snoring

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Classification according to ICD-10
R06.5 Mouth breathing

[Snoring]

ICD-10 online (WHO version 2019)
Audio recording

With snoring (med. Rhonchopathy from Greek  ῥόγχος rhonchos "snoring" and thrombocytopathy , gr. "Suffer") refers to a rattling noise in the upper airways of a sleeping generated humans. Normal snoring is also referred to as compensated snoring and is, to a lesser extent, a normal variant with no disease value. With age, around 60% of men and 40% of women snore. About 10% of children snore. In the case of very pronounced snoring, the oxygen supply can be reduced and sleep can be disturbed as a result. One then speaks of obstructive snoring .

Health relevance

If a person is regularly affected by obstructive snoring and suffers from it or is impaired in everyday life, a sleep-related breathing disorder is diagnosed according to the International Classification of Sleep Disorders (ICSD-2). One then speaks of a rhonchopathy or of the Upper Airway Resistance Syndrome (UARS), in which, in contrast to the obstructive sleep apnea syndrome (OSAS), there is only a temporary closure of the upper airways, but which also leads to hypoxia (lack of oxygen), arousals (waking reactions) and as a result, can lead to daytime sleepiness and concentration problems. The specialist literature discusses whether the upper airway resistance syndrome and the obstructive sleep apnea syndrome are two different sleep disorders or just different degrees of severity of one and the same sleep disorder. The International Classification of Sleep Disorders defines Upper Airway Resistance Syndrome as a mild form of Obstructive Sleep Apnea Syndrome.

Epidemiological studies have shown that people who suffer from untreated obstructive snoring have an increased risk of developing high blood pressure (hypertension), stroke, and heart attack . There is strong evidence that excessive snoring through the vibrations can lead to local neuropathy , which in turn can exacerbate health problems.

causes

The snoring noise is caused by fluttering movements of the palate and uvula , sometimes also of the base of the tongue and the throat when breathing. In some cases it can be caused by nasal obstruction.

When snoring, there is usually no complete blockage of the airways , but only a narrowing of the airways. Not every section of the airway is regularly involved in snoring. There is hardly any snoring noise through the inner larynx or the windpipe . However, the oropharynx is practically always involved in snoring. The pharynx behaves like a dynamic valve when you breathe in during sleep, which becomes increasingly narrower the stronger the negative pressure is during inhalation. Physically, Bernoulli's law of flow applies here to explain it. The increased flow velocity in the pharynx affects the soft palate ( soft palate ), which can be set in motion by the breath wind. If the connective tissue and the soft palate muscles are firm, snoring is prevented. If the connective tissue is soft and the muscles are slack, the soft palate flutters in the breath. The firmness of the soft palate depends on age and sleep stage . In REM sleep , the muscles are considerably relaxed. This is why snoring is more likely to occur in REM sleep than in NREM sleep and more likely in old age than in younger years. During inhalation, when snoring, the soft palate swings back and forth between the base of the tongue and the back wall of the throat . On exhalation, the soft palate folds forward and flutters between the hard palate and the back of the tongue. As the tissue ages, not only the soft palate but also the increasingly softer / flaccid throat, which is also a muscle system covered with mucous membrane, can be involved in snoring.

The tongue can also constrict the throat by falling back while lying down. So there are several factors that could be causing this symptom. Snoring is basically a fairly complex fluid dynamics problem.

For most people, snoring occurs depending on the position of the body. Snoring often occurs in the supine position when the lower jaw of the sleeper is not supported and he is breathing through the open mouth. If the body registers a lack of oxygen caused by the difficult breathing, it triggers a change in position.

Also overweight or genetic predisposition can be responsible for this, that an anatomical feature exists, which causes snoring ultimately The breathing apparatus of the sleeping person is unable to maintain the necessary tension in any body position which would prevent snoring.

Likewise, alcohol consumption or the use of sedatives, sleeping pills, tranquilizers and psychotropic drugs promote the relaxation of the soft palate and thus the process of snoring.

Snoring comes in different forms. There are people who only snore occasionally, e.g. B. with a cold. Other people snore almost every night, sometimes accompanied by very loud, highly annoying snoring noises. A constantly blocked nose, for example chronic inflammation, allergies or a crooked nasal septum are other possible causes of snoring.

Sleep apnea syndrome is often accompanied by severe nightmares . With sleep apnea, the sleeper suffers a massive lack of oxygen. The body activates a protective reflex. This increases the breathing effort and the tension of the airways and breathing muscles, so that you can breathe deeply. A stress reaction is triggered, which leads to increases in blood pressure and heart rate. There is also an adrenaline rush . The affected person may wake up gasping for breath and having a strong palpitation of the heart, but the majority of the stress reactions run unnoticed during sleep.

consequences

If it is severe, the snorer can even wake up to his own snoring noise.

Consequences for those affected

Often people who snore do not have a restful sleep, as the snoring cycles occur mainly in the important dream and deep sleep phases. Fatigue, nervousness and tiredness even after a long sleep are the result when you are awake. More severe snoring suffering can, if they occur in the long term and are not recognized impairments on heart - and circulatory system (high blood pressure) increased the heart attack - and stroke risk entail.

A US study suggests that snoring in early childhood could potentially have a negative impact on cognitive development: In the group of seventh and eighth graders surveyed, there were an above-average number of children who had poor school performance snored when they were 2 to 6 years old. A study among 4- to 5-year-olds showed that when parents reported their children's snoring and disturbed sleep, these children actually had insomnia and behavioral problems; this correlated with the mother's but not the father's smoking . A cause-and-effect chain of the effects of snoring in children cannot be conclusively proven. In addition, childhood snoring cannot be distinguished from sleep apnea syndrome solely on the basis of clinical history.

Sleep apnea syndrome

Breathing stops can occur as a result of the complete collapse of the throat or the soft tissue of the neck. Such pauses in breathing can occur very frequently each night, which severely affects sleep. An extreme form of snoring, combined with respiratory arrest, is called obstructive sleep apnea syndrome (OSAS); it is a serious sleep disorder.

Consequences for the partner

The noise level of snoring at 20 decibels is comparable to the volume of rustling leaves, but it can also reach significantly higher values. The Guinness Book of Records lists snoring at 93 decibels, which is equivalent to the noise level on a busy motorway.

Snoring endangers the health of the partner and the stability of the relationship. According to a 2005 study by the University of Surrey , among 25 couples, men often missed their partner's snoring because their sleep was deeper; as soon as the snoring bothered them, however, most woke their partner. Conversely, the women tried primarily not to wake their snoring partner, even if the snoring was costing them sleep.

According to the TK sleep study 2017, a survey of a representative cross-section of the adult population in Germany by Forsa on behalf of the Techniker Krankenkasse , 22% of women and 8% of men stated that their partner's snoring bothers them while they sleep; 10% bothers their own snoring while sleeping.

behaviour rules

You can try to combat snoring by taking simple, self-administered measures. Often this at least succeeds in alleviating snoring; however, these measures are not always successful.

Sleeping position
If the head is lowered too much, the nasal mucous membranes swell slightly in some people. If the nose is already tight, this can further impair nasal breathing, so that snoring occurs or increases. This can be counteracted by elevating the head. However, if the head is too elevated, it promotes snoring and, above all, the development of dangerous sleep apneas, as the kinked air duct in the throat further increases the lack of space and narrows the airways. Since the supine position often leads to snoring (due to gravity: pulls the soft palate or tongue down even more), one should practice posture training as a habitual change in sleeping position. B. by sewing tennis balls into the back of the pajamas, wearing a sleep vest, remember. Heavy snorers, however, snore in any position, so this countermeasure does not achieve any significant success in such cases.
Alcohol, medication
All alcohol consumption should be avoided in the last 3 to 4 hours before sleep. The ingestion of strongly relaxing drugs (sleeping pills, sedatives, muscle relaxants) should be avoided as far as possible.
Obesity
Since fat is also deposited in the throat area (on the walls of the cavities) and thus narrows the diameter of the breath, weight reduction is the therapy of first choice in the case of severe obesity.
Allergies
If there is a house dust mite allergy or a bed feather allergy , beds and pillows with synthetic, hypoallergenic filling material should be used; In addition, the bed linen should be changed every 5 days and the duvet and pillow washed at least every 8 weeks. Corresponding beds are available from specialist bed shops. Medical treatment (e.g. desensitization ) may also be necessary in the case of allergies .
constant, fixed bedtime
closed mouth
A so-called "snore bandage" or "snore bandage" fixes the lower jaw with an elastic belt and thus keeps the mouth closed (available in pharmacies and medical supply stores). The same is achieved by a so-called oral vestibule ("snore pacifier").

Measurement

Research into the analysis of snoring noises has increased since the 1990s. It can psychoacoustic are determined and statistically associated with the different types of snoring sounds characteristics such as volume, sharpness and roughness. An essential aim of the sleep noise analysis is to obtain clues for an objective measurement of the subjective impairment caused by snoring. An objective measurement is critical to measuring the success of treatments.

Medical treatment

Advertisement for a "guaranteed" anti-snoring agent from 1906

In many cases, those affected first turn to an ENT doctor. Its task should first be to identify which sections of the upper airway are narrow. Appropriate treatment should be given in cases where obstructed nasal breathing could be the obvious cause of snoring. Examples include curvature of the septum (septum deviation), maxillary sinus infections, enlarged turbinates and allergies. There is often a combination of several of these causes. The cause may need to be determined by somno endoscopy .

Surgical interventions

The success of surgical interventions is controversial; a disadvantage is that these are often irreversible.

It is possible to tighten the palate and the pharynx and to remove most of the uvula. During this procedure, the tonsils ( tonsilla palatina ) are usually also removed . This procedure is known as uvula-palato-pharyngoplasty (UPPP) . This operation can improve the snoreer's condition. This procedure must be carried out under anesthesia as an inpatient. Complications are rare; In addition to rebleeding within the first week, long-term problems such as swallowing with fluid leaking from the nostrils, swallowing pain or open nasalism can arise.

Another method is the use of a laser. Parts of the palate and uvula are removed. This surgical technique is known as laser-assisted uvula palato-plasty (LAUP) . The procedure can be carried out on an outpatient basis under local anesthesia; however, surgery under anesthesia is recommended. Complications of this laser surgery are relatively rare.

Radiofrequency therapy ( RFITT ) has also become established in recent years : It involves piercing the pharynx tissue with probes and using high frequency in the ISM band to boil the tissue at relatively low temperatures (approx. 80 ° C). Scarred shrinkage of the palate can stabilize the tissue and thus reduce snoring noise.

In the radio-frequency assisted uvulopalatoplasty (RF-UPP) is combined with the coagulation , excess tissue at the palatine arches (webbing) and the uvula away of the soft palate. This combined treatment can significantly reduce snoring. Since the temperature with radio frequency treatment is usually significantly lower than with laser and, in contrast to LAUP, the soft palate muscle is not cut, post-operative pain is comparatively low with this method.

Soft palate implants : The soft palate is stabilized by inserting plastic pins under local anesthesia. If the pins come off, they are simply replaced. The therapy is only suitable for around ten percent of all snorers, because if the soft palate of a patient is too large, the patient could choke on the implant .

UvulaFlap : The folded-up uvula is sutured to the palate. The mucous membrane is not affected. Symptoms during the act of swallowing and speech disorders are possible.

Almonds Removal : In adults, the tonsils have no important function. If the tonsils are too large, the removal can be combined with an operation on the soft palate. Secondary bleeding is possible.

The IGeL-Monitor of the MDS (Medical Service of the Central Association of Health Insurance Funds) rates the operative treatment of snoring as "tending to be negative" after a systematic research of the scientific literature. The studies clearly showed that the operations can have frequent but less serious side effects.

In the case of curvature of the nasal septum and enlargement of the turbinate, surgical straightening of the nasal septum and a reduction in the size of the turbinates are necessary.

There is a wide range of treatment options for maxillary sinus and paranasal sinus infections , depending on the extent of the maxillary sinus or sinus infection : These range from the administration of expectorants, antibiotics and sinus rinsing to maxillary sinus and ethmoid surgeries.

A neurostimulator can also be used against sleep apnea : a pacemaker for the tongue muscle implanted below the collarbone measures the movement of the diaphragm and controls the hypoglossal nerve and thus the tongue. By September 2015, around 400 such tongue pacemakers had been implanted worldwide.

Further surgical measures

The surgical intervention measures described below are partly controversial in German-speaking countries, they are mainly propagated in the USA. Some of them have their justification, especially in the case of congenital back displacements of the tongue and the lower jaw. Often there is a multi-level obstruction, which is responded to with multi-level surgery .

  • maxillomandibular advancement: forward displacement of the lower jaw by splitting the mandible
  • Tongue suspension: the tongue is pulled forward by a non-absorbable thread that is attached to a screw on the lower jaw
  • Hyoid suspension: To prevent the base of the tongue from falling back, the hyoid bone and larynx are wired so that the gullet opens. Difficulty swallowing and voice changes are possible. Change in the feeling of the larynx.

training

Several pilot studies have shown that active muscle training for the back of the mouth, palate, and throat can also lead to some successes against nightly respiratory slack. Special singing exercises have been developed for this.

However, there is still disagreement as to the extent to which such muscle training actually reduces snoring.

Anti-snoring devices

A nasal patch can be used against slight disturbances in nasal breathing . If there is no obstructed nasal breathing or if obstructed nasal breathing has already been surgically or otherwise eliminated, only the following measures remain:

There are various devices for sale on the market which are intended to wake up snorers at night when they snore heavily and to train them not to snore. As a rule, such devices are not promising because they ultimately cannot prevent the throat from collapsing; the snorer is rather additionally disturbed in his sleep by this device.

A mandibular protrusion splint holds the lower jaw in a fixed position while sleeping so that the tongue cannot fall back and block the airways. Most patients get along well with it, and the efficiency should be high.

An atrial plate (also called atrial splint) is placed in the outer oral vestibule between the lips and anterior teeth and thus blocks mouth breathing. The contours on the inside of the atrial splint / plate act as a toy for the tongue. The resulting swallowing reflex presses the tongue against the anterior teeth and the atrial splint / atrial plate and is placed there by the resulting negative pressure. The free space of the windpipe is expanded and the vibration of the soft palate is blocked. The snoring noises should thus be prevented. The bioplastic material becomes even more elastic when it is heated in the mouth and adapts individually to the oral vestibule.

Another possibility is to fix the soft palate with a simple brace: By inserting a palate into the oral cavity, the air channel behind the soft palate is mechanically prevented from closing. A low-resistance air passage is aimed for when sleeping and noise-generating vibrations are to be prevented directly at the point of origin.

Another possibility of snoring suppression is - in the case of a position-dependent symptomatology - position training. Some patients only snore in the supine position so that they can be helped by a positioning aid strapped to their back. This storage aid, e.g. B. in the form of a rucksack filled with towels with a waist belt, makes the supine position so uncomfortable that it cannot be taken unconsciously at night.

Nocturnal positive pressure ventilation with a mask ( CPAP treatment) is suitable for increasing the pressure in the airways, preventing the airways from collapsing and thereby suppressing snoring. However, this method is associated with the inconvenience of a nocturnal breathing mask, so that it is usually only used when the patient is particularly impaired in the form of daytime sleepiness and concentration disorders as well as when breathing pauses at night, i.e. with sleep apnea syndrome.

Snoring museum

The only snoring museum in the world is located in the district of Langenholzen in the Lower Saxon town of Alfeld . It shows around 400 exhibits from the 18th century to modern times relating to snoring and its treatment.

Web links

Commons : Snoring  - Collection of pictures, videos and audio files

literature

Individual evidence

  1. ^ PE Peppard, T. Young, M. Palta, J. Skatrud: Prospective study of the association between sleep-disordered breathing and hypertension. In: New England Journal of Medicine . 2000.
  2. ↑ awmf.org
  3. ↑ David Gozal, Dennis W. Pope Jr: Snoring During Early Childhood and Academic Performance at Ages Thirteen to Fourteen Years. In: Pediatrics . Volume 107, No. 6, June 2001, pp. 1394-1399 abstract
  4. ↑ NJ Ali, DJ Pitson, JR Stradling: Snoring, sleep disturbance, and behavior in 4-5 year olds. In: Archives of Disease in Childhood . 1993; 68, pp. 360-366, doi: 10.1136 / adc.68.3.360
  5. ↑ John L. Carroll, Susanna A. McColley, Carole L. Marcus, Shelly Curtis, Gerald M. Loughlin: Inability of Clinical History to Distinguish Primary Snoring From Obstructive Sleep Apnea Syndrome in Children. In: Chest. September 1995, Volume 108, No. 3, pp. 610-618, doi: 10.1378 / chest.108.3.610 .
  6. ↑ Sleep disorders: Snoring in Planet Wissen from February 24, 2010.
  7. ↑ Darkroom of togetherness. In: Spiegel Wissen . 4/2009.
  8. ↑ Women 'too meek' over men snoring in BBC News of March 14, 2005.
  9. ↑ Snoring: Noise in the bedroom. In: Stern . December 29, 2009.
  10. ↑ Why does snoring only wake others up? on: n-tv . April 17, 2012.
  11. ↑ Sleep well, Germany: TK sleep study 2017. Techniker Krankenkasse, accessed on August 31, 2018 . P. 26 and 28.
  12. ^ A b c M. Herzog, T. Bremert, B. Herzog, W. Hosemann, H. Kaftan, A. Müller: Analysis of snoring sound by psychoacoustic parameters. In: European archives of oto-rhino-laryngology: official journal of the European Federation of Oto-Rhino-Laryngological Societies (EUFOS): affiliated with the German Society for Oto-Rhino-Laryngology - Head and Neck Surgery. Volume 268, Number 3, March 2011, ISSN  1434-4726 , pp. 463-470, doi: 10.1007 / s00405-010-1386-9 , PMID 20859635 .
  13. ^ D. Pevernagie, RM Aarts, M. De Meyer: The acoustics of snoring. In: Sleep Medicine Reviews . Volume 14, Number 2, April 2010, ISSN  1532-2955 , pp. 131-144, doi: 10.1016 / j.smrv.2009.06.002 , PMID 19665907 (review).
  14. ↑ IGeL Monitor, Operative Treatment of Snoring , accessed on November 15, 2018. More on the justification for the evaluation in the evidence thesis
  15. ↑ PJ Strollo, RJ Soose, JT Maurer, N. de Vries, J. Cornelius, O. Froymovich, RD Hanson, TA Padhya, DL Steward, MB Gillespie, BT Woodson, PH Van de Heyning, MG Goetting, OM Vanderveken, N Feldman, L. Knaack, KP Strohl: Upper-airway stimulation for obstructive sleep apnea. In: The New England Journal of Medicine . Volume 370, Number 2, January 2014, ISSN  1533-4406 , pp. 139-149, doi: 10.1056 / NEJMoa1308659 , PMID 24401051 .
  16. ↑ Tongue pacemaker for snoring successfully implanted. ScienceDaily, August 14, 2012, accessed February 12, 2015 .
  17. ↑ Charité University Clinic implants a pacemaker against snoring for the first time. Merkur-Online.de, August 20, 2012, accessed on February 12, 2015 .
  18. ↑ http://tirol.orf.at/news/stories/2730740/ Tongue pacemaker against snoring, orf.at, September 9, 2015, accessed September 9, 2015.
  19. ^ Online edition of the British Medical Journal . See playing the didgeridoo as respiratory muscle training helps against snoring , JournalMED.de, January 20, 2006.
  20. ↑ The Asate therapy against snoring and sleep apnea! ( Memento of the original from August 1, 2015 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @1@ 2Template: Webachiv / IABot / www.asate.ch
  21. ↑ bmj.com
  22. ↑ Audio ( Memento of the original from November 9th, 2014 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. @ ardmediathek.de, exercise example by Alise Ojay, the author of “Singing For Snorers” (25.09.2014 | 00:50 min. | Available until 25.09.2015 | Source: Das Erste); Snoring 'cured by singing exercise' @ bbc.com, accessed September 28, 2014. @1@ 2Template: Webachiv / IABot / www.ardmediathek.de
  23. ↑ JS Valbuza, MM Oliveira, CF Conti, LB Prado, LB Carvalho, GF Prado: Methods to increase muscle tonus of upper airway to treat snoring: systematic review. In: Arquivos de neuro-psiquiatria. Volume 66, Number 3B, September 2008, ISSN  1678-4227 , pp. 773-776, PMID 18949285 (review).
  24. ↑ Eckart Roloff and Karin Henke-Wendt: Everything about the rhonchopathy that millions suffer from. (Das Schnarchmuseum Alfeld) In: Visit your doctor or pharmacist. A tour through Germany's museums for medicine and pharmacy. Volume 1, Northern Germany. Verlag S. Hirzel, Stuttgart 2015, pp. 79-80, ISBN 978-3-7776-2510-2
  25. ^ Bernhard Honnigfort: A reason for divorce is ripe for a museum. Joseph Wirth from Alfeld has dedicated a museum to nighttime horror. In: Frankfurter Rundschau of June 11, 2018, pp. 18-19.
  26. ↑ Compendium Sleep Medicine for Education, Clinic and Practice (Ed. H Schulz, P. Geisler, A. Rodenbeck) Interaction of the SBAS with constrictions in the upper airways. Hans-Wolfgang Mahlo