Why Bother About Snoring?
From a social perspective, a snorer may cause sleepless nights for their bed partner or roommates. This can lead to fatigue and frustration from the bed partner or roommates due to insufficient or disrupted sleep. A loud snorer may also be a subject of ridicule by his or her friends and family, resulting in psychological consequences.
Medically, snoring may be a sign of Obstructive Sleep Apnoea (OSA), a medical condition with potentially severe consequences if left untreated.
Obstructive Sleep Apnoea (OSA)
Obstructive sleep apnoea (OSA) is a common but potentially serious condition where breathing repeatedly stops and starts during sleep due to blocked airways. Characterised by snoring, OSA occurs when the throat’s muscles relax too much, narrowing the airway and reducing oxygen flow to vital organs
If left untreated, sleep apnoea can cause serious health problems such as:
- Hypertension
- Heart disease
- Stroke
- Diabetes
Thus, proper diagnosis and treatment at a sleep clinic are recommended to help manage complications. Sleep apnoea can be categorised into three types:
1. Obstructive Sleep Apnoea (OSA): The most common type of sleep apnoea, in which the airway has become narrowed or blocked.
2. Central Sleep Apnoea: There is no blockage in the airway; instead, the brain does not signal the respiratory muscles to breathe.
3. Mixed Sleep Apnoea: A combination of OSA and central sleep apnoea.
Causes
OSA is the most common type of sleep apnoea, and it can stem from various factors, including:
1. Excessive throat tissues
The throat can be congested and narrow if one has:
- Enlarged tonsils (Figure 1)
- Long uvula or soft palate (Figure 2)
- Bulky tongue at the back of the throat
- Obesity (with increased soft tissues in the throat)
2. Excessive nose tissues
A blocked nose may result in mouth breathing, leading to excessive breathing effort. This creates a vacuum that causes soft tissues in the throat to collapse, causing one to snore. The nose can be obstructed from:
- Enlarged inferior turbinates (Figure 2a & b)
- Enlarged adenoids (Figure 3)
- Deviated nasal septum (Figure 4)
- Sinusitis with or without nasal polyps (Figure 5)
3. Floppy soft tissues in the throat and poor muscle tone in the tongue
In people with these conditions, their tongue may fall backwards into the airway, and their throat tissues at the side may be drawn in during sleep. These may result in a partially obstructed airway, vibration of the tissues and snoring.
4. Small or receding jaw (micro- or retrognathia)
People with a small or receding jawbone are at a higher risk of snoring due to a smaller airway space behind their tongue.
It may occur in older people as well as those who are overweight. Making some lifestyle changes, such as weight management and sleeping positions, can mitigate OSA symptoms. However, understanding the specific causes is advisable for optimum treatment.
Risk factors
Anyone can be at risk of developing OSA, however certain factors can increase your susceptibility:
- Overweight: Fat deposits around the upper airway may play a role in obstructing breathing. Medical conditions associated with obesity, such as hypothyroidism, can also increase the risk of OSA.
- Narrow airways: Some people are born with narrow airways or have enlarged tonsils and adenoids blocking the airway.
- Chronic nasal congestion: OSA tends to occur more frequently in patients who have persistent nasal congestion at night.
Symptoms
When the airflow is blocked, OSA may cause episodes of decreased oxygen supply to the brain and other parts of the body. As a result, OSA patients may experience:
- Poor sleep quality
- Daytime drowsiness
- Morning headaches
- Mood changes
Other associated symptoms may include frequent urination at night, depression, and decreased sex drive. These symptoms may necessitate a consultation with a snoring specialist for proper diagnosis and treatment.
Complications
Patients who experience chronic or recurrent tonsillitis may also experience obstructive sleep apnoea (OSA). This may be a result of swollen airways, potentially preventing the patient from sleeping well and leading to other serious medical issues.
Diagnosis of Obstructive Sleep Apnoea (OSA)
It is advisable to consult a doctor to help diagnose the presence of OSA. Usually, it involves a consultation with the ENT specialist, who will review your clinical history and conduct a physical examination. The test may include nasoendoscopy (inserting a small lighted tube with a camera into the nose and throat – Figure 1), which will be performed in the clinic to evaluate the possible sites of narrowing in the upper airway.
An overnight sleep study (Figure 2), known as polysomnography (PSG), may be recommended to help diagnose OSA. Typically conducted in a sleep laboratory or at home, it involves recording the body’s activity during sleep, which may include brain waves, the oxygen level in the blood, heart rate, and breathing as well as eyes and leg movements.
Alternatively, the specialist may recommend a sleep study using a WatchPAT sleep study. While it may not offer as much information as a full sleep study, it has been shown to be a reliable option for patients with symptoms suggestive of OSA and for patients who are not able to sleep well with many wires and sensors attached to them. The advantage of a WatchPAT sleep study is its simplicity, and patients may sleep better with it (Figure 3).
The sleep study records the number of events known as apnoeas (when there is > 90% decrease in airflow to the lungs for >10 seconds) or hypopnoeas (when one has >30% decrease in airflow to the lungs for >10 seconds and >3% drop in oxygen saturation or arousal) during sleep.
In adults, the diagnosis of OSA is made when one has an AHI (Apnoea-Hypopnoea Index – the average number of apnoeas and hypopnoeas in an hour) of more than five in an hour. The severity of OSA in adults is based on the AHI as follows:
- Normal < 5 (diagnosed as primary snorer in the absence of daytime sleepiness)
- Mild – 5-15
- Moderate – 16-30
- Severe – >30
The scoring of AHI is different in children. The ENT specialist will discuss these differences with you.
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