenoidectomy↗

Snoring and risk of cardiovascular disease.

In order to evaluate the possible role played by snoring as a risk factor for cardiovascular disease, we studied 400 patients aged 30-80 years, divided into 4 groups matched for age, sex and body mass index. The first group consisted of 100 patients who snored, having risk factors (hypertension, diabetes, obesity, smoking, high serum cholesterol level) for cardiovascular disease. The second group consisted of 100 non-snoring patients with risk factors. The third and fourth groups were formed by 100 snoring and 100 non-snoring patients without risk factors. We investigated the morbidity and the mortality from cardiovascular disease over a period of five years (1982-1987). An increase in morbidity and mortality was found for snorers with risk factors (36 and 17 respectively) compared to non-snorers with risk factors (10 and 4, P less than 0.001), and also to both snorers and non-snorers without risk factors (7 and 3, P less than 0.001; 3 and 1, P less than 0.001 respectively). No difference was noted between snorers and non-snorers without risk factors. A higher morbidity and mortality for cardiovascular disease was found in snorers with risk factors as compared with non-snorers having risk factors. Furthermore, the morbidity and mortality in patients without risk factors was found to be lower compared with that found in snorers with risk factors. In conclusion, snoring worsened the prognosis of patients with risk factors for cardiovascular disease, but did not represent an independent or predictive risk factor in itself.

Adult↗

Acoustical analysis of snoring: can the probability of success be predicted?

PURPOSE: Palatal flutter snoring is the most common form of snoring. However, other types of snoring do exist. Does identifying palatal snoring beforehand translate into improved subjective treatment success with palatal stiffening procedures? METHODS: Fifty-three patients presenting with snoring were evaluated with a commercially available device. The proportion (%) and magnitude of palatal flutter (dB) were quantified. Patients then underwent a palatal stiffening procedure and subjective success/failure was assessed. RESULTS: Overall subjective treatment success was 85% (45 of 53). The percent palatal flutter was the most predictive of success (area under ROC = 0.8556, 95% CI = .7428-.9683). Patients exceeding 68% palatal flutter had a 95% (39 of 41) success rate (P = 0.001, Fisher's exact) and an adjusted odds ratio of treatment success of 25.2 (95% CI = 3.22-196, P = 0.002). CONCLUSION: Palatal stiffening treatments are successful in the majority of patients. However, identifying patients with predominant palatal flutter snoring significantly increases the probability of subjective treatment success. EBM RATING: B-2b.

Acoustics↗

Sleep complaints: snoring and daytime sleepiness in pregnant and pre-eclamptic women.

BACKGROUND AND PURPOSE: To examine whether snoring and sleepiness are linked in pregnancy and pre-eclampsia. PATIENTS AND METHODS: We recruited 167 healthy and 82 pre-eclamptic women in the third trimester of pregnancy and 160 non-pregnant women. Subjects and their partners completed a sleep questionnaire. Height, weight, neck circumferences and blood pressure were recorded for all. RESULTS: Pregnant and pre-eclamptic women were (mean +/-SD) 36+/-3.6 and 36+/-3 weeks pregnant, respectively. Age and height did not differ significantly between groups (P>0.2), but pre-eclamptic women were heavier than pregnant and non-pregnant women and had higher BMI than pregnant women before pregnancy (all P<0.05). Thirty-two percent of control, 55% of pregnant and 85% of pre-eclamptic women snored (P<0.001), but pre-pregnancy snoring rates (pre-eclamptic=36%, healthy pregnant women=27%) were similar to those in non-pregnant women (32%) (P>0.7). Sleepiness was reported by 12% of non-pregnant, 23% of pregnant and 15% of pre-eclamptic women (P<0.04), but non-pregnant women had lower mean Epworth Sleepiness scores than both pregnant and pre-eclamptic groups (P<0.001). Snoring was correlated with (P=0.002), but explained only <2%, of the variance in sleepiness. CONCLUSION: Snoring and sleepiness increased in the third trimester of pregnancy, particularly in patients with pre-eclampsia. However, the study suggests that sleepiness in pregnancy is largely due to factors other than snoring or breathing pauses.

Adult↗

[Treatment of simple snoring by radiofrequency velar coblation].

OBJECTIVES: Short- and long-term evaluation of the efficacy and safety of radiofrequency velar coblation for simple snoring. MATERIAL AND METHODS: From February 2000 to May 2004, 175 patients underwent a single radiofrequency session for velar coblation. All patients suffered from snoring without sleep apnea. They presented modifications of the velo-pharyngeal region but did not have tonsillar or basilingual hypertrophy. Outcome was assessed in terms of pain, changes in snoring, secondary effects and complications at three months and one, two, and three years. Secondary uvulectomy was performed in 28 patients. RESULTS: At three months, snoring had decreased in 82% of patients with complete resolution in 12%. Outcome remained unchanged in 70% of patients at one, two, and three years. After uvulectomy, snoring declined in 96% of patients with complete resolution in 48%. Post-treatment pain lasted less than five days in 68% of patients. Mean duration was three days. Fifteen patients developed pharyngeal paresthesia which regressed at one year. Two patients had a nasal voice and three developed necrosis of the uvula. CONCLUSION: Velar coblation is a simple treatment for snoring which can be performed in a single session. The best results are achieved in patients whose body mass index is below 25 and after secondary uvulectomy.

Adult↗

Is snoring a cause of vascular disease? An epidemiological review.

Eight studies that examined the relation between snoring and vascular disease were identified. The prevalence of habitual snoring, measured by questionnaire or interview, varied from 3% to 29% of adults and was dependent on age, sex, obesity, and smoking habit. In men, habitual snoring was associated with hypertension and ischaemic heart disease, with adjusted relative risks in the range 1.3-2.0. For women, only one study provided adjusted estimates of relative risk, which were 2.8 for hypertension and 1.2 for angina. Adequately adjusted relative risks for cerebrovascular disease have not been reported, but unadjusted estimates varied from 1.6 to 10.3. These studies had several limitations, including the lack of a standard definition of snoring, the use of unvalidated questionnaires, and failure to account for confounding variables and the possibility of reporting bias. Only one study was prospective. Epidemiological criteria for a causal association between snoring and vascular disease have not been satisfied. The apparent excess risk is probably due to the consequences of sleep apnoea rather than snoring itself.

Adult↗

Snoring, nightmares, and morning headaches in elderly women: a preliminary study.

Self-reported snoring in 37 females aged 65-94 years was assessed and the relationships between snoring and sleep characteristics, respiratory events, depression scores, sleep complaints and self-reported health problems were investigated. Sleep was recorded for two 24-h periods in the home on successive weeks, using the Home Monitoring System. Snoring was positively correlated with the frequency of nightmares and morning headaches; and nightmares and morning headaches were significantly correlated. Snoring was also significantly and positively correlated with the number of brief wakings during sleep, and was positively correlated with weight. While these relationships are ones that have previously indicated risk status, snoring was not related to respiratory events, sleep complaints, or other health problems. Snoring, nightmares and headaches each showed a significant, negative correlation with age, but this is a finding that cannot be readily interpreted from a cross-sectional study. Replication of this study with a larger sample, studied longitudinally, is required to confirm a significance of the snoring/nightmares/headaches constellation for aging women.

Age Factors↗

Snoring and risk of cardiovascular disease in women.

OBJECTIVES: To examine prospectively the association between snoring and incidence of cardiovascular disease (CVD) in women. BACKGROUND: Whether snoring increases risk of CVD remains unclear; most previous studies have been small, not prospective and limited to men. METHODS: Seventy-one thousand seven hundred seventy-nine female nurses 40 through 65 years of age and without previously diagnosed CVD or cancer at baseline in 1986 were followed up for eight years. Frequency of snoring was assessed using mailed questionnaires at baseline. RESULTS: During eight years of follow-up, we documented 1,042 incident cases of major CVD events (644 coronary heart disease [CHD] and 398 stroke). Compared with nonsnorers, the age-adjusted relative risks (RRs) of CVD were 1.46 (95% confidence interval 1.23 to 1.74) for occasional snorers and 2.02 (1.62 to 2.53) for regular snorers. The age-adjusted RRs of CHD were 1.43 (1.15 to 1.77) for occasional snorers and 2.18 (1.65 to 2.87) for regular snorers. The age-adjusted RRs of stroke were 1.60 (1.21 to 2.12) and 1.88 (1.29 to 2.74), respectively. After further adjustment for smoking, body mass index (BMI) and other covariates, the positive association between snoring and CVD was attenuated but remained statistically significant (RRs of CVD were 1.20 [1.01 to 1.43] for occasional snorers and 1.33 [1.06-1.67] for regular snorers. CONCLUSIONS: These data suggested that snoring is associated with a modest but significantly increased risk of CVD in women, independent of age, smoking, BMI and other cardiovascular risk factors. While further study is needed to elucidate the biological mechanism underlying this association, snoring may help clinicians identify individuals at higher risk for CVD.

Adult↗

Snoring assessment: do home studies and hospital studies give different results?

We have developed a device (Glan Clwyd Snore Box) suitable for the objective measurement of the loudness and duration of snoring. The device is simple for the patient to operate, portable, battery powered, and able to produce objective results. We have used the Snore Box to record the snoring at home and during sleep studies in the hospital. Twenty-nine patients were studied. Overall the Snore Index recorded in the home was greater than in the hospital (P < 0.001), the average difference being 67 snores/h. We conclude that snoring is more appropriately assessed at home than in the hospital. We suggest the deficit arises from sleeping in an unfamiliar environment and the presence of several wires connecting the patient to the recording monitor which interfere with natural sleep in the hospital setting.

Adult↗