Snoring has been plaguing the bedpartners and others, forced to listen to a snorer, for centuries. The solutions ranged from the rare radical ones, as exemplified by J.W. Hardin, the infamous gunfighter from Texas who shot and killed a loud snorer sleeping in the next room, to the most frequent passive submissive ones, as exemplified by many irate listeners finding a different place to sleep. Popular remedies for stopping snoring ranged from going to bed being "wholly unselfish in every thought" to sleeping with the mouth firmly closed by a tape or a gadget. The latter advice achieved a great deal of notoriety and credence after the publication in 1872 of a book by Cattlin who attributed good health of the native Indians to the fact that they are taught, from an early age, to sleep with their mouth shut, ie, to breathe through their nose. Following publication of this book there was a flurry of inventions, such as the one illustrated in Figure 1, designed to eliminate snoring by forced closure of the mouth.
Despite this long-standing awareness of snoring and the havoc it creates in many bedrooms, it was firmly believed that snoring was nothing but a social nuisance, without any adverse health consequences to the snorer. An attempts to eliminate snoring were clearly devoted to improving the suffering of the bedpartner. The classic textbook on sleep disorders, which contains 370 pages, only 5 of which deal with breathing and only one paragraph is devoted to snoring, concludes that "...snoring is harmless to the sleeper, but can be very annoying to others who may be awake at the time." Rob, who wrote one of the first scientific articles on snoring, sounded almost apologetic for "...taking snoring as my subject," admitting finally that "...I have no sensational cures to offer."
Following the recognition of the sleep apnea syndrome, snoring achieved a totally new status, being elevated from a social nuisance to an important clinical symptom. It is undoubtedly the most frequent complaint of patients with obstructive sleep apnea (OSA), which usually precipitates their referral to a sleep laboratory. This close linkage between snoring and sleep apnea delayed our understanding of the possible independent adverse medical consequences of snoring, simply because they have been invariably discussed in the context of sleep apnea.
The purpose of this review is to summarize our present knowledge about snoring by reviewing the available information dealing with the pathogenesis, medical evaluation, adverse consequences, and treatment of snoring. Whenever possible, I shall focus only on those studies that deal primarily with snoring indpendently of sleep apnea.
Pathophysiology and Pathogenesis of Snoring
Snoring is a consequence of changes in the configuration and properties of the upper airway (from the nasopharynx to laryngopharynx) that occur during sleep. In their pioneering observations performed more than 20 years ago, Lugaresi and colleagues[5,6] noted that snoring is associated with increased inspiratory swings in the esophageal pressure, leading to incomplete pharyngeal obstruction. They pointed out that this partial obstruction of the pharynx...
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