What are snoring and sleep apnea, and how common are they?
Snoring is the sound produced when the soft tissues of the upper airway (the soft palate, uvula, tongue base and throat walls) vibrate with the airflow during sleep. It is very common in the population, occurring at least occasionally in a large proportion of adults, and it becomes more frequent with age. Simple snoring is snoring that occurs without pauses in breathing during sleep and is generally considered harmless to health.
Obstructive sleep apnea, however, is a different clinical picture: during sleep the upper airway repeatedly closes partially or completely, causing breathing to stop temporarily (apnea) or to decrease markedly (hypopnea). It is a common health problem that affects a significant proportion of the adult population and often goes undiagnosed and untreated. It becomes markedly more common in middle-aged men, in people who are overweight and in people with a large neck circumference.
What are the symptoms?
In simple snoring, the main complaint is regular, disturbing snoring noticed by the bed partner; excessive daytime sleepiness or pauses in breathing are usually absent. In obstructive sleep apnea, by contrast, the picture is more complex: pauses in breathing noticed by people close to the patient, waking up as if choking or out of breath, getting up frequently at night to urinate, waking with a dry mouth, and restless, frequently interrupted sleep are common findings.
Daytime findings are also extremely important for the diagnosis: waking up unrefreshed in the morning, morning headaches, excessive sleepiness during the day, difficulty concentrating, memory problems and changes in mood (restlessness, irritability) are important signs that suggest sleep apnea. Symptoms such as dozing off at the wheel or in meetings are particularly important, as they can directly affect daily life and safety at work.
Causes and risk factors
The factors that lead to snoring and sleep apnea are generally related to narrowing at some level of the upper airway. At the level of the nose, a deviated septum, enlarged turbinates and nasal polyps restrict airflow and make snoring more likely. Enlarged adenoids, especially in children, and large tonsils, in both children and adults, contribute to obstruction at the level of the throat. A long or lax soft palate and uvula, and backward displacement of the tongue base, are also structural factors that play a role in the development of snoring and apnea.
Excess weight and obesity are among the strongest risk factors for sleep apnea because of fat tissue building up around the neck and throat. Sleeping on the back increases obstruction by making it easier for the tongue base to fall backward. Alcohol and some sedative medications relax the throat muscles and can markedly increase both snoring and the severity of apnea. Smoking, a family history of sleep apnea, older age and male sex are among the other known risk factors.
The structure of the jaw and facial skeleton is also an important factor; a set-back lower jaw (retrognathia) or a narrow upper jaw can reduce the space available for the tongue base and make obstruction more likely. It is also known that sleep apnea becomes more common in women after menopause because of hormonal changes. Because so many factors are involved, the treatment plan has to be tailored to each patient.
How does the diagnostic process work?
The evaluation begins with the complaints described by the patient and, if possible, by the person who sleeps in the same room; the nature of the snoring, witnessed pauses in breathing and daytime symptoms are asked about in detail. During the ENT examination, the nose, nasopharynx, tonsils, soft palate and tongue base are assessed for structural problems that could cause obstruction; nasal endoscopy is an important part of this evaluation.
The gold-standard method for confirming the diagnosis and determining its severity is polysomnography (a sleep study). This test simultaneously records breathing, oxygen saturation, heart rhythm, brain waves and body movements during sleep; by showing how many apnea–hypopnea events occur per hour (the apnea–hypopnea index), it distinguishes mild, moderate and severe sleep apnea. In selected cases, portable sleep tests carried out at home can also be used.
Body mass index, neck circumference and questions about accompanying chronic diseases such as hypertension and diabetes provide useful guidance for both risk assessment and treatment planning. Where considered necessary, a multidisciplinary evaluation can be carried out in collaboration with related specialties such as cardiology or endocrinology.
Treatment options
Conservative treatment and lifestyle changes
The treatment plan is always individualized to the patient and the underlying cause. Losing weight, avoiding alcohol and sedative medications, stopping smoking and sleeping on the side instead of on the back are basic measures recommended for almost every patient. In mild cases, these changes alone can bring significant benefit. In moderate and severe obstructive sleep apnea, devices that deliver continuous positive air pressure to the upper airway through a mask during sleep (PAP therapy) are today the gold-standard treatment and largely eliminate the pauses in breathing.
Surgical treatment
Structural obstructions that cause snoring or sleep apnea can be corrected surgically. A deviated septum and enlarged turbinates are treated with septoplasty and turbinate reduction, and nasal polyps with endoscopic surgery. Large adenoids and tonsils are removed by adenotonsillectomy in suitable cases; this is an extremely effective treatment option, especially in childhood sleep apnea. In selected adults, surgery on the soft palate and tongue base may also be considered; which method is appropriate is planned after the site of obstruction has been identified through detailed examination and, where necessary, additional tests.
Recovery and follow-up
In patients starting PAP therapy, improvement in sleep quality and daytime alertness is usually noticed within a short time; however, getting used to the device and building a habit of regular use can take a few weeks. Because technical details such as mask fit, pressure setting and humidity level directly affect how comfortable treatment is, it is important to tell the physician about any difficulties in the early period and, if necessary, to have the settings readjusted. In patients treated surgically, recovery time depends on the type of procedure; after nasal surgery, a return to daily life is possible within a few days, whereas after tonsil and adenoid surgery a sore throat is expected during the first week.
After treatment, a follow-up sleep study may be recommended, especially in moderate-to-severe sleep apnea, to assess objectively whether the symptoms have really improved. Keeping up weight management and lifestyle changes in the long term is an important factor supporting the success of both surgery and PAP therapy.
In long-term follow-up, the condition may need to be reassessed in patients whose symptoms persist despite treatment or in whom a new risk factor, such as a change in weight, appears. Because sleep apnea is a chronic condition that can change over time, continuing regular check-ups with the physician allows a possible recurrence or an inadequate response to treatment to be recognized early.
Frequently asked questions
Does everyone who snores have sleep apnea? No, most snoring is simple snoring; for sleep apnea to be suspected, additional findings such as witnessed pauses in breathing or excessive daytime sleepiness need to be present.
What happens if sleep apnea is not treated? Untreated moderate-to-severe sleep apnea has been associated with an increased long-term risk of hypertension, heart rhythm disorders and cardiovascular disease.
Will I need a PAP device for life? How long it is needed depends on the severity of the apnea and on how far the underlying cause can be corrected; in some patients, losing weight or correcting structural problems with surgery can reduce the need for it.
Is snoring normal in children? Occasional mild snoring is common, but regular snoring, sleeping with the mouth open and restless sleep in children should be evaluated, as they may be due to enlarged adenoids or tonsils.
How is a sleep study done, and is it painful? Polysomnography is a painless test; sensors placed on the body record breathing and other parameters during sleep, and the test is usually carried out overnight in a hospital or laboratory setting.
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Back to the short articleThis article is for general information purposes only; please consult your physician for diagnosis and treatment.