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Snoring & Obstructive Sleep Apnoea ( OSA )

Snoring & Obstructive Sleep Apnoea ( OSA )

Overview Of Obstructive Sleep Apnea

Whether it is loud rattling or mild snorting sound, snoring can be irritating for both snorers and bed partners. According to international studies, up to 40% of adults snore and this is a common experience for many in Singapore. Many people may brush it off as nothing more than just a nuisance or inconvenience. However, sometimes snoring may be the tip of the iceberg of more serious health concerns such as sleep apnoea.

 

It is crucial to consult an ENT specialist as soon as possible if you suspect that you or your partner is suffering from sleep apnoea. Your ENT specialist in Singapore may send you to a sleep clinic for further examination to provide you with optimal treatment options, relieving symptoms such as snoring.

What is snoring?

Snoring is the rattling or snorting noise made by a person during breathing while sleeping.

Obstructive sleep apnoea

 

Obstructive sleep apnoea (OSA) is a potentially serious sleep disorder. Under normal circumstances, the air flows smoothly from the mouth and nose into the lungs at all times throughout sleep. However, people with OSA often stop breathing involuntarily for brief periods of time during sleep. The flow of air stops because the space in the throat is too narrow. Snoring ends up as a characteristic of sleep apnoea and is often caused by airflow squeezing through the narrowed space.

 

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 essential in preventing 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 tends to occur in older people as well as those who are overweight. Some lifestyle changes such as weight loss can significantly improve OSA symptoms. Besides weight management, patients suffering from sleep apnoea should try to not sleep on their back to prevent further aggravation.

 

Risk factors

 

Anyone can be at risk of developing OSA, however certain factors can increase your susceptibility to it: 

  • 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 your risk for OSA
  • Narrowed airway: 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

 

Since airflow is obstructed, OSA causes episodes of decreased oxygen supply to the brain and other parts of the body. As a result, OSA patients have poor sleep quality, leading to daytime drowsiness. Furthermore, patients with OSA may also experience the following:

 

  • Headaches
  • Temperamental 
  • Poor memory
  • Drowsiness

 

Daytime drowsiness puts people at risk for motor vehicle crashes as well as industrial accidents. Thus snoring and sleep apnoea treatments are good for helping them relieve OSA symptoms.

 

Complications

 

Patients who experience chronic or recurrent tonsillitis may also experience obstructive sleep apnoea (OSA). This is a result of swollen airways, preventing the patient from sleeping well and leading to other serious medical issues.

 

Diagnosis

 

It is best to consult your doctor on how you can be evaluated for the presence of OSA. Usually, it involves a consultation with your ENT specialist who will make a thorough check of your clinical history and conduct a physical examination. It is likely that a flexible nasoendoscopy (the passage of a small lighted tube with a camera into the nose and throat – Figure 1) will be performed in the clinic to evaluate the possible sites of narrowing in the upper airway.

 

An overnight sleep study (Figure 2), also known as polysomnography (PSG), is required to diagnose OSA. A sleep study is conducted in a sleep laboratory or at home. It records 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. A reliable and less complicated alternative to a full sleep study would be the use of a WatchPAT sleep study. It does not monitor as much information as a full sleep study but has been shown to be a reliable alternative for patients with symptoms suggestive of OSA and for patients who are not be able to sleep well with many wires and sensors attached to them. The advantage of a WatchPAT sleep study is its simplicity and patients can often 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.

 

Treatment

 

The goal for sleep apnoea treatment is to ensure airflow is not obstructed during sleep. Some treatment methods include:

  • Nasal decongestants: Nasal decongestants tend to be more effective in patients 
  • Continuous Positive Airway Pressure: Often the first-line treatment option for OSA, CPAP is a facemask worn by patients at night. It delivers positive airflow to keep the airways open throughout the night. 
  • Dental devices: Customised oral appliances can be used to reposition the lower jaw and tongue forward during sleep
  • Surgical treatments

 

The type of surgery performed to treat OSA depends on the level of blockage or narrowing in the upper airway. These may include:

 

 In the nose: 

  • Inferior turbinate reduction surgery (refer to section on “Inferior turbinate reduction hypertrophy”)
  • Adenoidectomy (removal of adenoid)
  • Sinus surgery

 In the mouth and throat:

  • Uvulopalatalpharyngoplasty (UPPP) and tonsillectomy*: A surgical procedure to remove excessive or lax soft palate and tonsils to open the airway
  • Stiffening procedures: Coblation or radiofrequency ablation to the soft palate and tongue can be used to induce scarring and stiffen the tissues in these regions to reduce snoring
  • Tongue base reduction surgery: Tissue at the back of the tongue can be removed with a coblator or diathermy to reduce tongue bulkiness and open the airway
  • Genioglossus advancement and hyoid suspension: A surgical procedure to pull the muscles of the neck and tongue (forward) to open the airway.

 

Know of anyone who snores and is looking to seek treatment for their sleep apnoea? Let us help you improve your health and quality of life, make an appointment at our specialist ENT and sleep clinic today.

 

 

 

Frequently Asked Questions

What is snoring?

Snoring is the rattling or snorting noise made by a person during breathing while sleeping.

Why bother about snoring?

Socially

A snorer may cause sleepless nights for his or her 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.

What is Obstructive Sleep Apnoea (OSA)?

OSA is a medical condition where a person stops breathing repeatedly during his or her sleep due to collapse of the upper airway. In each episode of apnoea, the person stops breathing completely for a duration of greater than 10 seconds. As a result, less oxygen gets carried in the blood to the heart and brain (Figure 1).

What causes snoring & OSA ?

Excessive bulkiness of 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)

Excessive bulkiness of nose tissues

A blocked nose will often result in mouth breathing. Mouth breathing may result in excessive breathing effort. This excessive effort creates a vacuum that causes soft tissues in the throat to collapse, leading to snoring. 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)
Adenoid hypertrophy

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 results in a partially obstructed airway, vibration of the tissues and snoring

Small or receding jaw (micro- or retrognathia)
People with a small or receding jaw bone are at a higher risk of snoring as a result of a smaller airway space behind their tongue.

What Are The Symptoms Of Obstructive Sleep Apnea (OSA)

The most common symptom of OSA is snoring. OSA patients are often loud snorers with choking episodes during sleep, excessive restlessness at night and they may feel tired during the day. Other associated symptoms include morning headaches, frequent urination at night, depression and decreased sex drive.

How is OSA diagnosed?

It is best to consult your doctor on how you can be evaluated for the presence of OSA. Usually, it involves a consultation with your ENT Specialist who will take a thorough clinical history and conduct a physical examination. It is likely that a flexible nasoendoscopy (the passage of a small lighted tube with a camera into the nose and throat – Figure 1) will be performed in the clinic to evaluate the possible sites of narrowing in the upper airway.

 

An overnight sleep study (Figure 2), also known as polysomnography (PSG), is required to diagnose OSA. A sleep study is conducted in a sleep laboratory or at home. It records 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. A reliable and less complicated alternative to a full sleep study would be the use of a WatchPAT sleep study. It does not monitor as much information as a full sleep study but has been shown to be a reliable alternative for patients with symptoms suggestive of OSA and for patients who are not be able to sleep well with many wires and sensors attached to them. The advantage of a WatchPAT sleep study is its simplicity and patients can often 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, a diagnosis of OSA is made when one has an AHI (Apnoea-Hypopnoea Index – average number of apnoeas and hypopnoeas in an hour) of more than 5 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. Your ENT Specialist will discuss this differences with you.

Why is OSA serious?

Untreated, Obstructive Sleep Apnoea can affect your health

When ignored and untreated, sleep apnea can cause serious health problems. These problems include high blood pressure, heart disease, Type 2 diabetes, stroke and depression.

How do you treat snoring and OSA?

Is there cure for OSA? The management of snoring and OSA can be complex. The list below are common treatment options available in Singapore but are not meant to be exhaustive. It is recommended to consult your doctor for your snoring and OSA issues on the best treatment options for you.

Medical treatment

Weight reduction (for overweight or obese patients) and sleeping on the side are effective in both primary snorers and patients with OSA. The gold standard for the management of OSA is the use of Continuous Positive Airway Pressure (CPAP) therapy* (Figure 1). In CPAP therapy, a machine pumps air through a mask that the patient wears during sleep. This “positive pressure” or column of air passes through the patient’s upper airway will keep the upper airway splinted open during sleep. It has been shown to be very effective. However, some patients may not tolerate this and may want to consider other treatment options that can a more effective cure for OSA.

Dental devices

Customized oral appliances can be used to reposition the lower jaw and tongue forward during sleep

Surgical treatment

The type of surgery performed to treat OSA depends on the level of blockage or narrowing in the upper airway. These may include:

In the nose:
  • Inferior turbinate reduction surgery (refer to section on “Inferior turbinate reduction hypertrophy”)
  • Adenoidectomy (removal of adenoid)
  • Sinus surgery
In the mouth and throat:
  • Uvulopalatalpharyngoplasty (UPPP) and tonsillectomy*: A surgical procedure to remove excessive or lax soft palate and tonsils to open the airway
  • Stiffening procedures: Coblation or radiofrequency ablation to the soft palate and tongue can be used to induce scaring and stiffen the tissues in these regions to reduce snoring
  • Tongue base reduction surgery: Tissue at the back of the tongue can be removed with a coblator or diathermy to reduce tongue bulkiness and open the airway
  • Genioglossus advancement and hyoid suspension: A surgical procedure to pull the muscles of the neck and tongue (forward) to open the airway

*In children, the most common cause of OSA are enlarged tonsils and adenoids as well as obesity. If enlarged tonsils and adenoids are the likely reasons for OSA in your child, surgical removal of the tonsils and adenoids will be the first line treatment.

When Should You See An ENT Specialist In Singapore?

  • Any Ear, Nose or Throat symptoms that you are troubled with or concerned of
  • Persistent blocked nose with mouth breathing or snoring

Dr Gan Eng Cern

Dr Gan Eng Cern is a fellowship trained Consultant Ear, Nose & Throat (ENT) Surgeon. He completed his ENT training in Singapore and 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. Dr Gan was an avid researcher with numerous publications in reputable international ENT journals. He was also an invited speaker and surgical dissection teacher in many ENT conferences and courses.

Awards

  • 2020 – Reader’s Choice Gold Award for Best ENT Specialist
    (Expat Living Singapore)
  • 2016 – Best Educator Award (Eastern Health Alliance)
  • 2016 – “Wow” Award (Patient Compliment)
  • 2014 – Eastern Health Alliance Caring Award – Silver
  • 2014 – 19th Yahya Cohen Memorial Lectureship (awarded by the College
    of Surgeons, Academy of Medicine Singapore for best scientific surgical
    paper)
  • 2012 – Human Manpower Development Award (Ministry of Health,
    Singapore)
  • 2007 – Singhealth Best Doctor Award

Qualifications

  • MBBS - Bachelor of Science, Bachelor of Medicine, Bachelor of Surgery (University of New South Wales, Sydney, Australia)
  • MRCS (Edin) - Member of the Royal College of Surgeons Edinburgh, United Kingdom
  • MMed (ORL) - Master of Medicine in ENT (National University of Singapore)
  • FAMS - Fellow of the Academy of Medicine Singapore

Why Choose Dr Gan Eng Cern

1

Reliable & Reputable ENT Expert

Experienced and patient ENT Specialist who has your best interests at heart. We aim to provide you with accessible and specialized care for any ENT condition in a comfortable setting.

2

Friendly & Helpful Clinic Staff

Our friendly staff will assist you to the best of our ability and we are happy to accept most insurance providers and assist with E-filing with relevant insurance providers or Medisave.

3

Advanced ENT Equipment & Fully Equipped Facility

Our ENT Specialist, Dr Gan Eng Cern, will be able to diagnose and offer personalised treatments for your specific ENT condition. You can expect a high level of ENT care in a spacious setting with in-house minor surgical, endoscopy, allergy testing and microscopy services.

4

Financial Options

There are various financial options available for you to ensure that you are able to receive the most optimal treatment and care. Our ENT clinic staff will be able to assist you with your medical insurance claims and work with your chosen healthcare organization to minimize the hassle and paperwork required. In some cases, you may be able to utilise the funds in your Medisave account to defray part of the costs of your treatment. As our clinic is accredited by the Medisave board, we are able to process your claims from your Medisave for certain clinic procedures.

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