This interesting article appeared in The International Journal of Otolaryngology and Head & Neck Surgery – Vol.2 No.3(2013), Article ID:31850 by M. P. Hilton, J. Savage, B. Hunter, S. McDonald, C. Repanos, R. Powell from The Department of Otolaryngology, Head & Neck Surgery, Royal Devon & Exeter NHS Foundation Trust, Exeter

The study, a prospective single blinded randomised controlled trial was undertaken to assess the effectiveness of regular singing exercises in reducing symptoms of snoring and sleep apnoea.

Snoring & Sleep Apnoea.

Upper airway resistance during sleep can present with a range of symptoms from simple snoring (SS) through to severe obstructive sleep apnoea (OSA). The prevalence of OSA is 2% – 4% in men, and 1% – 2% in females. Severe sleep apnoea has a prevalence of 0.3% – 0.7%. The prevalence of SS is much higher. Pharyngeal narrowing or collapse leads to reduction or cessation in airflow during sleep, and is associated with loud snoring.

In adults, risk factors include alcohol, sleeping tablets, obesity, & nasal obstruction. Sedatives, including alcohol, act by reducing muscle tone in the upper airway and pharynx, rendering them more likely to narrow and collapse.The presenting symptom of OSA is usually excessive daytime sleepiness. Patients often report a gradual deterioration of symptoms of snoring over several years to the point of presentation. A more rapid onset of severe symptoms should prompt enquiry towards metabolic abnormality predisposing to rapid weight gain or hypothyroidism, or the presence of pharyngeal pathology, e.g. tongue base lymphoma.

Several studies have now shown a correlation of sleep apnoea with cardiovascular disease. Moderate to severe sleep apnoea, as defined by Apnoea-Hypopnea Index (AHI) greater than 20, is associated with an excess risk of hypertension and mortality from stroke and ischaemic heart disease. The Wisconsin Sleep Cohort study also identified an association of increased motor vehicle accidents with OSA.

Conventional definition of OSA has been on the basis of an AHI value: a greater value implying progressively more severe disease. However, there is generally poor correlation between sleep study parameters and self report of sleepiness. Many would now consider that severe symptoms of excessive daytime somnolence carry equal weight in determining pragmatic approach to treatment.

High quality evidence for treatments associated with snoring and sleep apnoea is limited. Conservative measures, such as weight reduction, treating nasal obstruction, reduction of evening alcohol and hypnotics are widely recommended and seem sensible and reasonable approach for many people but have no evidence base.

Continuous positive airways pressure (CPAP) is the main treatment modality for OSA in adults. CPAP therapy in patients with moderate to severe sleep apnoea is associated with a significant improvement in daytime sleepiness and overall quality of life. There is a reduction in blood pressure when OSA patients are treated with CPAP, but no evidence that intervention with CPAP or any other modality of therapy alters long term morbidity and mortality from cardiovascular disease

Surgery: In Children tonsillectomy and adenoidectomy may be useful surgical treatment when they suffer from OSA. In adults the principal surgical intervention for primary snoring is laser uvulopalatoplasty, radiofrequency palatal ablation, or palatal implants. These techniques demonstrate improvement of symptoms in the short term . Longer term results for palatal surgery diminish over time, with only 34% of patients reporting good symptom control after 2 years

A local singing teacher (AO) observed that some patients undergoing formal singing training, which involved exercises of repetitive contraction-relaxation cycles of pharyngeal muscles over a period of several weeks, reported reduced snoring and improved sleep as a consequence. This was the basis on which the study was undertaken.

The Study: 127 adult patients with a history of simple snoring or sleep apnoea were recruited (72 with SS, 55 with OSA). 93 patients completed the study. Patients were excluded because of severe sleep apnoea (apnoea index > 40), or morbid obesity (BMI > 40). The study group completed a self-guided treatment programme of singing exercises contained on a 3CD box set (“Singing for Snorers”, UK), performed for 20 minutes daily for 3 months.

Outcome measures: included the Epworth Sleepiness Scale (a widely used, validated and reliable measure of sleep quality, and is rated from 0 to 24; higher scores representing greater daytime somnolence), the SF-36 generic quality of life assessment tool, visual analogue scales (VAS range 0 – 10) as rated by the patient and/or partner of snoring loudness and frequency and visual analogue scale of compliance 0 – 10 cm representing “never doing the exercises” to “doing the exercises every day”(for intervention group).

Results: The Epworth scale improved significantly in the experimental group compared to the control group (difference ?2.5 units; 95% CI ?3.8 to ?1.1; p = 0.000). Frequency of snoring reduced significantly in the experimental group (difference ?1.5; 95% CI ?2.6 to ?0.4; p = 0.01), and loudness of snoring showed a trend to improvement which was non-significant (difference ?0.8; 95% CI ?1.7 to 0.1; p = 0.08). Compliance with exercises was good; median 6.6 (quartiles = 4.1, 8.3).

Their Conclusion: Improving the tone and strength of pharyngeal muscles with a 3 month programme of daily singing exercises reduced the tendency of these muscles to collapse during sleep thereby reduced the severity, frequency and loudness of snoring, and improved symptoms of mild to moderate sleep apnoea.

(For the full article refer to the journal listed above)