by Jayne Carberry, Nathaniel Marshall, Danny Eckert - Guest bloggers
What is snoring?
Noisy breathing or snoring is the sound that occurs due to vibrations of tissues in the throat (e.g. uvula, soft palate and tongue banging on the throat wall) during sleep. Prevalence estimates vary, likely because there is no systematic approach to ‘quantifying’ snoring. In one large population epidemiology study, 50% of the adult population self-reported snoring. People who are overweight with increased neck fat or those who have enlarged tonsils or adenoids are more likely to snore. The repetitive vibrations can cause inflammation in nose and throat which can further perpetuate the vicious cycle of snoring. Men (middle-aged) are at higher risk than women.
Untreated snoring is not just the problem of a bed partner or family member. Snoring may cause daytime sleepiness and impaired memory. Snoring can also be a sign of another major medical condition, Obstructive Sleep Apnoea (OSA) where the upper airway narrows and collapses repetitively during sleep. Similar to OSA, it has been hypothesised that snoring may increase stroke risk .
Sometimes, simple strategies such as not sleeping on your back or avoiding alcohol can prevent snoring and its symptoms. Sadly, for others, it is not so simple and more invasive treatments are required. Some people have surgery or laser treatment to remove excess tissue in the pharynx or to remove the tonsils and adenoids. Some have injections to stiffen the soft palate to vibrate less. Others wear dental devices (mandibular advancement splints) to widen the airway by pushing the jaw forward during sleep. Unfortunately, upper airway surgery can be very painful and predicting who will respond favourably to snoring therapies is not easy.
How could singing potentially help?
When we breathe in, the muscles around the throat are activated and stiffen the upper airway. This enables us to draw air into lungs without the upper airway collapsing. When we sleep, the muscles around the nose and throat relax, which contributes to a more narrow and ‘floppy’ airway. In snorers and people with OSA, upper airway muscle tone during sleep is inadequate.
Singing requires precise control over breathing and challenges the respiratory system. When we sing, air passes through the larynx (voice box) and causes the vocal cords to vibrate. To produce changes in pitch and volume during singing, accurate regulation of the pressure below the vocal cords is required. This is coordinated by precise control and coordination of the laryngeal, diaphragm, abdominal and accessory respiratory muscles. Repetitive use of these muscles to continually adjust the pressure below the voice box to optimise pitch and volume may increase resting muscle tone.
Therefore, it is conceivable that training the muscles of the throat may reduce collapsibility of the upper airway and therefore snoring and sleep apnoea.
Indeed, other methods of muscle training such as targeted tongue exercises or didgeridoo playing reduce sleep apnoea severity, symptoms of sleepiness and snoring frequency. Interestingly, in individuals with quadriplegia, neck muscle (sternocleidomastoid) activity is enhanced following singing training. This highlights the potential benefits from singing. However, snoring was not assessed in this population.
What does the evidence say?
Time to face the music! There is limited data on singing and snoring.
An observational study of 20 chronic snorers found that snoring duration (measured from 1 hour tape recordings over 7 nights) was reduced in snorers who completed singing exercises for 20 minutes a day for 3 months. The participants that improved the most were more compliant with the prescribed exercises and were not obese (body mass index (BMI) <30kg/m2). They also reported improved sleep. Similarly, snoring reported from a questionnaire (snoring scale score) was lower in semi-professional choir singers compared to non-singers, when results were adjusted for age and BMI.
We have found only one interventional study to date examining singing as a treatment for snoring.
This was a randomised controlled study of 127 participants who were snorers or had OSA. The intervention group was provided with a self-guided singing exercises video (recommended for 20 mins a day for 3 months) and received a phone call from a singing teacher to offer support after 4-6 weeks. The control group received no intervention with a similarly timed phone call from a researcher to offer support. Sleepiness was assessed by the Epworth Sleepiness Scale questionnaire. Snoring frequency and loudness were measured using a subjective visual analogue scale (0-10) rated by the participant or bed partner.
Compared to the control group, measures of sleepiness and snoring frequency improved in the singing group. Snoring “loudness” also tended to reduce.
While these findings offer hope, the study did not objectively quantify snoring or sleep. Lack of blinding may have also influenced the subjective outcomes measured in the study. Thus, we still don’t know if singing exercises translate to quantifiable measures of improved upper airway tone. Regardless, there is no evidence to suggest that singing makes snoring worse. Assuming the singing is more harmonious than the snoring there are other good reasons to take up singing such as improved mood and overall quality of life.
Of course, if you or others are concerned about your snoring or if you think you may have OSA, it is best to seek professional medical help.
Disclosures
Jayne Carberry has no disclosures
Nathaniel Marshall receives research funding from the National Health and Medical Research Council (NHMRC) of Australia and has received in-kind support in the form of investigational product from Teva Pharmaceuticals and Neurim
Danny Eckert receives research funding from the National Health and Medical Research Council (NHMRC) of Australia, Cooperative Research Centre Project Grant (collaborative grant between the Australian Government, Academia and Industry [Industry partner: Oventus Medical]), Bayer and Apnimed and has received loan research equipment from Philips Respironics, ResMed and Nox Medical.