Choice Feb 2018 by Karina Bray : Do anti-snoring aids work?

We look at treatments that can help you: from lifestyle changes and the DIY 'tennis ball' technique, to dental appliances, the CPAP machine and surgery.

What causes snoring?

Snoring happens when a collapse, blockage or restriction to the upper airway obstructs the flow of air through the back of the mouth or nose. The sound is created by the vibration of the soft tissues at the back of the throat.

A common cause of snoring is obesity – overweight people have extra bulk around the neck that can restrict their airways. There's also experimental evidence that abdominal fat pushes the chest up towards the upper airway, which then loses its tension, becoming floppy.

Snoring is one of the main symptoms of sleep apnoea, where airways are obstructed during sleep until the person wakes up – often gasping for air. Sleep apnoea is more common among overweight people.

Drugs such as alcohol, muscle relaxants and sleeping tablets can also cause snoring by making the tongue and muscles in the throat relax, go floppy and vibrate. Smokers are also more likely to snore than non-smokers.

Nasal congestion from a cold or allergies can cause snoring, as can eating too much at night, though this would be only temporary.    

Anatomical problems that cause snoring are a bent septum (the wall that separates the nostrils), or an enlarged tongue, uvula (the dangly thing at the back of your mouth), tonsils or adenoids.

Treatment

Snoring is a chronic condition, with no cure – rather, treatment strategies are based on management of it. Because there are many different reasons for snoring, there is no one-size-fits-all solution.

Lifestyle modifications

Certain lifestyle changes can help with snoring, and are worth trying as a first line of treatment.

• If you snore because you're overweight, get some support to help you stick to a sensible eating and exercise plan. Even moderate weight loss has been shown to reduce or stop snoring.
• Avoid sleeping pills, tranquillisers and muscle relaxants. Talk to your doctor about alternatives to medication for anxiety and sleep problems, such as cognitive behavioural therapy.
• Don't drink alcohol for at least four hours before going to bed.
• Quit smoking.

Talk to your doctor

Start with talking to your doctor. They can do a physical examination and make sure there's nothing more serious going on. Many regular snorers, especially heavy snorers, also have sleep apnoea. Sleep apnoea can cause high blood pressure, diabetes, heart attack and stroke. Poor sleep due to sleep apnoea can lead to daytime drowsiness, which impairs job performance and increases the risk of accidents.

Your GP may refer you to a specialist sleep physician, or perhaps an otolaryngologist or ENT (ear, nose and throat) surgeon.

Back snorer? Positional therapy may help

Many snorers only snore when they sleep on their back – the tongue and throat muscles relax, and slump backwards causing a partial blockage of the airway. If this is you, lying on your side may reduce the problem.

So-called positional therapy involves techniques designed to make you sleep in a position where you don't snore, usually on your side. A simple DIY solution is the tennis ball technique - yep, that's its official name. It involves placing a tennis ball into a pocket sewn onto the back of your pyjama top, making it uncomfortable to sleep on your back.

Various anti-snoring pillows claim to prevent snoring by holding your head in a certain position –perhaps to encourage you to sleep on your side, or to 'correct head and spine alignment'. Unfortunately, given that they're such a simple solution, experts doubt a pillow could hold a person in one position for the whole night, particularly if they're prone to tossing and turning.

ENT surgeon Associate Professor Stuart Mackay sometimes recommends for his patients a Rematee, a neoprene chest belt with back pockets that hold inflatable bumpers – a more sophisticated version of the tennis ball technique. They cost around $300, depending on size and shipping costs.

Another positional therapy product he uses is a Night Shift Sleep Positioner, an electronic device worn around the neck which vibrates when the wearer sleeps on their back, training them over time to sleep on their side. It costs $400. BuzzPod is another vibrational positional therapy device, and is strapped around the chest. The device can be trialed for a week for a cost of $88, so you'll discover if the device works for you. It costs an additional $300 if you decide to buy it.

Talk to a dentist who specialises in 'dental sleep medicine'

Dentists specialising in dental sleep medicine (or oral sleep medicine) supply and fit oral appliances to prevent snoring, usually in the form of a mandibular advancement splint (MAS). This device forces the lower jaw forward, increasing the air cavity at the back of the throat. They're very effective – as long as people can tolerate using them.

Experts say the newer appliances are more comfortable than the bulky mouthguards of old, and are good for people with apnoea who can't tolerate the CPAP machine (see below). The best devices are those customised to the individual – 'boil and bite' models are a lot cheaper, but not as effective.

You may need to go to the dentist a few times in the first few months for adjustments. You'll also need to get checked once a year for permanent movements of the jaw and teeth, which are not uncommon. Other potential negatives include dry mouth, irritation, dental discomfort and pain around the joint of the jaw.

A specialist we spoke to said the devices cost about $1700, including the visits required in the first few months. You may get about half of this back on private health insurance. He also said they offer a satisfaction guarantee – if you're not happy after three months, they'll refund 80% of the cost. If you go down this route, check for similar offers from your practitioner.

With only a handful of suitably qualified practitioners in major cities – and it's not something any random dentist can do – it's important your sleep physician refers you to someone with appropriate experience.

CPAP as a snoring solution?

The most effective treatment for sleep apnoea is the continuous positive airway pressure (CPAP) machine. By forcing air into the airways through a nasal mask, it prevents tissue in the throat from collapsing and cutting off air – and therefore oxygen – supply. And in keeping airways open, CPAP also prevents snoring.

The prospect of using a CPAP machine, especially if it's only for snoring, rather than sleep apnoea, can be daunting – the notion of wearing a mask all night can put some people off, and people feel embarrassed about all the equipment or concerned about the effects on their bed partner. Once people have started using it, problems may include dryness (though you can get a humidifier) and air leakage (you may need a different mask).

However, it's very effective. The equipment is expensive, starting at around $1000, with a typical cost closer to $2000 or more, but you can rent a machine for a few weeks to see if it helps and decide whether you find it acceptable. Talk to your doctor about whether it could be right for you.

Snoring on the nose? Nasal strips and Theravent

Nasal strips and dilators are designed to open the nasal passages so the user can breathe more freely through the nose rather than the mouth. These devices could help a small number of people whose snoring is caused by certain types of nasal obstruction.

Based on the same principle as CPAP, Theravent is a single-use adhesive device with valve-type holes that you stick over the nostrils. The valves open when you breathe in, allowing the air to flow in easily, but partially close when you breathe out, providing resistance which increases the pressure in the airways. This pressure helps keep tissue from collapsing and thus prevents snoring. If you sleep with your mouth open, however, the pressure is lost.

Clinical trials have found them effective, and experts we spoke to agreed. However, they did point out that not many people chose to use them every night because they are somewhat intrusive. That said, they can be useful, perhaps even a substitute for a CPAP machine, when traveling or camping.

They're quite cheap, though at $1.25 to $1.50 per day you may find the cost more noticeable over time.

THERAVENT USER TRIAL

Given devices like Theravent are such a cheap and portable solution, we thought we'd put them to the test. We asked five CHOICE snorers to try Theravent Regular for a week, with a device to record the amount of time and volume of snoring.

Some triallists had trouble applying them - one went so far as to remove his moustache to get a better seal! Another commented they wouldn't stick properly when she wore face cream.

Our triallists said they took a few nights to get used to, though one found it intolerable and dropped out after the first night. The main issues were difficulty breathing though the nose, and a dry and/or sore mouth or throat from mouth-breathing. Two reported a whistling sound, which could potentially annoy bed partners as much as snoring.

Three found it reduced snoring, but only two thought they might use them again – perhaps in situations where snoring would bother others, such as on holiday when sharing a hotel room.

Surgery

There are several procedures that tighten the palate by causing tissue scarring and shrinkage, making it firm and less prone to vibration. Such treatments include some types of laser treatment (non-ablative laser that doesn't remove or cut tissue), radio frequencytreatment and 'snoreplasty' – injections of hardening (sclerosing) agents into the palate. Another palate tightening treatment is the Pillar implant system, where small plastic rods are inserted in the palate, causing it to become firm and reduce vibration.

These treatments are considered less invasive than other surgical procedures, because they can be done under local anaesthetic, don't involve cutting and stitching, there's little if any down time, and little pain afterwards.

However, these therapies may still cost thousands of dollars without providing a long-term solution – you may need to go back for more. There's also some concern that scarring could make other treatments, such as CPAP, more difficult if needed in the future.

More invasive surgical procedures can help with snoring, but only if it's appropriate for the particular person, such as those who aren't overweight but have a large palate, a nasal blockage, enlarged tonsils or enlarged tongue that's causing obstruction.

Kids who snore

For kids, snoring and nighttime breathing difficulties may be linked to learning difficulties, aggressive behaviour and hyperactivity.

• If your child snores and has behavioral or learning problems, take them to a sleep specialist.
• If a weight problem is causing the snoring, change their diet and aim for more exercise.
• Surgical removal of the adenoids and tonsils (adenotonsillectomy) may be recommended for children whose snoring is caused by enlarged tonsils or adenoids.
• If snoring is severe or accompanied by pauses, gasps or snorts, have your child tested for sleep apnoea.

Over-the-counter treatments should not be used on children, as their effectiveness and safety for children haven't been confirmed and some products may interfere with a child's development.