When Snoring Therapies Fail

Despite the many snoring devices and procedures, except for CPAP, failures of relief are common. By emphasizing procedures that can be overlooked, a higher incidence of snoring relief can be obtained. We stress throat exercises and correcting nasal valve obstruction. Today Google lists almost a million snoring therapies. The medical literature lists some hundreds. In the medical device advertisements, you see the happy smiling faces of those cured of their snoring. Notice these happy faces all have remarkably bright shiny teeth. Unfortunately, in Otolaryngology practice, when the snoring patient is brought in – unwillinglyby their partner, the history is that they have tried many inserts, dental appliances, tape applicators, etc. Typically, the patients I see fit this pattern [1-4]: John Lewis, age 44. Weight 230 pounds. Has a desk job and is not particularly athletic. He belongs to a health club and goes on occasion. Before he had his surgery, he had tried various dental and strips devices. Two years ago, he had uvulopalatopharyngoplasty (UPPP). For about 3 months he snored very little. Then his snoring returned and now his wife forces him to sleep in another bedroom. He noted that his wife snores too. Examination shows tonsils well removed, uvula and soft palate trimmed. Why did his UPPP surgery fail? Examination shows a significantly deviated septum to the right. Moderate swelling of left middle turbinate. Post pharyngeal wall showed 2+ edema and lymphoid hyperplasia. His surgery failed because [5,6]: Deviated septum continued to block his breathing His pharyngeal tissues were flaccid He had a lowgrade sinus infection. He was unable to lost weight because he continued to sleep poorly and was fatigued; this required him to take extra calories for energy in order to function Another common pattern: Jose Gonzales had had surgery and has successfully reduced his weight to a normal 160 pounds. He attends brisk walking regularly. Examination shows no anatomical abnormality whatsoever. He previously had a CT scan showing no sinus pathology. Careful examination showed evidence of allergic rhinitis; allergy testing showed significant dust and dander allergies. He was currently living with a new girlfriend whose cat slept in her bed. With allergy Rx, his snoring ceased. Many patients who snore do not voice a complaint when they are seen for routine hearing test or tinnitus. However, even of the tinnitus disturbs their sleep, getting better sleep with snoring relief is important [7,8]. Richard Fleming, age 50, was seen for tinnitus. History of poor sleep. Examination showed a depressed nasal tip. On lifting the nasal tip, his airflow increased significantly. I demonstrated to him how to secure his nasal tip elevated in sleep. On a return visit he related that his snoring had reduced significantly and he was not fatigued in mornings.


Global Journal of Otolaryngology
to increased snoring -more weight gain. The worst complication is that simple snoring, with accompanying weight gain, results in GERD. This acid reflux makes simple snoring worse. This can lead to significant sleep apnea with associated hypertension, diabetes and disorders of the heart [8].
Whether it is sleep apnea or snoring without apnea, statistics show that 30% of auto and industrial accidents are sleep related. The experienced railroads engineer who rounds the curve at a dangerous speed; the driver who crosses the freeway divider and crashes into a bus; all are sleep related. Thus, it is essential to properly diagnose and treat early stages of snoring.

Examination
In order to properly clear snoring, the entire upper respiratory system must be properly evaluated. This includes a.
Nasal Airway Blockage: Clear deviations, chronic nasal congestion and infection. Pulsed irrigation using Ringer's solution with 1% Xylitol is often effective.

b.
The Nasal Valve: Flaccid alar cartilages or dependent nasal tip may need attention.

c.
Upper Pharyngeal Airway: Adenoids in children is a primary problem and adenoidectomy in such cases can clear the fatigued sleepy child who is cranky, with bad breath and poor grades.

d. Enlarged Tonsils and fatty soft palate:
Clearing sinus infection helps. Pulsed irrigation of the throat with stream directed to swollen tonsils is excellent for tonsil and throat therapy. This includes lingual, as well as palatine tonsils [9,10].

e.
Voice Exercises: Essentially most professional singing exercises can vibrate the throat, to reduce muscle flabbiness. These specific exercises are from Chest.
Place tongue hard against upper teeth and pronounce the vowels loudly many times. A, E, I, O and U for a minute.
ii. Now force tongue against middle of hard plate and say the vowels loudly for a minute iii. Now do this with tongue pressed against back of hard plate for a minute iv. Push the tip of the tongue against the hard palate: slide the tongue backward for a minute v.
Lift the entire tongue against the palate repeatedly for a minute vi. Force the back of the tongue against the floor of the mouth while keeping the tip of the tongue against the lower incisor teeth -for a minute vii. Elevate the soft plate and uvula while saying the vowels for a minute viii. Blow up a balloon as forcefully as possible. (Almost any inexpensive balloon can be used) Vibrating the throat muscles is also helpful. Hum "oooommm." Feel the throat vibrate. Hum the "Star Spangled Banner." Trumpet practice, playing the didgeridoo have been studied and show benefit. Conditions often missed include allergy, anatomical deformities of the jaw -micrograthism, laryngeal edema or impairment. I ask every hoarse patient if they snore.

Partner Also Snores
The partner also snores. Studies have shown that the partner of the snoring person also develops snoring. The mechanism is that the partner loses sleep. Then the partner takes extra food to make up for the morning fatigue. The partner gains fat in the soft palate. The palate becomes heavy and blocks breathing with resultant further weight gain.

CPAP
Despite the many failures of snoring devices, use of CPAP has a high rate of success. Most patients voice objection, but by providing phone numbers of successful CPAP users, these objections can be overcome. It is best to caution the patient that it is normal to have 1-2 weeks difficulty with CPAP, and give it the full two weeks of trial. It helps to inform the patient that CPAP improves libido [11].

Conclusion
It is vital to clear snoring in its early stages. A multi-prong total patient approach is necessary because a simple solution can be overlooked. Emphasis should be on non-surgical therapies first including voice exercises, sinus/allergy relief, and even simple humming. The more thorough the examination, the greater the chance of finding a solution as simple as elevation of the droopy nose that closes the nasal valve.