Snoring: More Than a Bad Habit

Interview with Samuel A. Mickelson, M.D.
Conducted by Dan Rutz

DAN RUTZ: Snoring is the brunt of many jokes in our society. People like to laugh about it, usually at other people's expense. Does that have an affect on how we deal with it clinically?

DR. SAMUEL MICKELSON: Well, it does, because people think of it as a joke and they often don't want to be going to a doctor for something that is considered, maybe, funny to them. It's also an issue because of society and how people look at a snorer. Many men are viewed as a problem to their bed partner and yet, it is socially acceptable for a man to snore. And yet, a woman can be very embarrassed over her snoring.

DAN RUTZ: I think of some of the cartoon characters that are built around that as the central theme of a gag. It really does reinforce those stereotypes, doesn't it?

DR. SAMUEL MICKELSON: Yes, it does. And it's unfortunate because women snore very frequently, not as often as men. Men are about twice as likely to snore as a woman.

DAN RUTZ: Surprising when you think about it as much as women tend to be smaller, that their airways ought to be smaller as well and isn't that one of the risk factors for snoring?

DR. SAMUEL MICKELSON: Well, it is and women's airways are smaller. But, probably one of the largest reasons why women don't snore as much as men has to do with more hormonal factors. With certain hormones, testosterone, men have more fat deposition in areas in and around the airway. So, when a man gains weight, they tend to get a larger neck, whereas, when a woman gains weight, they tend to put the weight on in the hips or in the abdomen and very frequently, have a very thin neck, even though they may be very heavy.

DAN RUTZ: And the fat, presence of fat in the neck, does have an affect on one's snoring?

DR. SAMUEL MICKELSON: Well, it does. The more fat you have in your neck; it makes your neck larger on the outside. But it also presses inward and makes your airway smaller on the inside. More importantly, the fat is actually deposited in the tissues of the throat, so your palate may be longer, the roof of the mouth, that's the palate. Your uvula may become larger. Your tongue may become larger because of fat being deposited within those structures.

DAN RUTZ: Is there anything physiologically that distinguishes the occasional snorer from the habitual one?

DR. SAMUEL MICKELSON: Not really. Just probably size of the airway, matter of severity. The tissues are a little bit closer together. The airway's a little bit smaller. And therefore, someone with a smaller airway tends to snore more.

DAN RUTZ: But they may not snore all the time. So, what has to happen? What the configuration of events or positions conspire to create this problem?

DR. SAMUEL MICKELSON: Well, there are really multiple factors. Having a small airway and tissues being too large creates a situation where you are more likely to snore. But when you fall asleep, your muscles relax. So, as soon as you fall asleep, the muscle relaxation causes the airway to get smaller. If you are in a very deep sleep, your airway relaxes even more because of more muscle relaxation. So people who are over tired tend to get into a deeper level of sleep and they will tend to snore worse. People who drink alcohol before bedtime, for instance-the alcohol relaxes the muscles of the throat and will make somebody snore more. So, certainly certain situations like being over tired will make you more likely to snore. Being in a deeper level of sleep will make you more likely to snore. So, at certain times of the night, you may be more likely.

And then, of course, being in certain positions, body positions. Being on your back tends to make you snore worse because your tongue tends to fall backward and makes the airway smaller.

DAN RUTZ: And I suppose then there's two mechanisms perhaps for nudging somebody. One is to rouse them from a deeper level of sleep and perhaps stop the snoring. And another is they would change positions.

DR. SAMUEL MICKELSON: Right. And what most bed partners would do is they would nudge their partner and hopefully get them to either wake up or roll over, is more common approach.

DAN RUTZ: At what point would you consider snoring to be a problem worthy of a physician's attention?

DR. SAMUEL MICKELSON: Well, snoring and sleep apnea are very similar conditions. Both are caused by small airways. And when you have snoring that's bad enough that it leads to stop breathing spells during sleep, that definitely warrants a physician's attention. From a social perspective though, I think when an individual snores so bad that somebody else can't sleep in the same bedroom as him or her, then it certainly warrants a physician to look into it.

DAN RUTZ: And, how do you go about investigating this, short of putting them in the sleep lab? Obviously, that isn't always necessary.

DR. SAMUEL MICKELSON: No, it isn't. If there are no symptoms of sleep apnea and no daytime sleepiness, no morning fatigue, no observed stop breathing spells, then generally a sleep study is not necessary. But we evaluate it by asking questions. I usually ask my patients what sort of factors may be contributing to their snoring-a recent weight gain, maybe snoring in only certain body positions, maybe only snoring after they drink alcohol or take a sleeping pill. Those sorts of situations tend to be easy to deal with because you can address them and tell them to change that behavior and often help the problem. For the habitual daily or nightly snorer, we will then go ahead and do a physical exam and identify which areas may be causing the snoring. The best approach is to use a little scope, a little flexible tube placed into the back part of the throat and the person imitates a snore sound and you can identify what's vibrating.

DAN RUTZ: Having done so, what's the next step?

DR. SAMUEL MICKELSON: It depends how bad the snoring is. Most of the time, the approach is to make the tissue that's vibrating-make it smaller or eliminate it. The idea is to stiffen that part of the airway. And that depends where the problem is. If they have a problem in the nose, such as a deviated septum, a crooked septum, the partition down the center that's crooked, we can do a surgery to straighten it out. If somebody has allergies, we generally treat that with medications-antihistamines or nasal sprays, prescription nasal sprays. If somebody has polyps in the nose, we may have to do surgery to remove them. If somebody has an elongation of their palate or their uvula, then we can do an operation to shrink that down and tighten it up.

DAN RUTZ: How common do these tend to be-these kinds of anatomical defects or alterations over time?

DR. SAMUEL MICKELSON: Snoring is due to a variety of conditions that lead to vibration of tissues. But the most common is an elongation of the palate and uvula. And that actually accounts for snoring about 90% of the time. The nose accounts for snoring probably the other, maybe, 8 or 9%. And then in a small number of people, it's just a generalized narrowing, maybe too large of a tongue or too much fat in the neck, just in everything being small and vibrating against one another.

DAN RUTZ: Is this ever resolved by weight loss; can that help?

DR. SAMUEL MICKELSON: Oh, sure. Weight loss works best for people who recently gained weight and developed snoring. They never snored before, they put on 20 pounds, they started snoring. That's a perfect person to put on a diet. The person whose been overweight 50, 60 pounds their entire life is probably not a person to treat with a weight program.

DAN RUTZ: With respect to the 90% that have this extra soft palate tissue, there are a couple of interventions now, some of them quite remarkable, aren't there-in terms of what they can do with minimal side effects?

DR. SAMUEL MICKELSON: Yes, there's actually been remarkable advances in treating snoring over the last fifteen years. The first surgery that was developed for snoring was an operation done in the operating room under anesthesia, where we trim the lower edge of the palate and remove the uvula. And it was quite painful, very effective, about 90% success, but costly for somebody and painful. About six years ago, a laser surgery was developed which lowered the price dramatically because it could now be done in the office under a local anesthesia-still very effective, but still fairly painful. The most recent development is a radio frequency reduction of the palate, what's known as somnoplasty. And that's also done in the office under local anesthesia. And the idea behind it is we use a radio frequency energy that is developed and placed into the palate with a little tiny needle and it shrinks the palate from inside out. And because the nerve endings are on the outside and we're treating the inside of the palate, it is virtually pain free. The average patient has the treatment done and has maybe Tylenol for a day or two. And that's it.

DAN RUTZ: But it takes awhile, doesn't it, for the good effects to occur as well? Do these tissues shrink gradually or do you, nobody, is it unreasonable to expect an instant fix for many of these?

DR. SAMUEL MICKELSON: An instant fix is very rare. We usually expect the healing process to tighten up the tissues. The scar tissue development in and around the palate really stiffens that area and prevents the vibration. With the somnoplasty, for instance, the treatments often require weeks, three or four weeks to have their effect, and often we need more than one treatment. In fact, the average person needs between two and three treatments.

DAN RUTZ: But once they've accomplished that, is this a permanent change for the better?

DR. SAMUEL MICKELSON: For most people, yes. Most of the time, once that tissue is tightened up, the snoring is controlled and it doesn't come back. The times that it tends to get worse over time is usually with weight gain. So, if you have the treatment and you are better and then you gain 50 pounds, you may get a reoccurrence of your snoring.

DAN RUTZ: What would you say to people who worry about burning their bridges with respect to procedures that involve the removal of tissue or the permanent alteration of tissue? Is there, perhaps, a price to pay later in life or are those fears unfounded?

DR. SAMUEL MICKELSON: Well, I think for the most part, those fears are unfounded. I'm a believer in conservative therapies though. I think you should try something simple before you go on to something more aggressive. So, I recommend my patients to try staying off their back and trying to avoid the alcohol and losing some weight-the conservative approaches. And then, if those things don't work, then by all means, to go ahead to one of the more surgical procedures.

DAN RUTZ: What percent of patients, would you speculate, can be managed conservatively?

DR. SAMUEL MICKELSON: Realistically, it's probably less than half. Most people are not very compliant with a weight reduction program. People are usually good at losing weight, but they don't tend to keep it off. And it's not very easy to stay off your back at night. Many people like to sleep on their back. So, ultimately, over a period of time, many of my patients who are tried on conservative therapies do end up coming back for something more definitive.

DAN RUTZ: But again, you're really seeing the worse cases that are referred in here or self-referred, however they find you?

DR. SAMUEL MICKELSON: Oh, sure.

DAN RUTZ: What about the tennis ball in the back? Does that really work?

DR. SAMUEL MICKELSON: Well, it does. If you only snore on your back, the tennis ball works great. The idea is you put a tennis ball in a sock, take a couple of safety pins, pin the sock to a tee-shirt that you are wearing so that the sock and tennis ball are right in the middle of the shoulder blades. And it trains you to not sleep on the back.

DAN RUTZ: What's your impression of oral appliances that perhaps reposition the jaw or, in some other way, promote an open airway?

DR. SAMUEL MICKELSON: Again, it's... it is another option. It is a device therapy. Some people like devices because they are easy and simple. You put it in your mouth, you wear it, you wake up in the morning, you take it out. The difficulty is that it takes time to get used to a device like this. Some people drool a lot. Some people have muscle soreness when they wake up in the morning. But they work around 50 or 60% of the time for snoring. So, I do fit people with oral appliances if they prefer not to have a more permanent surgical treatment.

DAN RUTZ: But in terms of a pecking order, you would perhaps skip the appliance stage and go right to surgery in suitable candidates?

DR. SAMUEL MICKELSON: I often do. I offer the oral appliance to my patients and I would say most of them prefer to get a more permanent fix rather than wear an appliance forever.