When to Get Serious About Snoring.

That nighttime rumbling may be a warning sign for major medical problems.

If you snore, or if your bed partner snores, this article may give lifesaving information. Most people view snoring as an annoying and intrusive sleep disturbance. Yet, contrary to popular belief, snoring is more than just nighttime noise. In fact, snoring may be an early warning sign of various medical problems, especially obstructive sleep apnea (OSA).

Snoring is caused by the vibration of the soft parts of the throat while inhaling air during sleep. With OSA, this noise may be continuous with almost every breath, or intermittent with breath-holding spells. These periods of suspension of breathing are called apneas, in which breathing actually stops during sleep for 10 seconds or more, sometimes more than 300 times a night. Apneas are caused by obstruction of the upper airway at the level of the uvula or base of the tongue and may be interrupted by a brief arousal that can be recorded from brain waves in a sleep disorder's laboratory.

While daytime sleepiness has been estimated to occur in 5 percent of the population, of these people, 30 to 40 percent also have obstructive sleep apnea. Those with obstructive sleep apnea not only snore, but may experience other very serious symptoms after what they thought was a good night's sleep. This is because the nighttime arousals fragment or ruin the normally refreshing nature of sleep. The low oxygen levels, which result when the blockages prevent air from getting to the lungs, also affect the brain and heart function.

Studies suggest that anywhere from 70 to 95 percent of people with major sleep apnea go undiagnosed. This is because millions of those who snore have not been diagnosed with this serious problem, yet have the serious symptoms. According to a study from researchers in California, sleep apnea can do more than disrupt a night's sleep: snoring and gasping for breath may damage the arteries of the neck and increase the risk of stroke. Those with more than 20 apneas (complete obstructions) per hour of sleep may have a greater risk of dying than people with fewer apneas.

A Weighty Issue

Up to two thirds of the people who have obstructive sleep apnea are overweight. Analysis of data from several studies suggests that the association between snoring and high blood pressure, coronary disease, and strokes may be attributed to obesity and the presence of obstructive sleep apnea.

Men may be more prone than women to develop sleep apnea because they have a larger amount of soft tissue in the neck, consisting mostly of muscle. Disorders such as sleep apnea have been linked to obesity and a larger neck circumference. Common risk factors include:

Gender: Males twice as common as females

Obesity: Greater than 120 percent of one's ideal body weight

Neck size: Collar greater than 17 inches in men and 15 inches in women

Enlarged tonsils

Nasal septum deviation

Small jawbone or backward displacement of jawbone

Glandular disorders: Hypothyroidism, acromegaly

Genetic predisposition: Family history

Specific genetic disease: Down's syndrome, while not common, may be associated with abnormal facial or upper airway anatomy.

Medicines or drugs: Alcohol, hypnotics (sleeping pills), narcotic pain relievers, tranquilizers

What You May Feel

Are you feeling a bit foggy and dense during daytime hours? Impairment in intellectual performance (attentiveness, alertness, memory) has been found in more than half of those with OSA. The major problems you may experience are deficits of thinking, perception, memory, communication, and the ability to learn new information. This can result in high anxiety, confusion, irritability, and often depression. These symptoms are then magnified by their effects on interpersonal relationships and work performance. Some people with obstructive sleep apnea awaken frequently to urinate and think their arousals are the result of urological problems. Actually the real cause of their sleep disruption is sleep apnea.

Making the Diagnosis

While more than 55 percent of those who snore never even discuss this with their physician, getting an accurate diagnosis is important to determine if you have OSA. If you snore and have one or more of the common symptoms, your primary care physician may refer you to a sleep clinic, where you will be evaluated by a sleep disorders specialist. This is a physician (usually a pulmonologist, neurologist, psychiatrist, or sometimes an otolaryngologist) who has done additional training and obtained experience in this area in order to pass special qualifying examination for certification by the American Board of Sleep Medicine.

The Epworth Sleepiness Scale

During the initial evaluation the doctor will give you a simple questionnaire known as the Epworth Sleepiness Scale, developed by Dr. Murray Johns (see sidebar). This is used by sleep medicine experts for evaluating the tendency to doze off during the day and involves assigning a number to the likelihood of falling asleep in certain circumstances. A total score of about seven is considered abnormal. The higher the score, the more likely you will doze off.

If you snore but have no evidence of more serious symptoms, overnight oximetry (oxygen level monitoring) during sleep in the home may be used to see if sleep apnea is present. If this test shows a significant pattern of oxygen drops, a full polysomnogram may be ordered by your physician.

A Sleep Study Can Reveal OSA

Polysomnography is done at an accredited sleep disorder's center and is safe and painless and will give required information about the oxygen drops associated with apneas and of the breathing problems on sleep quality. Importantly, the sleep study also tells if there are other diseases of sleep, such as thyroid disease, accounting for your symptoms. During the sleep study, the technician will monitor and record:

* airflow at your nose and mouth

* respiratory effort signaled from monitors on the chest wall and abdomen

* oxygen levels

* leg movements

* body position (supine, prone, side)

* electrocardiogram (measurement of heart muscle activity)

Each Person Is Different

If you have OSA or suspect it may be a problem, keep in mind that each person is different. Talk to your doctor about your snoring concerns and see if further testing is needed to diagnose obstructive sleep apnea. Once the diagnosis is made, take the necessary steps to find the best treatment for your situation.

Finding Treatment That Works

While there are different treatments for OSA, both surgically and nonsurgically, losing weight is often the best way to guarantee that the treatments will work. In fact, gaining weight after having surgery for sleep apnea could increase the problem.

The most guaranteed treatment is called continuous positive airway pressure, or CPAP. This is done by wearing a custom-fitted nasal mask during sleep. This mask is attached to a quietly functioning pump, which delivers air into the airway to prevent it from collapsing. CPAP is successful in almost 90 percent of cases, helping to improve sleep quality and alleviate daytime drowsiness, as well as other serious symptoms. It acts as a support to prevent further narrowing or collapse of your airway, and it actually increases the size of the airway behind the palate and at the back of your tongue. Nasal-CPAP not only relieves the symptom of excessive daytime sleepiness, but has also been shown to be effective in improving and reducing the severity of medical problems associated with sleep apnea. You may experience such minor side effects as drying of the nasal membrane, nasal congestion or skin abrasion on the bridge of the nose, but your doctor will help you reduce these effects.

Surgical procedures, which are done as an outpatient or with hospitalization, are also used to treat OSA. Commonly used surgical procedures include:

Nasal surgery--surgery to correct nasal valve collapse, septal deviation, enlarged turbinates, nasal polyps, sinusitis, and nasal tumor.

Tonsillectomy and adenoidectomy--procedures that can eliminate the cause of airway obstruction in OSA.

Uvulopalatopharyngoplasty (UPPP)--a procedure using general anesthesia and requiring a two- to three-day stay in the hospital for those with moderate to severe sleep apnea. The surgeon will trim the size of the back of the tongue base to give you a wider oral airway and reduce obstruction. This surgery also removes most of the soft palate, uvula, and tonsils using an electrocautery, laser, or knife.

Laser-assisted uvulopalatoplasty (LAUP)--a new and effective laser surgery, reshapes the uvula and palate and is helpful for mild sleep apnea. With LAUP, you will need three to five treatments, and it can be done on an outpatient basis with local anesthesia.

Epworth Sleepiness Scale

So, how likely are you to doze off or fall asleep in the following situations, as opposed to feeling just tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to imagine how they would have affected you. Use the scale below to choose the most appropriate number for each. A total score above seven is considered abnormal, and the higher the score, the more likely you will doze off.

Situation                                               Ch

Sitting and reading                                     []

Watching television                                     []

Sitting, inactive in a public place                     []
(for example, at a concert or meeting)

Lying down to rest in the afternoon                     []

Sitting and talking with someone                        []

Sitting quietly after lunch                             []

In a car, while stopped for a few minutes in traffic    []

Would never doze = 0

Moderate chance of dozing = 2

Slight chance of dozing = 1

High chance of dozing = 3