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More to snoring than meets the eyes

Ever had sleepless nights from the loud snoring of your bed partner? Or have you been told that your snoring is annoying, intolerable or even worrisome? If your answer is yes, your bed partner or you should seek help! Dr Gan, an ENT Specialist from A Specialist Clinic for Sinus, Snoring & ENT will help answer some common questions about snoring and why the sufferer should be concerned about it.

What is snoring?

Snoring is a rattling or snorting sound produced due to some upper airway (breathing passageway) narrowing during sleep.

Why bother about snoring?

Majority of my patients come to me about their snoring problem because their bed partner has complained bitterly about it and has given them an ultimatum to get the problem fixed. However, many snorers are unaware that snoring does not affect just their bed partner and may be a sign of a potentially serious health condition. This condition is known as Obstructive Sleep Apnoea or OSA.

What is Obstructive Sleep Apnoea (OSA) and how is this different from primary snoring?

When a person sleeps, the muscle around the upper airway relaxes and this can sometimes cause partial blockage of the upper airway. When air flows through a partially blocked upper airway, it becomes turbulent. Turbulent air results in vibration of the walls of the upper airway and produces the noise that we hear in someone who snores. If there are no breathing pauses or choking episodes during sleep, this is called primary snoring.

In patients with OSA, the upper airway blockage is severe enough to cause breathing pauses or choking episodes during sleep. The sufferer literally “stops breathing” or “chokes” for 10-30 seconds during sleep. At the end of the 10-30 seconds, the body has a “mini-awakening” episode known as an arousal, resulting in restoration of upper airway muscle tone and reopening of the upper airway. In patients with OSA, this “choking” episodes occurs many times throughout the night.

How common is OSA in Singapore?

A local study showed that 3 in 10 middle-aged Singaporean male has OSA

What causes snoring and OSA?

Contrary to popular belief, snoring and OSA is not a problem of only overweight or obese male patients. It can happen to anyone with a predisposition for narrowing of the upper airway during sleep. These include patients have the following conditions:

1) Blocked nose from nasal allergies, sinus infection and a deviated nasal septum

2) Large tonsils and adenoids

3) Large tongue

4) Small or receded chin

5) Overweight or obesity

6) Family history of OSA

What are the symptoms of OSA?

Classic symptoms of OSA include:

· Loud snoring

· Choking or gasping episodes during sleep

· Excessive daytime sleepiness

· The need to pass urine frequently at night

· Inability to focus or concentrate at work

· Morning headaches

· Feeling unrefreshed in the morning

· Behavioural problems in children

What should I do if I snore or suspect that I might have OSA?

You should visit an ENT Specialist if you snore or have symptoms suggestive of OSA. During a visit to your ENT Specialist, a thorough assessment will be performed. This will likely include a:

· Clinical history

· Head & Neck examination

· Height & weight measurements and Body Mass Index calculation

· Nasoendoscopy (a relatively painless scope through the nose and throat region under local anaesthesia)

How is OSA diagnosed?

A sleep study is required to diagnose patients with suspected OSA. According to the American Academy of Sleep Medicine, the gold standard for diagnosing OSA is a Polysomnograhy (PSG). It involves placements of wires and sensors on different parts of the patient’s body to analyse various body activities during sleep. This include the recording of patient’s brainwaves, heart activity, eye movements, airflow, oxygen level in the blood and limb movements. The study can be performed in the hospital (in a sleep laboratory) or at the patient’s home.

For patients who have a clinical history and profile that is suggestive of OSA but are not able to tolerate the inconvenience of a full PSG, a simpler sleep study known as a WatchPAT study, can be considered. The WatchPAT does not measure as many body activities as a full PSG during sleep. However, it has been shown to be approximately 85-95% as accurate as a full PSG.

A sleep study helps determine the average number of times a patient “stops breathing” or “chokes“ during sleep per hour. The index used to measure this is known as the Apnoea-Hypopnoea Index (AHI). The severity of OSA can be mild (AHI of 5-14), moderate (15-29) and severe (AHI of 30 or more).

Why worry about OSA?

OSA has been shown to increase the risks of the following complications:

1. Daytime sleepiness and tiredness – Due to repeated choking episodes during sleep, the poor quality sleep in OSA patients can lead to daytime sleepiness. Studies have shown that the risk of being involved in road traffic accidents is much higher in patients suffering from OSA.

2. Heart complications (e.g. higher risk of high blood pressure, heart attack, heart failure, irregular heart beats etc)

3. Brain complications (e.g. higher risk of stroke, inability to focus or concentrate etc)

4. Diabetes and insulin resistance

5. Behavioural problems in children (e.g. higher risk of Attention Deficit Hyperactivity Disorder)

6. Sexual dysfunction

7. Sleep deprived bed partners – Loud snoring can also prevent your bed partner from having a good night’s sleep. A sleep deprived partner can be frustrated and this may put a strain on your relationship.

What are the treatment options for patients with OSA?

The treatment of OSA depends on the severity and likely cause of the OSA. Treatment modalities include:

1. Lifestyle modifications – This include losing weight for overweight or obese patients and getting patients to sleep on their side.

2. CPAP (Continuous Positive Airway Pressure) Therapy – This involves the use of a machine that pumps air through a tube and mask to ensure that the upper airway is “splinted” open by a column of air during sleep. This is the gold standard treatment for patients with moderate or severe OSA and has been shown to reduce or reverse the complications associated with OSA. However, some patients may not tolerate this therapy and may opt for other treatment options.

3. Dental devices – This is a denture-like device that usually works by pulling the tongue and lower jaw forward during sleep. It works best for patients with mild or moderate OSA.

4. Surgery – The type/s of surgery recommended for the treatment of OSA depends on where the area of blockage or narrowing is in the upper airway. Surgery to unblock the nose is sometimes recommended to facilitate the use of a CPAP machine. Patients with large tonsils or adenoids are also more likely to benefit from surgical removal of these tissues.


Dr Gan Eng Cern
Dr Gan Eng Cern

Dr Gan Eng Cern is a fellowship trained Consultant Ear, Nose & Throat (ENT) Surgeon. Before moving to private practice, he was the Chief Rhinologist (Nose and Sinus Subspecialist) at Changi General Hospital, Singapore. He obtained his subspecialty training in Rhinology and Endoscopic Skull Base Surgery at the world renowned St Paul’s Sinus Centre, University of British Columbia, Vancouver, Canada. He was also a Senior Clinical Lecturer at Yong Loo Lin School of Medicine at the National University of Singapore.

A Specialist Clinic for Sinus, Snoring & ENT

+65 6253 7296 38 Irrawaddy Road #08-45 Mount Elizabeth Novena Specialist Centre Singapore 329563

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