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Snoring and obstructive sleep apnea (OSA)

Q: Ever since I was a little girl, I amazed my parents with my powerful snoring. Sometimes I wake myself at night. Other times, however, I wake up gasping for air. I used to scare my husband when we were first married. He said I would be snoring loudly, then suddenly the room would be dead silent. I didn't breathe for such an extended period that he would shake me to see if I was okay. Twenty years ago I consulted an ear, nose and throat specialist. He could find no cause for my snoring. My questions are 1) Is my snoring curable? 2) Do I have sleep apnea?

A: Here are the quick answers to your questions:
(1) Yes. 

(2) Maybe.
But first things first. You either suffer from snoring or obstructive sleep apnea. (Apnea, by the way, means "no breath.") The difference is one of degree; a snorer makes everyone else in the house miserable, but sleeps well and has no ill health effects as a result of the snoring. An obstructive sleep apnea (OSA) patient makes everyone else in the house miserable, AND sleeps poorly, AND (if the OSA is sufficiently severe) may develop high blood pressure, bedwetting (not just in children!), right heart failure, and pulmonary hypertension. Patients with even moderately severe OSA have an increased risk of dying prematurely from heart attack, stroke, or accidental death (e.g., by falling asleep behind the wheel.)

Snoring is usually due to "rattling" of the uvula and soft palate against the back of the throat during inhalation. OSA is a more extreme problem. In some patients, the uvula and soft palate block the airway, while in other patients, the tongue falls backward, blocking the airway. Still others have obstruction at both levels. The patient is unable to take a breath, but may struggle mightily to take a breath. The obstruction wakes the patient, who "catches her breath" (often with a loud gasp), then goes back to sleep without realizing that she was ever awake. In patients with extremely severe OSA, this process may repeat 100 or more times each hour! 

Patients with OSA often (but not always) complain of daytime sleepiness; however, many patients come to medical attention only because their spouses are frightened by their nocturnal airway calisthenics. You might think it would be easy to determine who has OSA and who is just an "innocent snorer" based on the history provided by the spouse or the patient... but it is not at all easy. The ONLY way to make this determination is with a sleep study (polysomnography, or PSG.)


During a sleep study, the patient is connected to a variety of monitors, which record the electrocardiogram (electrical activity of the heart), electroencephalogram (electrical activity of the brain), pulse, respiratory rate, and oxygen saturation (the amount of oxygen in the blood). A wealth of information is derived from the sleep study. How many apneas does the patient have per hour, and how many hypopneas per hour? (Hypopneas are episodes of dangerously shallow breathing, but breathing does not cease, as in an apnea.) How often does the patientís blood oxygen content drop to dangerous levels, and how low does it get? Does the patient have any heart rhythm problems during sleep? How poorly does the patient sleep? Most importantly, does the patient have obstructive sleep apnea?


Weíve come a long way in the understanding of OSA in the last 20 years. I suggest you find an ENT or pulmonary medicine specialist who can evaluate and treat you for OSA. By the way, beware the doctor who proposes to treat you without first obtaining a sleep study: this is definitely below the standard of care. How are OSA and snoring treated? The treatment of choice for OSA is CPAP, which stands for "continuous positive airway pressure." CPAP is a device worn by the patient during sleep, which provides air under pressure; this stents open the airway, preventing obstruction. Provided the patient can tolerate the device, CPAP is almost always effective. If the patient cannot tolerate CPAP, the only other option is surgery. Surgery is a second-best option because it entails risk, pain, and the success rate is less than that achieved with CPAP. A variety of operations are available to modify the soft palate and uvula, pull the tongue forward, reduce the size of the tongue base, or even provide a direct path for air to travel into the trachea (tracheostomy.) The choice of operation depends on the site of obstruction and the severity of the OSA. There is also an oral device which holds the tongue forward during sleep. This device is effective only if the patientís obstruction is solely at the level of the tongue base, and only if the patient can tolerate the device. Snoring, on the other hand, is treated by a variety of procedures which reduce and/or stiffen the uvula and soft palate. 

Currently, the two most popular treatments are: 
(1) a laser procedure, in which furrows are burned into the soft palate; as the furrows heal, the soft palate and uvula stiffen and shorten. This procedure can also be performed using an electrical cautery tool. The two procedures are known, respectively, as laser-assisted uvulopalatoplasty (LAUP) and cautery-assisted uvulopalatoplasty (CAUP).

(2) a procedure in which an electrode is embedded into the soft palate and uvula in 5 or 6 places, and radiofrequency energy is applied at each location; this also creates separate injuries, which, in healing, cause the soft palate and uvula to stiffen. This procedure is called a radiofrequency-assisted uvulopalatoplasty, and has also been called "somnoplasty."

I am a proponent of the second procedure, since it is much less painful than the laser procedure. It is less aggressive, however, so the patient is more likely to require repeated treatments. Another downside of the radiofrequency procedure is its novelty; it has not been in use as long as the laser procedure, so the long term results (greater than 4 or 5 years) are unknown.

This letter originally appeared in Dr. Hoffman's column on
Copyright (c) 1998 - 2000, Douglas Hoffman, MD all rights reserved
Reprinted with permission from The Medical Consumer's Advocate 



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