My sleep technician is applying globs of cold green gel to my chest, my legs, my jaw, my forehead, and several spots in the thinning brown hair that covers most of my 48-year-old skull. Now he is attaching little adhesive patches with electrodes and connecting them to various colored electrical wires.
The entire process takes nearly 45 minutes, and when he is finished, I have 11 red, white, yellow, black, blue and green wires trailing all over me. I am fully wired. Monitors measure my heartbeat, brain waves, chest and abdominal breathing, and blood oxygen level. Sensors detect eye movement, leg twitches and chin muscle activity. A tiny gizmo records the air flow from my nostrils, and a microphone attached to my neck will pick up any sounds I make in slumber.
"Ready to go to sleep?" asks the technician, whose name is Peter.
"You're kidding, right?"
Only he's not. For this is Sleep Room 3 at the Georgetown University Hospital Sleep Disorders Center and I am here for some serious shut-eye. The setting is intended to be restful, more hotel than hospital. The private room has muted blue carpeting, tasteful herringbone wallpaper, a plush burgundy chair, a multicolored comforter -- and an infrared TV camera mounted on the ceiling to record the sleeper's movements.
Snoring has driven me here. Snoring and guilt, and concern about my health. After 24 years of marriage, my wife, Nina, started to complain about my snoring. Actually, she doesn't really complain that much. Rather, she elbows. Gently, lovingly, of course. She nudges my sleeping carcass until it shifts position and I stop snoring -- until I start again. And then she complains.
Only in the last year has my snoring consistently awakened her. Once, twice, many times a night. I feel so bad about waking her that I am always apologizing profusely, when I am not unconscious. Mostly, though, I just grunt and shift positions. In the morning, I invariably ask her how the night went. "Not too bad," she says on some nights, reporting that I only woke her once or twice. "Not good" on others.
Besides tormenting the woman I love, my snoring is worrying me. Loud snoring can be a harbinger of obstructive sleep apnea, which is basically the blockage of breathing during sleep. This condition can cause chronic severe fatigue, along with hypertension, stroke, heart disease and, in the rarest cases, death. Roughly 1 million apnea sufferers in the United States must sleep with machines that pump their vital air supply through nasal masks.
For nearly six months, I've been exploring my snoring problem in readings and research, in a series of doctor visits, and in various attempted remedies such as nose bandages, homeopathic throat sprays, and vegetable-based nose drops I found on the Internet. But I am still snoring pretty heavily and I haven't been sleeping particularly well. Then, after nearly falling asleep while driving to New York one late afternoon, I realized I'd better seize the moment and follow my doctor's advice to really get checked out in a "sleep study."
Before Peter the technician comes back, I stand and look at myself in the mirror. The wires are sticking out of me in all directions and I look like a badly injured extraterrestrial whose visit to another world has gone horribly wrong. I am hoping this strange sleep experiment will be worth it and start giving me some answers.
Peter returns, hooks my wires to a large monitor and tells me to get in bed, which I manage to accomplish with the grace of a mummy. The room goes totally dark and he leaves. Then Peter's disembodied voice commands me over an intercom to move my eyes up and down, and clench my jaw, to see if all the gizmos are working. All systems are go. Then he cheerfully says, "Have a good night's sleep."
Snoring inevitably evokes laughter and jokes because the snorer looks and sounds quite ridiculous. Loud snoring often spawns family folklore of the father whose snoring is of such symphonic, heroic magnification that he not only wakes Mom, Junior, Sis, the dog and the cat, but even the neighbors -- across the street.
An anthropological theory suggests modern-day snorers are actually reenacting the primitive instinct of making loud noises during the night to scare away animals. I didn't try that one out on my wife -- "Sorry, dear, just trying to keep away the mastodons" -- but I suspect most bed partners of snorers would not be amused.
The fact is that snoring is one of the most pervasive of all obnoxious human habits, as I discovered in launching my search for a cure. Some 40 to 45 percent of the adult population -- up to 90 million people -- snore at least occasionally, according to surveys by the National Sleep Foundation and other estimates. For the baby-boom generation, it is an epidemic: More than half of middle-aged American men are believed to be chronic (and the loudest) offenders, and roughly a third of adult women snore, too. A study released last month by the Mayo Clinic shows that spouses of heavy snorers lose an average of one hour's sleep per night.
The cause of all this is a partial blockage of the upper air passage somewhere between the nose and throat. This unseen realm of the body is populated by various soft tissues -- the tongue, the soft palate, the tonsils, the adenoids and the uvula (Latin for "little grape"), which dangles in the throat for no apparent major purpose except noise-making. This region is known as the collapsible airway because it has no rigid framework or support. The open passage is normally at least the diameter of a pencil, but in snorers it narrows to more like a cocktail straw when the soft tissues sag and produce a flutter-valve effect, like a flag flapping noisily in a stiff breeze.
Promised remedies are numerous. Earplugs for your mate are the most obvious, but they don't work that well. There are also sprays, drops and various potions designed to shrink the offending tissues, plus more than 300 anti-snoring devices registered with the U.S. Patent and Trademark Office, dating back more than a century. Chin straps, neck collars and dental inserts have been used to reposition the tongue and reopen the airway. Modern electronic gadgets use flashing lights, loud noises and even electric shocks to jolt snorers into quiet. Some attempted cures mimic the method used as far back as the American Revolution, when soldiers sewed small cannonballs into pockets on the back of their comrades' uniforms to keep them from sleeping on their back and waking the whole brigade.
Unfortunately, most of these remedies don't work on most snorers -- or if they do, it's because they keep you awake. Some severe snorers resort to surgery. Doctors can remove or tighten the various flapping soft tissues through an operation pioneered in Japan in the 1950s known as uvulopalatopharyngoplasty, or UPPP, which doctors say is fortunately easier to perform than pronounce. Or they can use a more modern, laser-assisted method or an even newer technique employing low-frequency radio waves to painlessly burn away noisy tissue.
I learned more about all this firsthand at a neighbor's 50th birthday party when Nina mentioned my research. We were immediately surrounded by friends and strangers regaling one another with snoring tales: ruined vacations, threatened marriages, snoring so severe that several of the men had tried various kinds of surgery. None of these surgical options were attractive to me. They can be either risky or painful or costly, particularly since most insurance policies won't cover $2,000 operations just for snoring unless there is also serious airway blockage. And surgery doesn't always work.
I have to confess that for a time I didn't really, truly even believe that I snored. I didn't think Nina was lying, but maybe exaggerating. So initially I wasn't that motivated to cure something that, after all, didn't bother me. Then I began tape-recording my sleep with my little Sony at my bedside. The verdict was clear. I snore. It doesn't sound horribly loud, but it is horribly unrelenting. Each momentary pause is tension-filled because you know another snore is coming. It is like listening to the theme music from "Jaws."
If that didn't fully convince me of the need for action, there was the night that Nina herself snored. Mildly, delicately. Yet even at low volume, the snores became maddening in their rhythmic inevitability. I could hear nothing else. Pillow over the head did not work. I finally elbowed her, gently, lovingly, to get her to change positions, and it stopped long enough for me to get to sleep -- with a new perspective.
Sleeping with someone is a most intimate act, in some ways perhaps even more than sex. Sharing a bed is sharing a life; you must accommodate your needs and your partner's. Nina needed sleep, and a few times she ended a disrupted night by retreating to our guest room. Often, older couples in search of rest will opt for this as a permanent arrangement, a form of aural divorce. I was determined to avoid it.
Michael Siegel, a well-recommended otolaryngologist, otherwise known as an ear, nose and throat doctor, sprays a horribly bitter anesthetic up my nose. This bothers me at first, but I welcome the numbness when I see that his plan is to probe the recesses of my nasopharynx with a long section of garden hose.
Okay, it is actually a fiber-optic endoscope, but it seems awfully large when he sticks it up my nose and keeps probing until it reaches somewhere near my ankles.
"You've got quite a blockage," he says. "When was your nose broken?"
The question catches me by surprise. My nose hadn't been broken, or had it? I immediately flash on pitching a sandlot baseball game when I was 12 and getting hit hard in the right eye socket by a line drive. My parents and doctor were so concerned about possible damage to the badly blackened eye that we didn't pay much attention to the nose.
Mine is a prominent and slightly hooked proboscis. But in all my years of studying it, I somehow had never really noticed that it tilts ever so slightly, almost imperceptibly, to the right.
I tell the doctor I've had my share of nasal congestion and hay fever, but never been conscious of any permanent blockage. I tell him my nose is usually clogged when I'm lying down, but that I assumed it was just a minor allergy. He says that if the nose is as badly blocked as it appears, it could be a strong contributor to the snoring. He suggests a CAT scan.
"Beautiful!" Siegel says 10 days later, as he examines the computer-generated film. "You certainly have a lot of pathology." He shows me the image of my badly deviated septum (the divider that separates the nostrils) and the misshapen nasal turbinates (spongy bones in roughly seashell shape) that apparently grew abnormally after my injury and nearly closed off one side of my nose.
He recommends surgery, which would involve general anesthesia and extensive remodeling of my nasal passages over a few hours. It will help me breathe better, he says, with maybe a 50-50 chance of solving my snoring problem. The other likely culprit, he says, is my uvula, which is about 50 percent larger than normal and a contributor to the noise. It, and some surrounding loose tissue, should probably be surgically removed, which Siegel at that time was doing by laser, in a procedure that cost about $1,000.
Siegel delivers the sad fact of midlife. "As you age, things hang a little more," including the tissues inside the throat, he says. "Your uvula hangs a bit."
"But Doc," I say, as we discuss removing my uvula, "what if I want to have more children?"
Siegel smiles, tolerantly.
Personal habits can be crucial in the struggle against snoring because it turns out that alcohol, fat and laziness, things with which I have some familiarity, all contribute to it. I am willing to do almost anything to solve this problem, even change my lifestyle -- up to a point.
I enjoy a cocktail or two at home after work and have no intention of giving that up. But now I began to heed the warning that drinking within three hours of bedtime will likely increase snoring because booze relaxes muscle tissues. So I start making sure that last call is before 8 p.m.
Diet and exercise are also key variables because fat and poor muscle tone usually worsen the problem. Men with neck sizes over 161/2 are most likely to be heavy snorers. I exercise vigorously virtually every day, and while I am slightly overweight, I'd already lost more than 30 pounds in a serious diet five years ago. I know my limits and I have no intention of wasting further effort on dieting.
Snoring is worst when sleeping on your back, but I had trained myself years earlier to sleep on my side to relieve back pain.
All of this means that I'd done almost everything I could, in terms of behavior modification. It was time to experiment with remedies.
The Breathe Right strip is the creation of a self-taught inventor-engineer from Minnesota named Bruce Johnson. He suffered from a deviated septum that caused severe nasal congestion when he tried to sleep. Unsatisfied with medicines, Johnson tried various tubes, wires and clips in an effort to keep his nostrils open. Finally, he came up with the idea of two little pieces of plastic within an adhesive pad that attaches to the outside of the nostrils and arches them open.
Approved for sale in 1993 as a possible remedy for nasal congestion and snoring by the Food and Drug Administration, the product has been a huge success. With several million regular users, including many athletes who use it to enhance oxygen intake, it generates sales of about $70 million a year.
I have high hopes for a cheap, easy fix for roughly 50 cents a night. The strips are silly-looking, but early on I have a few evenings with moderately promising results. Then the snorting returns with a vengeance.
I decide I will need a multi-front attack. Conventional nose sprays and drops seem to reduce congestion, but ultimately they are no match for my schnoz. On the Internet, there are dozens of snoring-related Web sites, a cyber-carnival with barkers shouting about miracle cures. I select three promising products, and soon, with a $60 investment, I have my own little snoring pharmacopeia at my bedside: SnoreStop chewable tablets are a homeopathic remedy, relying on the principle that microscopic doses of natural irritants will stimulate the body's natural healing processes. The pills, it is claimed, can combat mucus congestion and reduce swelling of the uvula through the action of ominous-sounding ingredients such as belladonna, nux vomica and ephedra vulgaris. Snoreless throat spray bills itself as "an all-natural herbal spray that lubricates the throat, palate and uvula with rich emollients such as almond oil, olive oil, sunflower oil, eucalyptus oil" and vitamins. Y-Snore nose drops come in a tiny bottle of homeopathic herbal extracts that, when applied, feel something like dripping Tabasco into the nostrils.
Y-Snore has the added cachet of a celebrity endorser -- Melvyn Switzer, a 60-year-old British cabbie, the man who is to snoring what Michael Jordan is to basketball. Switzer is immortalized in the Guinness Book of World Records: On June 28, 1984, his snoring was measured at 87.5 decibels, approximately as loud as a motorcycle. Switzer won the dubious distinction as the world's loudest snorer as part of a British tabloid newspaper contest. Later, he lost out to a prodigious Canadian snorer -- but then regained his crown at 92 decibels, which puts him in the company of revving lawn mowers and pneumatic drills.
I telephone Switzer and his wife, Julie, who have been married for 38 years. "Luckily, I am deaf in one ear, so I could muffle the sound," Julie says. "I never left the marital bed. I realized he wasn't doing it on purpose." She endured it cheerfully for many years, she says, but when she recently started working outside the home she prayed for a remedy.
Mel says he tried most everything over the years: "Golf ball strapped on me back . . . various kinds of pillows . . . gum shields to move me jaw around . . . electric wristbands to give you a little electric shock . . . clips you put on your nose." Nothing worked.
The Switzers, who say they have had several neighbors move away because of Melvyn's noise, were amazed several years ago when he tried Y-Snore nose drops and did not snore. Melvyn was skeptical: "I said, `It's a total bit of luck. Let's give it a little bit of a test.' So I went out and had a few beers and a few more beers and a late meal" and still didn't snore. When I ask Melvyn if he was paid to endorse Y-Snore, he is insulted. "I wish they did pay me . . . If I was getting paid, I wouldn't be a taxi driver at night."
Unfortunately, Y-Snore does not work for me. It follows the same pattern as the Breathe Right strips and the other products. One night it seems to help, but the next night is as bad as ever. I try Breathe Right, SnoreStop, Snoreless and Y-Snore, individually and in various combinations over a period of months. The only thing that seems to solve the snoring problem is when one of us is out of town.
"He's an animal in bed . . ." proclaims the newspaper advertisement, with a photo of a big guy sleeping with his mouth open. "He snores like a lion."
The catchy ad is a blurb for a seminar on somnoplasty, a new technique using radio waves, and it draws 30 middle-aged people, white and black, male and female, to a banquet room at a downtown Washington hotel.
"This is not surgery. This is just tightening tissue so that it doesn't rattle around at the end of the throat." This is the disarmingly low-key pitch from Anita Lane Ver Voort, sales director for a California firm that invented the method and sells its $20,000 machine, plus supplies, to doctors. She is selling the treatment on behalf of an ENT (ear, nose and throat) group practice that is the first in the region to offer it.
Ver Voort bad-mouths the UPPP and laser-assisted surgeries as invasive and painful, compared with somnoplasty. She shows a slide of the aftermath of the laser, an angry-looking reddish mass of wet flesh inside the throat. "It hurts to even look at," she says, as several audience members groan in agreement. She says the laser method claims at least a 75 percent success rate, but hurts badly for up to two weeks.
By contrast, she says, somnoplasty is virtually painless. "You will feel like you swallowed a golf ball" and have a slight sore throat for a few days, she says.
The 20-minute treatment involves anesthetizing the throat and inserting a needle one-half inch below the surface at three spots around the uvula and palate. The radio frequency energy, at relatively low temperature, burns tissue beneath the surface, which then scars and tightens as it heals.
Somnoplasty was approved by the FDA in 1997 and has been used on about 6,000 patients. Ver Voort says about 60 percent of patients are happy with the results after a single treatment, and the rest are offered additional treatment at no charge. She says 30 percent more are satisfied after the second treatment, for an overall success rate of about 90 percent. The American Academy of Otolaryngology, however, estimates success rates differently. The academy says various studies suggest that laser surgery is roughly 85 percent successful and somnoplasty about 75 percent.
Success, however, is relative. "We don't say that it totally eliminates snoring," Van Voort says. ". . . But the best way to describe it is that it will eliminate snoring as a problem in your life."
From the audience, someone asks if there are any drawbacks. Before Ver Voort can answer, somebody else calls out, "Yeah! Two thousand dollars!" which elicits laughter.
It sounds to me like a relatively promising treatment, but I've got two kids going to college and $2,000 sounds like an awful lot of money. The next morning I get a call from the doctors' office, which is offering a discount on somnoplasty for people attending the seminar. Can they schedule me for a visit?
The results of my overnight sleep study finally come in. The good news from this $1,200 examination (most of it covered by my insurance) is that I do not suffer from sleep apnea. But the readout of my polysomnogram has some unsettling data: I had 11 episodes of hypopnea, which is a partial blockage of air flow that causes the brain to awaken. I also had 22 sleep arousals, which are brief disruptions of sleep up to 15 seconds, and 18 awakenings, which last more than two minutes.
Richard Waldhorn, medical director of the Georgetown Sleep Disorders Center, tells me that my rate of breathing disturbances -- 2.4 per hour of sleep -- is relatively mild. People with apnea have five or more deep disturbances per hour, sometimes even more than 50. But he notes that my various disruptions prevented me from getting to the deeper and more restful stages of sleep.
The printout shows that during my six-hour sleep adventure, I actually slept only 4 hours 40 minutes. During that 280 minutes of sleep, however, only 14 minutes were in the deepest stages of sleep and only 31 minutes were REM, or rapid eye movement sleep, which is also necessary for rest and dreaming. Those figures are only about half the normal duration, according to the report, meaning essentially that my snoring is robbing me of a restful sleep.
Noting my deviated septum and enlarged uvula, Waldhorn suggests that nasal surgery is probably necessary to improve my breathing, but he cautions that it is not necessarily going to cure my snoring.
Nonetheless, I am tired of dealing with this. I am finally starting to come to grips with the idea of surgery. But fear and inertia make me postpone. I try a few other last-ditch remedies. A new vaporizer and an allergenic pillow cover are supposed to clear my breathing passages, but they don't seem to make much difference. Then I try putting four-inch blocks under the head of our bed, as recommended, but Nina says it gives her vertigo and makes her feel like she's part of a sleep-deprivation experiment.
These efforts feel more and more pathetic, not to mention ineffective. I'm ready to do something.
David Fairbanks is a gray-haired, avuncular guy who has been treating snorers for nearly 30 years and he wrote the book on snoring. Actually, he edited the textbook, Snoring and Obstructive Sleep Apnea. His ENT partners call his practice "surgical marriage therapy," Fairbanks says. "There are no more grateful patients than my snorers who have been cured."
Fairbanks, the fourth and final doctor I consult, is an entertaining fellow who has a Washington-oriented slide show for prospective patients. He points out that snorers are in good company: Washington, Lincoln, Grant, Cleveland and FDR were all said to be fairly heroic snorers, and Teddy Roosevelt supposedly snored so loudly during a hospital recuperation that nearby patients had to be moved.
When he sees my nasal CAT scan, Fairbanks, like the others, is quite impressed. "Wow! This is really something . . . I'd like to show this to my colleagues." He says the nasal blockage creates a vacuum effect when I breathe, which could be intensifying the noisy flapping of my throat tissues.
He starts describing the work that should be done on the septum, sinuses and turbinates, but I get lost and ask him to explain. "We'd tunnel into your nose," he says, "and it's like taking a sandwich apart. We'd take out the sandwich, take out the baloney part, work on that and put it back in."
Fairbanks declares my uvula to be large and flabby, suggesting it should be removed. It is only a vestigial blob of flesh, after all. In some animals, it helps separate the breathing and swallowing passages, but humans don't need it. "I had my own cut off, and I quit snoring then and there," he says. "I just make it numb and cut it off with a scissor . . .
We can do it right now, if you want." He is quite serious. He'll do it right here, right now.
I am stunned by the offer but pass on it. I am encouraged by how routine Fairbanks makes it sound. He stresses that he can't promise results from either procedure, but suggests that doing both should give me at least a 50-50 chance of success. "We don't `cure' you," he says, "but we probably will make you better."
The $2,000 cost of fixing the deviated septum will be covered by insurance, while the uvulectomy will be a few hundred dollars, and might be at least partially covered. I'll be under general anesthesia about two hours, and I will probably be able to go home on the day of the surgery. The nose will hurt quite a bit and will have to be packed with gauze for several days. I'll be out of commission perhaps five days or so.
Soon afterward, I decide to have the surgery. Soon after that, I have second thoughts. I fear that it not only will it be painful and dicey, but it also may not work. Then again, I also feel that at least I will have tried everything possible to deal with my snoring, and I can at least sleep -- and snore -- with a clearer conscience.
My memory of my visit to the Sibley Memorial Hospital operating room begins with a nurse gently slapping me awake, followed by hours of pained grogginess. My head feels like I lost a heavyweight fight. My nose and throat are throbbing. I am offered morphine, which I gladly accept, and later ask for a refill.
The biggest shock, though, comes when I get the first look at my nose in the mirror. I look like Jake LaMotta, the long-suffering prizefighter portrayed by Robert De Niro in "Raging Bull." I don't have the black eyes, but my face is puffy and my nose is the size of a kielbasa.
I did not realize that packing the nose actually means jamming it to the bursting point with five yards of surgical gauze impregnated with ointment. I refuse to believe that this nose I'm looking at will ever shrink back to the relatively normal size I've come to know and love.
I keep opening my mouth to observe the absence of the amputated uvula. I keep saying "aaahhh" so I can get a good look at it, but the sound comes out all wrong, and I realize I'll have to wait until I get home and get a flashlight to explore the remodeled cavern.
The packed nose means that all my breathing must be through the mouth, but my throat is fiercely sore from the uvulectomy. So much so that I can't drink or eat, and can barely swallow a few ice chips. Overall, I'm a fairly dazed, hurtin' mess and am relieved when the doctor decides I should stay overnight.
I come home on a Thursday and the next four days are a blur of painkillers and rented videos. Nina takes off two sick days to care for me, which is very nice, since I am feeling miserable, sorry for myself, and deserving of attention because I have valiantly gone under the knife in the interest of marital harmony.
On Day 5 I finally get my nose unpacked, which turns out to be the most harrowing part of all, even with local anesthetic. As Fairbanks pulls and pulls and pulls the packing out, my body arches in the chair and I have a horrible fantasy that along with the five yards of gauze, my eyeballs and maybe my brain are going to be pulled out as well.
It takes an eternity to unpack the whole thing, but when it's finally over, the change is stunning. I feel as if a whole new nasal passage has been drilled deep into my head. I immediately have a greatly increased air flow. As I sit in the doctor's chair, I exhale through my nose and can feel the breeze rustle the hair on my arms. It is like a new toy, although in a Washington summer it also means inhaling more allergens and pollutants and for a while I feel hypersensitive, as if I'll overdose on the air and everything in it.
But the snoring gets worse! Actually, Fairbanks had warned that could happen for the first few days because surgery leaves the nose and throat a mass of swollen tissues. It's so bad that Nina sleeps in the guest room. I am worried that I will be among that 1 or 2 percent for whom such operations make things permanently worse.
Then, starting on the third night, things get better. The snoring is not altogether gone, but it is greatly diminished in both volume and pitch. "It was a different sound, a quiet sound more in the nose than the throat," Nina says. "I wasn't wakened at all. It's nothing like before!"
We don't immediately celebrate because it's only one night. Then the pattern repeats. Repeatedly. I still get off an occasional snort now and then, but I sleep quietly. What little snoring she detects is a gentle sound of air rustling through the nose.
We have done it. Weathered the storm of nightly blasts. It is a great relief going to sleep, knowing that I don't have to feel like a heel upon awakening. Nina is definitely sleeping better these days.
I am also sleeping better. Waking up less often, and dreaming more. I am feeling rather good about it all, although I am still cognizant that if I gain weight or start hitting the booze a bit too much or otherwise age excessively, those throat tissues will start sagging and it's trouble.
I am determined not to backslide, though, and I am guided in this resolve by the ageless wisdom of whoever first said, "Laugh and the world laughs with you -- snore and you sleep alone."
Peter Perl is a staff writer for the Magazine.