Snoring; Causes, Symptoms, Diagnosis, Treatment

Snoring

Snoring is the vibration of respiratory structures and the resulting sound due to obstructed air movement during breathing while sleeping. In some cases, the sound may be soft, but in most cases, it can be loud and unpleasant. Snoring during sleep may be a sign, or first alarm, of obstructive sleep apnea(OSA). Research suggests that snoring is one of the factors of sleep deprivation.

Snoring and OSA syndrome are prevalent and important causes of sleep disturbance. Snoring, historically considered to be only a habitual annoyance, has significant physical and social consequences. OSA is now considered to be a major public health concern with significant morbidity and mortality. CPAP is considered the treatment of choice for OSA syndrome, but poor patient acceptance and compliance remain problematic. Surgical procedures have been developed to alter the offending anatomic abnormalities responsible for OSA. Identification of the offending anatomic site with application of the most appropriate surgical procedure is essential for effective surgical treatment of OSA. When the region of the retropalate is correctly identified as the site of obstruction, UPPP can effectively treat OSA in a majority of patients. Surgical correction of nasal obstruction is advocated in conjunction with sleep apnea surgery when nasal obstruction exists. In OSA patients with retrolingual airway obstruction, a number of surgical procedures have been performed, with or without UPPP, with some improvement over UPPP alone. MMO has been effective in the treatment of OSA in patients with significant retrolingual airway obstruction with contributing skeletal abnormalities and in patients who have failed multiple other surgical procedures. MMO, however, is a procedure of considerable magnitude, requiring extensive oromaxillofacial surgical expertise. MMO is likely appropriate only in a limited number of patients. Tracheostomy is completely effective in the treatment of OSA syndrome but is undesirable to patients and is associated with significant physical and emotional morbidity.

snoring

Snoring occurs when the muscles of the airway relax too much during sleep and vibrate (creating noise) when air we breathe passes in and out. Most people will snore at some time, however loud or chronic snoring can disrupt sleep-quality and disturb others. Particularly when loud, it is often associated with other sleep-related breathing disorders, such as obstructive sleep apnoea (OSA).

Anatomy of Snoring

HOW you snore reveals WHY you snore
Type of snoring What it may indicate
Closed-mouth snoring May indicate a problem with your tongue
Open-mouth snoring May be related to the tissues in your throat
Snoring when sleeping on your back Probably mild snoring—improved sleep habits and lifestyle changes may be effective cures
Snoring in all sleep positions Can mean your snoring is more severe and may require a more comprehensive treatment

snoring-causes

Common Causes of Snoring

  • Allergies
  • Eating too much at night
  • Nasal congestion
  • Deformity of the nose
  • Consumption of alcohol close to bed-time, especially if the amount is large
  • Being overweight or obese
  • Pregnancy
  • Swelling of the muscular part of the roof of the mouth
  • Swollen adenoids or tonsils, especially in children
  • Medications, including sleeping tablets
  • Sleep position – sleeping on your back may cause your throat muscles and tongue to relax; the tongue is then more likely to fall back and compress the airway, causing snoring or making snoring louder.
  • Age – As you reach middle age and beyond, your throat becomes narrower, and the muscle tone in your throat decreases. While you can’t do anything about growing older, lifestyle changes, new bedtime routines, and throat exercises can all help to prevent snoring.
  • Being overweight or out of shape – Fatty tissue and poor muscle tone contribute to snoring. Even if you’re not overweight in general, carrying excess weight just around your neck or throat can cause snoring. Exercising and losing weight can sometimes be all it takes to end your snoring.
  • The way you’re built – Men have narrower air passages than women and are more likely to snore. A narrow throat, a cleft palate, enlarged adenoids, and other physical attributes that contribute to snoring are often hereditary. Again, while you have no control over your build or gender, you can control your snoring with the right lifestyle changes, bedtime routines, and throat exercises.
  • Nasal and sinus problems – Blocked airways or a stuffy nose make inhalation difficult and create a vacuum in the throat, leading to snoring.
  • Alcohol, smoking, and medications – Alcohol intake, smoking, and certain medications, such as tranquilizers like lorazepam (Ativan) and diazepam (Valium), can increase muscle relaxation leading to more snoring.
  • Sleep posture – Sleeping flat on your back causes the flesh of your throat to relax and block the airway. Changing your sleep position can help.

Structural factors related to craniofacial bony anatomy that predisposes patients with OSA to pharyngeal collapse during sleep, e.g

  • Retrognathia and micrognathia
  • Maxillo-Mandibular hypoplasia
  • Adenotonsillar hypertrophy, particularly in children and young adults
  • High, arched palate (particularly in women)

Nonstructural risk factors for OSA include

  • Central fat distribution
  • Male sex
  • Age
  • Postmenopausal state
  • Alcohol use
  • Sedative use
  • Other conditions associated with the development of OSA are as follows: Hypothyroidism, Stroke, and Acromegaly.

Smoking and alcohol consumption are often considered as risk factors for sleep apnea despite the limited evidence, especially in females.

It is well-known that alcohol consumption before going to bed worsens sleep apnea in males and that smoking is related to snoring in males and females.

snoring-causes

An overnight sleep study can be performed to assess the nature and severity of snoring, and to check for other sleep-disorders that often accompany snoring, especially obstructive sleep apnoea (OSA).

Symptoms of Snoring

Obstructive Sleep Apnea (OSA) symptoms begin insidiously and are often present for years before the patient is referred for evaluation.

Nocturnal symptoms may include:

  • Frequent loud snoring, witnessed apneas, restless sleep, nocturia and mouth breathing associated with the presence of obstructive SDB.
  • The hallmark of OSA are the witnessed apneas during sleep.

Daytime symptoms may include:

  • Nonrestorative sleep (e.g., “waking up as tired as when they went to bed”)
  • Morning headache, dry or a sore throat
  • Excessive daytime sleepiness (EDS) that usually begins during quiet activities
  • Daytime fatigue/tiredness
  • Cognitive deficits; memory and intellectual impairment
  • Sexual dysfunction, including impotence and decreased libido.
  • Disruptive snoring: A history of disruptive snoring has 71% sensitivity in predicting sleep-disordered breathing (SDB).
  • Disruptive snoring and witnessed apneas: These factors taken together have 94% specificity for SDB.

Physical exam findings may include:

  • Obesity – Body mass index (BMI) greater than 30 kg/m
  • Large neck circumference – Greater than 43 cm (17 in) in men and 37 cm (15 in) in women
  • Abnormal (increased) Mallampati score (Mallampati score assessment (originally designed for quantifying different intubation) is a simple and fast method for assessing upper airway dimensions)
  • Enlarged, or “kissing,” tonsils (3+ to 4+)
  • Retrognathia or micrognathia, macroglossia
  • Large degree of overjet
  • High-arched hard palate
  • Systemic arterial hypertension, present in approximately 50% of patients with OSA

Clinical assessment of tonsillar size (Brodsky score) is a weak predictor of presence or severity of obstructive SDB. During an evaluation, other differential diagnoses must be considered before labeling as sleep apnea.

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Causes of nocturnal dyspnea include bronchial asthma, gastroesophageal reflux disease, and panic disorder. EDS might be a result of poor sleep hygiene, alcohol or drug abuse, atypical depression, and narcolepsy. Nocturia is prevalent and increases sharply with age. It might be caused by urological and other medical conditions such as hypertrophic benign prostate, diabetes mellitus, congestive heart failure, renal disease, diabetes insipidus and intake of diuretic medication.

Treatment of Snoring

All patients with OSA should be counseled about the potential benefits of therapy and the hazards of going without treatment.

Non Pharmacological Measure including Diet, Devices and Surgery.

Pharmacological

  • Treatment depends in part on the severity of the sleep-disordered breathing (SDB). People with mild apnea have a wider variety of options, while people with moderate-to-severe apnea should be treated with nasal continuous positive airway pressure (CPAP).
  • CPAP treatment is indicated for all OSA patients with an RDI of 30 or more events per hour, regardless of symptoms, based on the increased risk of hypertension.
  • Treatment with CPAP is indicated for patients with an RDI of five to 30 events per hour for documented cardiovascular diseases to include hypertension, ischemic heart disease or stroke.
  • A randomized clinical trial shows significant improvement in all sleep-related symptoms, including snoring, witnessed apnoeas, choking, nightmares, daytime hypersomnolence (all p<0.001) and nocturia (p=0.049), in the CPAP group. In elderly patients with severe sleep apnea, CPAP treatment achieves an improvement in all domains of quality of life measured by QSQ, including day-time and night-time symptoms and social and emotional domains.
  • Effective CPAP is defined as the pressure level at which all apneas, hypopneas, respiratory-effort related arousals and snoring events are abolished. This pressure level could be maintained constantly throughout the night (Standard CPAP) or it could be automatically adjusted by the CPAP-device according to the patient needs (Auto-CPAP).
  • In patients with mild-to-severe obstructive sleep apnea who refuse or reject nasal CPAP therapy or who cannot tolerate CPAP due to persistent massive nasal mask air leakage or discomfort, BiPAP therapy should be tried next. If this therapy fails or is rejected, Oral Appliances should be considered.
  • Adequate adherence to PAP is defined as more than 4.5 hours of PAP use per night on a routine basis. Maximal improvement in neurocognitive symptoms can require as long as two months of PAP treatment.

Oral appliances

  • Oral appliances are considered an alternative to CPAP for treating OSA. Mandibular advancement devices/tongue retaining devices reduce sleep-disordered breathing and subjective daytime sleepiness, improve the quality of life compared with control treatments and are recommended in the treatment of patients with mild to moderate OSA.
  • General and behavioral measures, such as weight loss, avoidance of alcohol for four to six hours before bedtime, and sleeping on one’s side rather than on the stomach or back, are elements of conservative nonsurgical treatment.
  • Because obesity is a major predictive factor for OSA, weight reduction reduces the risk of OSA. The best data suggest that a 10% reduction in weight leads to a 26% reduction in the respiratory disturbance index (RDI). Patients with sleep-disordered breathing should be advised to have sufficient sleep and appropriate sleep hygiene.

Sleep hygiene instructions

  • Restricting caffeine after lunch
  • Restriction of other drinks or foods with activating properties (e.g. coke, tea, chocolate)
  • No alcohol intake in the evening
  • Restriction of smoking especially close to bedtime
  • Regular physical activity
  • Reduction of noises in the bedroom
  • Instructions to make the bed comfortable and to keep the bedroom dark during the night
  • Proper ventilation of the bedroom

Positional treatment aims at avoiding the supine horizontal posture while sleeping. This method might be effective in patients with positional OSA. Tennis ball attached to the back of a night-shirt, a variety of straps and vests with foam attachments, auditory alarms aimed at training patients to refrain from sleeping in the supine posture are a number of devices used for postural therapy.

Surgery: Upper airway surgery and Barriatric Surgery for weight loss.

Medications

  • Dronabinol – Nonselective agonist of cannabinoids type I and type II receptor reduces central apneas and reduction in AHI index in small studies but still need further safety data to be estabilshed treatment.
  • Modafinil –  is approved by the US Food and Drug Administration (FDA) for use in patients who have residual daytime sleepiness despite optimal use of CPAP. The most improvement has been seen in patients who have taken modafinil at doses of 200-400 mg/d. The mechanism of action of modafinil in wakefulness is unknown. It has wake-promoting actions similar to sympathomimetic agents.
  • Armodafinil – the R-enantiomer of modafinil, is also now FDA approved for use in these patients. Patients in whom noninvasive medical therapy (e.g., CPAP, BiPAP, OAS) fails should be offered surgical options.

Surgery

  • Various surgical techniques are available for treatment of OSA. Their aim is to permanently increase upper airway patency and decrease pharyngeal resistance. Surgery may be applied as a first-line therapy in selected patients with mild OSA who have surgically correctible anatomical abnormalities contributing to upper airway collapse during sleep.
  • Nasal surgery, radiofrequency tonsil reduction, tongue base surgery, uvulopalatal flap, laser midline glossectomy, tongue suspension and genioglossus advancement cannot be recommended as single interventions. Uvulopalatopharyngoplasty, pillar implants, and hyoid suspension should only be considered in selected patients, and potential benefits should be weighed against the risk of long-term side-effects.
  • Hypoglossal nerve stimulation for the treatment of OSA may be a safe and effective alternative for improving OSA outcomes in individuals with moderate to severe OSA who have difficulties with CPAP therapy.
  • The most appropriate treatment for snoring varies according to the severity of snoring, presence of sleep apnoea, age, body-weight, degree of daytime sleepiness, alcohol-consumption, medical history and the anatomy of the upper airway. A Sleep Physician is a doctor who specialises in treating patients with snoring and other sleep-disorders, and who is qualified to help sufferers make an informed decision about which treatment is the most appropriate.

 Theravent

  • Theravent Snoring Therapy is available in Australia for patients with snoring (but no obstructive sleep apnoea).  The treatment involves small adhesive devices that cover the nostrils.  Similar to Provent Therapy, the unique valve system is designed to eliminate snoring by increasing the pressure inside the airway.
  • Theravent is an effective treatment for many patients with troublesome snoring, particularly when combined with other conservative snoring treatments (including lateral sleep and weight-reduction).

Exclusively Lateral Sleep

  • Exclusively lateral sleep can be an effective, non-invasive treatment of snoring and obstructive sleep apnoea.  It achieves this by preventing the tongue, soft palate and uvula from falling backward under the effect of gravity, thereby causing the pharyngeal airway to be restricted. This, in turn, results in an increased speed of air-flow through the narrowed airway, causing an increase in soft-tissue vibration and resultant snoring.  A variety of simple measures can be implemented to encourage exclusively lateral sleep, such as the use of a bolster pillow placed lengthwise in the bed (to lean against) or pinning tennis balls (or the like) to the back of a pajama top.  As the tennis ball causes discomfort to the wearer when supine, it typically causes the wearer to turn back to a lateral position.  Within a few weeks, most people learn the habit of sleeping laterally and will no longer require tennis balls or similar measures.  Exclusively lateral sleep is limited however in its effectiveness, particularly in sufferers with severe obstructive sleep apnoea.  In this case alternative treatments are required.
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Night Shift Device

snoring-causes

  • Night Shift is a new lateral sleep position aid that assists patients to sleep exclusively on their side.  Many patients have obstructive sleep apnoea that is significantly worse (or only present) when sleeping on their back (the supine position).   The device accurately monitors sleep-position and vibrates when supine sleep is detected, helping many patients with position-related airway disorders to avoid other OSA treatments. It records positional data and snoring volumes that can be downloaded, either to provide you with information on your sleep, or to provide to your Sleep Physician to monitor the progress of your treatment.
  • Night Shift can also be used in conjunction with other OSA treatments, including Provent Therapy.  Patients who require CPAP can use Night Shift as well to lower their nightly CPAP setting.
  • For ethical reasons, we do not sell Night Shift or any other treatment device, but our doctors may recommend a trial based on the results of your sleep study.

Weight-loss

  • Weight loss will generally decrease the severity of snoring, although not all people who snore are overweight, but weight gain will typically make existing snoring even worse.  Losing even a little weight can reduce fatty tissue in the back of the throat and decrease snoring. In some patients, weight loss may not cure snoring, but can significantly reduce its loudness

Cessation of Tobacco Smoking

  • In addition to causing cancer and being a major health risk, tobacco smoke causes the walls of airways to retain fluid and swell (this is called oedema). This causes the airway to narrow, worsening snoring (and sleep apnoea). Smokers are 4 to 5 times more likely than non-smokers to suffer from snoring and obstructive sleep apnoea. Nicotine also contributes to insomnia and poor sleep-habits.

Mandibular Advancement Splint (MAS)

  • A Mandibular Advancement Splint is a small device (a type of dental splint) which is placed in the mouth during sleep, causing the lower jaw and tongue to be held more forward than usual. This in turn opens the pharyngeal airway, resulting in a lower rate of air-flow.
  • This minimises vibration of the tissues at the back of the pharynx, thereby reducing the volume of snoring. However, there are a number of problems which can occur for users of a MAS, including a build-up of excessive amounts of saliva, discomfort of jaws and teeth, problems with the gums and other oral tissues with certain types of MAS, particularly if fitted incorrectly and in a significant percentage of patients, permanent repositioning of the teeth and an altered bite over a period of years.

Continuous Positive Airway Pressure (CPAP)

  • As for obstructive sleep apnoea (OSA), CPAP is currently the most effective treatment for simple snoring. CPAP involves the use of a compact air pump to deliver a continuous flow of pressurized air (via a mask) to an individual’s airway. This pressurised air acts as a pneumatic splint and prevents the airway from collapsing, which in turn causes snoring to cease. Each individual’s pressure-requirement differs, depending on a variety of factors, including weight and severity of snoring. These and other details of

Nasal Steroids and Allergy Treatments

  • Naso-pharyngeal congestion from allergies can also contribute to a narrowing of the airways.  Nasal congestion limits the amount of air a person can breathe through their nose while asleep.  This can be caused by the presence of an allergen in an individual’s immediate environment, resulting in an inflammatory response and mucosal swelling, which blocks the nose.
  • Mouth-breathing is then the only available means to ensure that sufficient oxygen is delivered to the body. Nasal steroids can be an effective way to combat the underlying allergic reaction, eg, with prescription agents such as ‘Nasonex’.  Certain over-the-counter nasal steroids are also available from pharmacies.

Non-Steroidal Over-The-Counter Nasal Sprays and Other Anti-Allergy Treatments

  • Other over-the-counter treatments may also be beneficial in patients prone to nasal allergies or troublesome nasal congestion at night-time.  The most common cause of nasal congestion is temporary swelling of nasal passages due to colds or allergic reactions to pollen, dust, mould, animals or some foods.
  • These can cause the lining of the nasal membrane to become inflamed, and mucus to thicken and become acidic. There are a number of over-the-counter nasal sprays that can be helpful in the short term, eg, FESS Nasal Spray, a non-medicated saline nasal spray.
  • Nasal sprays like Afrin, Neo-Synephrine, NasalCrom (Cromyln) and anti-histamines can also be useful as decongestants. However the use of such sprays for more than 72 hours can cause a rebound, negative effect.  Allergy desensitization treatments will sometimes be recommended by a Sleep Physician, Allergist or General Practitioner.

snoring-causes

ENT Interventions and Surgery and Other Procedures on the Soft Palate

  • When narrowing is due to structural abnormality, ENT surgery can be very helpful as a means of opening the nasal passages, thereby improving nasal air-flow and eliminating the sufferer’s need for mouth-breathing.

Surgical procedures which have been used in the hope of reducing snoring include uvulopalatopharyngectomy (UPPP), radio frequency uvulopalatopharyngectomy (RFUPPP) and laser-assisted uvuloplasty (LUAP). These treatments tend to be painful and expensive, and they often fail to cure snoring, especially when this is loud.  They have no place as a treatment for snorers who also suffer from moderate or severe OSA (and in fact, can complicate later treatment of OSA with CPAP).

  • Injection snoreplasty is a nonsurgical treatment for snoring whereby the soft palate is injected in front of the uvula with a hardening agent. This creates an inflammatory reaction and results in scar tissue, which in turn stiffens the soft palate and ultimately reduces the amount of palatal tissue ‘flutter’.
  • When this is the cause of snoring, the treatment can result in reduced snoring volume. Unfortunately, a number of other pharyngeal tissues can vibrate and cause snoring and this technique cannot assist when this is the case. Also, this is presently a new treatment, with limited long-term evidence of its effectiveness.

External Nasal Strips

  • Nasal strips such as ‘Breathe Right’ appear to reduce snoring in some patients through opening the nasal passages, but there are no published scientific studies which definitely prove that these strips do in fact assist significantly with snoring.  These strips probably have their main place in the 5-10% of individuals whose nostrils collapse during inspiration.

Nocturnal Sedatives and Alcohol

  • Nocturnal sedatives (such as sleeping pills) and alcohol (especially in large quantities) can cause narrowing of the pharynx as a result of relaxation of pharyngeal muscles, with a resulting increase in soft-tissue vibration and snoring.  Reducing the intake of these agents commonly therefore helps to reduce snoring volume.
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Bedtime remedies to help you stop snoring

  • Change your sleeping position – Elevating your head four inches may ease breathing and encourage your tongue and jaw to move forward. There are specifically designed pillows available to help prevent snoring by making sure your neck muscles are not crimped.
  • Sleep on your side instead of your back – Try attaching a tennis ball to the back of a pajama top or T-shirt (you can sew a sock to the back of your top then put a tennis ball inside). If you roll over onto your back, the discomfort of the tennis ball will cause you to turn back onto your side. Alternatively, wedge a pillow stuffed with tennis balls behind your back. After a while, sleeping on your side will become a habit and you can dispense with the tennis balls.
  • Try an anti-snoring mouth appliance – These devices, which resemble an athlete’s mouth guard, help open your airway by bringing your lower jaw and/or your tongue forward during sleep. While a dentist-made appliance can be expensive, cheaper do-it-yourself kits are also available.
  • Clear nasal passages – If you have a stuffy nose, rinse sinuses with saline before bed. Using a Neti pot, nasal decongestant, or nasal strips can also help you breathe more easily while sleeping. If you have allergies, reduce dust mites and pet dander in your bedroom or use an allergy medication.
  • Keep bedroom air moist – Dry air can irritate membranes in the nose and throat, so if swollen nasal tissues are the problem, a humidifier may help.

Self-help strategies for snoring

  • There are so many bizarre anti-snoring devices available on the market today, with more being added all the time, that finding the right solution for your snoring can seem like a daunting task.
  • Unfortunately, many of these devices are not backed up by research, or they work by simply keeping you awake at night. There are, however, plenty of proven techniques that can help eliminate snoring.
  • Not every remedy is right for every person, though, so putting a stop to your snoring may require patience, lifestyle changes, and a willingness to experiment with different solutions.

Bedtime remedies to help you stop snoring

  • Change your sleeping position – Elevating your head four inches may ease breathing and encourage your tongue and jaw to move forward. There are specifically designed pillows available to help prevent snoring by making sure your neck muscles are not crimped.
  • Sleep on your side instead of your back – Try attaching a tennis ball to the back of a pajama top or T-shirt (you can sew a sock to the back of your top then put a tennis ball inside). If you roll over onto your back, the discomfort of the tennis ball will cause you to turn back onto your side. Alternatively, wedge a pillow stuffed with tennis balls behind your back. After a while, sleeping on your side will become a habit and you can dispense with the tennis balls.
  • Try an anti-snoring mouth appliance – These devices, which resemble an athlete’s mouth guard, help open your airway by bringing your lower jaw and/or your tongue forward during sleep. While a dentist-made appliance can be expensive, cheaper do-it-yourself kits are also available.
  • Clear nasal passages – If you have a stuffy nose, rinse sinuses with saline before bed. Using a Neti pot, nasal decongestant, or nasal strips can also help you breathe more easily while sleeping. If you have allergies, reduce dust mites and pet dander in your bedroom or use an allergy medication.
  • Keep bedroom air moist – Dry air can irritate membranes in the nose and throat, so if swollen nasal tissues are the problem, a humidifier may help.

Lifestyle changes to help you stop snoring

  • Lose weight – Losing even a little bit of weight can reduce fatty tissue in the back of the throat and decrease, or even stop, snoring.
  • Quit smoking – If you smoke, your chances of snoring are high. Smoking irritates the membranes in the nose and throat which can block the airways and cause snoring. While quitting is easier said than done, it can bring quick snoring relief.
  • Avoid alcohol, sleeping pills, and sedatives – because they relax the muscles in the throat and interfere with breathing. Also talk to your doctor about any prescription medications you’re taking, as some encourage a deeper level of sleep which can make snoring worse.
  • Be careful what you eat before bed – Research shows that eating large meals or consuming certain foods such as dairy or soymilk right before bedtime can make snoring worse. Placing a household ban on the following snore-hazards right before bedtime can make for quieter nights.

Six anti-snoring throat exercises

  • Exercise in general can reduce snoring, even if it doesn’t lead to weight loss. That’s because when you tone various muscles in your body, such as your arms, legs, and abs, this leads to toning the muscles in your throat, which in turn can lead to less snoring. There are also specific exercises you can do to strengthen the muscles in your throat.

Studies show that by pronouncing certain vowel sounds and curling the tongue in specific ways, muscles in the upper respiratory tract are strengthened and therefore reduce snoring. The following exercises can help

  • Repeat each vowel (a-e-i-o-u) out loud for three minutes a few times a day.
  • Place the tip of your tongue behind your top front teeth. Slide your tongue backwards for three minutes a day.
  • Close your mouth and purse your lips. Hold for 30 seconds.
  • With your mouth open, move your jaw to the right and hold for 30 seconds. Repeat on the left side.
  • With your mouth open, contract the muscle at the back of your throat repeatedly for 30 seconds. Tip: Look in the mirror to see the uvula (“the hanging ball”) move up and down.
  • For a more fun exercise, simply spend some time singing. Singing can increase muscle control in the throat and soft palate, reducing snoring caused by lax muscles.

References

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