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Snoring is normal. At some point, we all snore during sleep. However, snoring can also be a key sign of obstructive sleep apnea (OSA) which is a severe sleep disorder where people actually stop breathing during sleep. We asked Dr. Soon Sue Rene, Senior Ear Nose Throat (ENT) Surgeon about OSA and when to consider surgery to treat the condition.
“In 2005, the American Academy of Sleep Medicine defined obstructive sleep apnea as when the patient is symptomatic of loud snoring, witnessed breathing interruptions, awakenings such as choking, gasping at least five episodes per hour, and occurrence of daytime sleepiness,” Dr. Soon explained.
The diagnosis of OSA is made by polysomnography, a sleep study that can be done in a laboratory or at home.
“The sleep study can tell us whether the patient is just a primary snorer or having OSA which leads to oxygen deficiencies during the episodes of choking or gasping at night. The index recorded will be able to measure the severity of sleep apnea, which can range from mild, moderate to severe and guide management.” she added.
In Singapore, it is estimated that about 30.5 per cent1 of the population has moderate to severe sleep disorder.
“This means that one in three patients would actually have OSA,” Dr. Soon said
Unlike most chronic diseases such as diabetes or cholesterol, which can directly affect organ functions, the effects of OSA are not apparent. Some may even argue that when the body senses it's not getting enough oxygen during sleep, it will force the body to wake up; breathing airways will then be open, allowing breathing to resume. Thus most patients may not come forward to seek help for the condition and mistakenly think that their snoring and breathing is harmless.
However, Dr. Soon said the effects of OSA can be felt if left untreated.
“I have a patient who has been seeing me for sleep apnea. Besides talking about his snoring and choking episodes at night in the middle of his sleep, he would also tell me about how he would experience headaches in the morning and sleepiness during the day. His quality of life is impaired with decreased energy levels and impaired daytime performance, affecting his work,” she revealed.
The effects are not only prevalent in adults. They can affect children as well.
“OSA in children can affect learning, growth and give rise to behavioural problems,” Dr. Soon shared.
OSA is also linked to multiple systemic conditions including an increased risk of heart disease, hypertension, cardiac arrhythmias, stroke and metabolic diseases such as diabetes and obesity.
In a population study in Iceland conducted in 2021, it showed that patients with OSA actually had a twofold increase in the risk of having severe COVID-192.
Hence, as a COVID-19 preventive measure, she advised patients to seek treatment to avoid the risk of having severe COVID-19 which may lead to hospitalization or even death.
“Lifestyle modifications and weight management is generally advised to all patients,” Dr. Soon says. Other common upper airway conditions which contribute to OSA such as rhinitis and gastroesophageal reflux requires evaluation and management too.
"Positional therapy to condition patients to sleep laterally on the side, either on the left or right normally improves snoring, airway obstruction and sleep. Most patients with OSA will also relate that their preference is to sleep on their side rather than sleeping on their back (supine). This is because the tongue falls directly backwards when one sleeps on their back. Sleeping sideways naturally opens up the airway," Dr. Soon said.
Myofunctional therapy has been shown to reduce the intensity of OSA symptoms from recent published literature. This involves performing exercises to strengthen the muscles of the tongue and throat.
Definitive management of OSA will involve sleeping with devices such as dental appliances or continuous positive airway pressure (CPAP) therapy.
“I tell all my patients that if they are able to tolerate CPAP therapy well, it can potentially cure OSA. Air at a pressure is delivered from a mask and works like a mechanical splint, opening up the upper airway and normalizing oxygenation,” Dr. Soon explained.
“However, for CPAP therapy to be an effective treatment, the patient has to be consistent in using the device for at least four hours nightly and for most days of the month (>80%) ,” Dr. Soon added.
In a study conducted in 2018, the rate of CPAP treatment rejection is high among Singaporeans, both at the time of diagnosis and after the 1-month CPAP trial3.
"The continued use of the device is dependent on patients' commitment and perception if they see a need. For example, most patients think it is inconvenient and troublesome to put on every night and not the management for life. Another factor that influences the uptake is the affordability of the device," Dr. Soon said.
Surgery is considered if patients are intolerant and are not suitable for the CPAP device, be it for primary use or for use in conjunction with CPAP.
“It is advisable to bring your bedtime partner during the first consult as commonly the patient himself may not know of his breathing problems. OSA does not occur overnight and the body may have adapted to a chronic suboptimal state” Dr. Soon says.
“A head and neck examination, together with nasoendoscopy is performed in all patients with OSA during their first sleep consult. OSA is a result of upper airway collapse. Visualising the upper airway and its dynamic movement is key to patient selection for successful surgical outcomes. For example, for patients with OSA with enlarged kissing tonsils, performing tonsillectomy is potentially curative. Uvulopalatopharyngoplasty, a surgery that involves reconstruction of tissues at the back of the throat is useful for patients with primary palatal airway collapse," Dr. Soon explained.
“Surgery is not advisable for patients with alcohol or drug abuse history, psychiatric issues contributing to poor sleep and having unrealistic expectations from sleep apnea surgery,” she cautioned. Dr. Soon advises patients opting for surgery to be clear about the desired outcome of sleep surgery. “Sleep symptoms can recur after a few years after surgery, especially if one gains excessive amounts of weight.” Dr. Soon adds.
“We can divide them into global upper airway procedures for patients who are obese or patients with dento-facial deficiencies and upper airway soft tissue procedures,” Dr. Soon explained.
Bariatric surgery can be considered for patients with morbid obesity. For the latter group of patients, it would require jaw surgery (maxillomandibular advancement) to move the upper and lower jaw forward to increase the airway size.
“Nasal surgeries in OSA with nasal obstruction has been proven to improve sleep parameters such as sleepiness and breathing disturbances. Radiofrequency ablation reduces the size of swollen inferior turbinates and is a popular option these days for patients with nasal obstruction without nasal septal deviation. The procedure can be done comfortably as a day procedure, with minimal risk, complications and provides quick recovery.” Dr. Soon says.
The tongue or tongue base is a frequent cause of blockage in OSA. “Tongue surgery such as tongue channelling or radiofrequency can reduce the volume of the tongue to improve the space behind the tongue for ease of breathing. The procedure is safe in an experienced sleep surgeon and beneficial to patients with big tongues and patients with predominantly supine sleep apnea.” Dr. Soon explains.
Unless someone else tells you, you will not be aware. This is a common reason why sleep apnea is often underdiagnosed.
One way to find out if you snore during sleep is to set up a recording device using a smart phone or even an old tape recorder. Other telling signs include red flags such as noticeable daytime sleepiness, fatigue, if your sleep is disrupted by sudden waking up gasping at night.
Lastly, knowing the basics about snoring such as what causes it, when it is dangerous, and how to manage and treat it helps to facilitate better health and eliminates health risks relating to OSA.
