Snoring is the sound of soft tissue in the throat vibrating as you breathe in your sleep. On its own it is mostly a nuisance for whoever sleeps next to you. In some people, though, the airway closes for seconds at a time, again and again through the night: that is obstructive sleep apnoea. This article explains how the two are told apart, what usually comes first and where palate and tonsil surgery fits.
Telling snoring from sleep apnoea
As you fall asleep, the throat muscles relax, and the soft palate, the uvula, the tonsils or the base of the tongue can come close enough for the passing air to make them vibrate. A blocked nose adds to this by making you breathe through your mouth.
In obstructive sleep apnoea, breathing stops or becomes shallow for several seconds at a time. The brain wakes you just enough to breathe again, often with a snort or a gasp you do not remember, and this can happen many times an hour.
A partner often notices the pauses in breathing and the gasping or choking. During the day you may feel tired however long you slept, struggle to concentrate or wake with a headache. Obesity, a large neck, older age, alcohol, smoking and sleeping on your back all make sleep apnoea more likely.
The difference matters because untreated sleep apnoea is linked with high blood pressure and a higher chance of stroke, and tiredness makes accidents more likely. If you feel sleepy during the day, do not drive until this has been assessed and is under control.
The sleep study
Snoring alone does not show whether apnoea is present or how severe it is. A sleep study records your breathing and heartbeat while you sleep, usually at home with a small device you put on before bed, sometimes during a night in a sleep clinic.
The result is the number of times an hour your breathing stops or becomes shallow: 5–14 is mild sleep apnoea, 15–30 moderate and more than 30 severe. It guides the choice of treatment, and a repeat study later shows what a treatment has changed.
What usually comes first
The first steps are the same for snoring and for sleep apnoea. If you are overweight, losing weight can reduce both. Drink less alcohol, and none in the hours before bed, as it relaxes the throat muscles further. If you smoke, stopping helps too. Both are often worse on your back, so try to sleep on your side.
A nose that is often blocked makes you breathe through your mouth at night, which tends to worsen snoring. Strips that hold the nostrils open may help, and a nose blocked most of the time is worth having examined, since a deviated septum, swollen turbinates or an allergy can be treated in their own right.
When sleep apnoea is mild, these changes may be all that is needed. Another option is a device like a gum shield, worn at night, that holds the lower jaw slightly forward so the airway stays more open.
CPAP for moderate or severe apnoea
CPAP (continuous positive airway pressure) is a small bedside machine that blows air gently through a mask, and the pressure holds the throat open. For moderate or severe sleep apnoea it is the treatment usually offered first. A guideline of the American Academy of Sleep Medicine recommends starting with it even when the throat is clearly narrow, as its risks are small compared with those of surgery.
Getting used to the mask takes time. For adults who cannot get on with CPAP or do not want it, the same guideline recommends discussing a referral to a surgeon as one of the other options.
Where palate and tonsil surgery fits
Surgery can only help if the narrowing is where the operation acts. Before it is considered, an ENT specialist examines the nose, mouth and throat, often with a thin flexible camera passed through the nose. The narrowing may sit at the palate, the tonsils, the base of the tongue or in several places, and palate surgery alone does not address a narrowing lower down.
Surgery is therefore an option for selected people, usually after a sleep study, and not a general treatment for snoring. The guideline notes that the benefits seen in studies apply to patients a surgeon judged suitable, and that the balance of benefit and risk depends on the person, from the severity of the apnoea to the operation chosen. For snoring without apnoea, surgery is sometimes used when other measures have not helped, but it does not always work.
What the operation involves
Uvulopalatopharyngoplasty, or UPPP, widens the airway behind the soft palate. The soft palate is trimmed, the uvula shortened or removed and the tonsils taken out if they are still there. When large tonsils are the main cause of the narrowing, removing them (tonsillectomy) can be the whole operation.
The operation is done under general anaesthetic through the open mouth, with no cut on the outside, and the stitches dissolve within a few days. A blocked nose may be treated beforehand or at the same time. Your surgeon will tell you in advance whether you need to stay in hospital overnight.
Recovery
Expect a sore throat for about two weeks, often a painful one, with the first days up to a week usually the worst. Earache is common too, because the throat and the ear share a nerve. Take your painkillers regularly and as prescribed, and avoid aspirin unless a doctor has prescribed it.
Eat and drink normally rather than living on soft food, as using the throat muscles helps healing, and drink plenty. At first some fluid may come out of your nose when you drink and your voice may sound nasal, because the healing palate is shorter and moves less; both usually settle within one to two weeks.
For two weeks, keep away from people with coughs and colds and from smoky or dusty places, and avoid alcohol and smoking. Plan for up to two weeks off work; feeling fully yourself can take about a month.
Bleeding from the mouth or throat is an emergency: call 112 or go to the nearest emergency department straight away. Call the practice the same day if you have a fever, bad breath with a coated tongue, or pain your painkillers do not control, as these can be signs of infection.
Risks and results
Like any throat operation, UPPP can be followed by bleeding, on the day or in the two weeks after, and by infection, and general anaesthesia carries its own risks. After healing, some people notice a dry throat, a change in taste, a feeling of something stuck in the throat or difficulty swallowing; these usually fade, but in a small number of people they last.
Results differ from person to person. In some people the apnoea improves clearly, in others only partly, and CPAP or a mouth device is still needed. Snoring can also come back over the years, especially with weight gain or alcohol in the evening, so the everyday measures still count after surgery.
Whether surgery is worth considering in your case depends on your sleep study and the examination; questions about your own situation are answered at a consultation.