04-Sleep&SnoringProblems

Why do people snore?

Snoring is a low frequency noise that is produced by the vibration of the soft palate and back part of the tongue. These vibrations are caused by the turbulent flow of air as it passes through a narrowing in our throat. The soft palate and back part of the tongue flaps like a flag in the wind to give rise to the low frequency sound we recognize as snoring.

Air passing through our throat becomes turbulent when it has to squeeze through a narrowing. The area of narrowing can be found at the level of the nose, soft palate or back of tongue. Like the turbulent currents of a river as it passes through a constriction between two rocks, air that passes through a narrowing in our throat becomes turbulent.

Someone who has a blocked nose or sinus infection may start to snore. Those with repeated tonsil infections, which cause the tonsils to swell and enlarge, may also develop snoring. A very common reason for snoring occurs in those who are obese or have recently put on weight, and start to snore.

Can snoring affect the quality of sleep?

That depends on whose quality of sleep you are referring to! Are you referring to the wife, children, or the snorer himself? Some people snore so loudly that doctors have coined them – ‘heroic snorers’. A heroic snorer in your home can create more noise and disturbance for your family than if you had the MRT trains running under your home. Snorers do deprive other family members of sleep and rest. In some countries, snoring can be a cause of marital discord, divorce, family embarrassment and other social problems. The snorer himself usually does not know that he is snoring. He does not know he is a nuisance unless someone tells him so. Ignorance is bliss. Occasionally I have encountered people who say that they can hear themselves snoring. But they are exception rather than the rule.

Very severe snorers with extremely narrowed airways may go into episodes during sleep when they stop breathing for a few seconds. These episodes are called apnea, which literally means ‘no breathing’. Sufferers with this condition are unable to enjoy deep restful sleep. It is not because they are troubled by the noise. The reason is that severe snorers with apnea used to exhaust more energy in trying to keep their airways opened so that enough air can pass through their narrowed air passage. The energy is spent trying to do two things:

  1. To draw air from the atmosphere into the lungs, and
  2. To keep the airways open to prevent them from collapsing.

This is hard work. It keeps the snorer vigilant and ‘on his toes’, preventing him from lapsing into deep slumber. The snorer is prohibited from entering deep restful sleep because when that happens, not enough air would flow into the lungs and the airways would collapse and obstruct. Thus, the snorer is in a constant state of alertness even during sleep. It is like doing aerobics in bed. Because he was deprived of good result sleep, he would wake up the next day feeling tired – a condition called daytime somnolence. People with daytime somnolence feel tired at work, became irritable, and perform below their potential at work. This has serious repercussions in individuals who rely on a sharp creative mind for a living. Those who operate on heavy machinery or drive taxis may pose a hazard to others.

Is snoring a common problem? Does it lead to other more serious diseases?

Most of us have snored before. I personally had feedback from my wife who claims that I snore after I have had a few drinks with the boys. That is because alcohol depresses our brains so that we sleep deep. Our muscles relax more and the air passages become narrower. Turbulence builds up, tissues vibrate and snoring occurs. People also tend to snore more when they are sleeping flat on their backs. If you push those people so that they lie on sides, the snoring becomes softer and more tolerable. Yet others snore because they have been deprived of sleep over past few nights, or have been burning midnight oil studying for exams or meeting deadlines at work.

Yes, snoring is a common problem! However, these intermittent snorers are not a cause for concern. I am particularly worried about 3 categories of snorers:

  1. Those individuals whose snoring has become a cause of, embarrassment, social problems or marital discord.
  2. Those who develop daytime somnolence, poor work performance, and who pose hazard on the roads.
  3. Those snorers who have sleep apnea and who have a higher chance of developing hypertension, heart problems and strokes later on in life.

People who snore and experience daytime somnolence will need a sleep study. This will help a doctor to determine if the airways actually collapse completely during sleep so as to obstruct breathing. The oxygen levels are also monitored during sleep to determine if there is a drop in the patient’s oxygen levels. The more severe the obstruction, and the greater the drop in oxygen levels, the greater is the risk of developing daytime sleepiness, high blood pressure, heart problems and strokes.

What are the symptoms and signs of sleep apnea?

  1. Loud and chronic (ongoing) snoring, pauses may occur in the snoring, choking or gasping may follow the pauses
  2. Day time sleepiness
  3. Feeling un-refreshed on awakening in the morning
  4. Headache
  5. Memory and learning process, unable to concentrate
  6. Feeling irritable
  7. A dry throat when you wake up
  8. Urination at night
  9. Decreased libido

What kind of people snore? Can snoring be prevented?

The majority of people who snore are obese. Obesity causes fat to deposit not only on the belly and thighs, but on the neck as well. The deposition creates a cosmetic problem like a fat double chin, but more seriously it reduces the diameter of the airways. The prevention for these types of snorers is to lose weight, keep slim, eat in moderation and exercise regularly. Prevention is cheap and can yield other health benefits too. It saves you the hassle of having to go for the other treatments for snoring and surgery. It is for this group of obese snorers that prevention is possible.

There is another group of adult snorers who are slim, fit and healthy. Prevention is a less feasible option in these cases, as there is usually a specific underlying problem. These people may have sinusitis and blocked nose, or enlarged tonsils. Weight control, regular exercise and other preventive measure may help to a minor degree. Treatment in these cases may involve either medications or surgery to clear the sinus infection, alleviate blocked nose, or remove the tonsils.

Snoring in Children

Children can also snore. But the causes of snoring in children differ from adults. Children snore when their adenoids start to enlarge at the age of three to five years. They may also snore when they catch a viral infection that causes the nose to get blocked.

Treatments may be directed at the nose, and may include nose sprays, oral medications or surgery. If the adenoids or tonsils are enlarged, these may be surgically removed to create a wider air space for easier breathing. If the patient is obese and unmotivated to lose weight, then a period of observation may be all that is needed. Specific treatment for snoring may include surgery to the palate or tongue. Alternatively, the patient may use appliance that delivers air at positive pressure via a nose mask to prevent the airways from collapsing during sleep. This treatment is referred to as CPAP or continuous positive airway pressure. Whatever the options, snoring is a problem that is highly amenable to treatment – surgical or otherwise.

How is Sleep Apnea Diagnosed?

Your doctor will ask you and your family members questions about how you sleep and how you function during the day. Consider keeping a sleep diary for 1 or 2 weeks. Write down how much you sleep each night, whether you wake up in the night, how sleepy you feel at various times during the day.

A thorough clinical history including a flexible nasolaryngoscopy is usually done in the evaluation of patients with suspected sleep apnea. Patients suspected of obstructive sleep apnea is usually advised to undergo an overnight sleep study (polysomnography) either at the hospital or the patient’s own home or hotel.

Polysomnogram Sleep Study

Patients suspected of obstructive sleep apnea is usually advised to undergo an overnight sleep study (polysomnography) either at the hospital or the patient’s own home or hotel.

A Polysomnogram (PSG) is a multiple-component test, which electronically transmits and records specific physical activities while you sleep. The recordings become data, which will be “read” or analyzed by the doctor to determine whether you have a sleep disorder.

Disadvantages of Polysomnogram:

  • With the many wires and electrodes attached to the body and head, very often patients complained that they are unable to sleep naturally in a new environment such as the hospital.
  • Additional hospital and nursing treatment cost of staying overnight

Watch-PAT 200 Sleep Study

The Watch-PAT is a new, clinically proven diagnostic device utilising innovative technology that enables accurate detection of sleep related breathing disorders, in the comfort of the patient’s home. Monitoring changes in peripheral arterial tone and activity, as well as in blood oxygen saturation levels, the Watch-PAT identifies sleep apnea events at very high sensitivity and specificity levels. The wrist-mounted Watch-PAT has been clinically validated in multiple studies as a very reliable and effective technology, with outcomes comparable to in-hospital PSG sleep studies.

The advantage lies in its comfort during sleep and is a convenient way of assessing a patient’s risk for obstructive sleep apnea.

Figure.1 Watch-PAT 200 Sleep Study done in the comfort of your home

snoring2

What can be done to fix a snoring problem?

People who snore constantly and loudly need medical attention. Those who have apnea need even more urgent intervention. Selection of the right treatment will depend on what specific causes result in snoring, and whether any complications have occurred.

Treatment of obstructive sleep apnea is directed at solving the current problems that the patient is experiencing as well as to avert the future complications that will arise if sleep apnea is left untreated. Current problems include daytime sleepiness, poor job performance, impaired cognitive and intellectual functioning, reduced motor skills, and increased risk while on the road. Future complications that may arise from untreated sleep apnea include hypertension, heart disease and stroke.

We always try to troubleshoot first before attempting to fix the problem. Proper diagnosis should always precede any therapeutic measures we take to alleviate the problem.

  • Weight Management

Obesity and weight gain play a dominant contributory role in many cases of obstructive sleep apnea. A rational dietary program that aims to help the patient lose weight is an important part of management. Other simple measures include abstinence from alcohol and sleeping pills, as these tend to exacerbate the severity of apnea.

The patient’s cardiovascular status should be evaluated. Many of these patients may already have hypertension without knowing it. Identification of hypertension is essential as it necessitates active management to prevent the future development of heart disease and stroke. Good control of hypertension is also a prerequisite for safe surgery. If this option is contemplated,. Hormonal problems like low thyroid levels should also be looked for and treated when present.

  • Nasal Treatment

Patients with blocked nose should have that treated. Nasal obstruction worsens snoring and apnea. This is because the lungs would need to generate a greater amount of suction in order to draw air past the obstructed nose into the lungs. A simple course of nasal sprays may be all that is required to alleviate the blocked nose.

  • Oral Appliances

When all the prior preliminary treatments have been undertaken, it is now time to grab the bull by its horns. The first choice of treatment for moderate to severe obstructive sleep apnea is continuous positive airway pressure (CPAP). This is a treatment method using a devoice that administers compressed air into the patients collapsible airways in order to keep them open, and to allow air to flow.. The patient wears a mask that fits over his nose. Administered compressed air converts the negative suctioning pressure in the airways that was generated by the lungs during inspiration into positive pressure. The hardware that is required is about the size and weight of a laptop computer. It can easily be carried around in case the patient travels. This cures the patient of snoring and sleep apnea as long as he patient wears the CPAP machine to sleep.

Some patients find CPAP cumbersone and are unable to tolerate using a mask for long periods of time. Others find it unappealing to entertain the prospect of having to use an equipment for the rest of their lives. These people resort to surgery.

  • Surgery

Surgery for snoring and obstructive sleep apnea may consists of removing the tonsils, trimming away excessive tissue at the back of the throat and refashioning the soft palate. This operation is called uvulo-palato-pharyngoplasty or UP3 for short.

When apnea is mild and snoring is unassociated with sleep fragmentation, then a lesser operation may be performed. This consists of simply fashioning the soft palate without any attempt to remove the tonsils using either a laser or electrocautery. This operation has a fanciful name: Laser Assisted Uvulo-palatoplasty (LAUP).

Occasionally, when the tongue or small chin is the cause of airway collapse during sleep, operation can be performed to advance the chin and to draw the tongue forward. This would be done together with an oral maxillofacial surgeon.

When the nose is obstructed or when sinusitis is persistence and refractory to drug treatment, surgery may be performed to widen the nasal passageways, remove the adenoids or to facilitate the drainage of the sinuses.

Simple procedure includes radiofrequency (RF) treatment to the soft palate, done under local anaesthesia. This procedure would only take about 10 minutes, done in the clinic.

In the past before we had all this modern approaches to surgery, the cure for snoring and sleep apnea was achieved by simple opening a hole in the trachea over the neck. This is called a tracheostomy. The operation achieved a cure by allowing air to flow directly into the trachea and lungs instead of having to flow through an obstructed and collapsed airway in the neck. In effect, the tracheostomy operation allowed air to bypass the obstruction in the neck. A tracheostomy is extremely effective in alleviating snoring and sleep apnea. The reason why it is not so often done nowadays is because of the social stigma of having a hole in the neck. Presently, a tracheostomy is performed for snoring and sleep apnea only when the problem is severe, life-threatening and when other options have failed in salvaging the situation.

Whatever the options, snoring is a problem that is highly amenable to treatment – surgical or otherwise.

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