Snoring: The Sleeping Siren- Dr Ahmad Nordin

DDI3IG98ygYou have a meeting at work today. Supposed to wake up at 6:00am, but you only manage to get out of bed at 6:30am. You drive to work, it was already jammed traffic by the time you left the house. At a green traffic light, suddenly you were waken up by a loud car horn from behind. Then only you realized, you have been sleeping all the while when the traffic light was red. At the meeting, while your boss was talking, you fell asleep. The worst thing was, your boss made a sarcastic remark about you sleeping in meeting and everyone had a good laugh when you snored. 
Sounds familiar? Any idea what ties all these problems together? The key was the last word of the paragraph- snoring.
Snoring is the loud noise produced by the partially blocked upper airways when we sleep. It can be blocked at the nose, soft palate, throat or tongue. When we are awake, we stand upright and we have good muscle tone, therefore we don’t snore. But when we sleep, we lie down and the tongue fall backwards. We further lose muscle tone as we sleep, and that is where the noise gets more pronounced.
In this period, the oxygen that we breathe gets lower. In severe cases, it gets so low that we stop breathing (this is called apnea). Luckily for us, the brain reacts seconds later to wake the body up to breathe.
If you witness a snorer sleeping in this situation, he will first snore continuously. After repeated snoring, you will be puzzled for a period where he will suddenly stop snoring. Maybe for about 15 seconds, he will dramatically gasp for air, and will later go back to that repeated snoring & gasping cycle. And this repetition may continue many times during his sleep.
The danger is, the oxygen in the body gets very low as we sleep & snore. The heart needs to pump harder to meet oxygen requirement. The heart which is supposed to relax at night, needs to work extra instead. In the end, this will give rise to hypertension (high blood pressure). This is known as Obstructive Sleep Apnea (OSA).
Other signs & symptoms of OSA:
  • Excessive daytime sleepiness (as in the story above)
  • Difficulty concentrating
  • Morning headaches
  • Restless sleep
  • Gasping or choking at night
  • Chest pain at night
  • Snoring is so loud it’s disrupting your partner’s sleep
  • Waking up choking or gasping
  • Sore throat
The diagnosis is by history and clinical assessment. The ENT doctor will also do a complete assessment using flexible nasopharyngolaryngoscopy (FNPLS) in the clinic.
This is to assess the most likely site of obstruction. If there is a need for surgery, the respective obstructive site will be addressed accordingly.
Not all snorers have OSA. If OSA is suspected, the person will need to undergo a sleep study. Here, he will be placed with a monitoring system which be placed on his body while he sleeps. Data will be recorded to see how severe the apnea is. It can be done in the hospital or at home, depending on availability.
Treatment includes:
  1. Weight loss– the most effective and cheapest treatment especially those who are overweight. Recommended 10% weight loss is good enough to reduce the symptoms, but some have experienced better sleep even with few kilogram of weight loss. Don’t give up.
  2. CPAP machine– this machine delivers pressure to the airway via a sealed mask to stent the airway open when they sleep. This is the best treatment so far, but not fully accepted by patients as the machine is rather expensive. Some do not feel comfortable wearing the mask at night and may feel dry in the mouth the next day.
  3. Sleep position– it is best to lie on the side to reduce the snoring. Few techniques have been implemented to maintain you lying on the side; such as sewing tennis balls to the back of the night wear, wearing backpack, among others.
  4. Oral appliances– these are devices worn in the mouth to maintain the airway while sleeping. Some pushes the jaw forward, some pulls the tongue forwards, just to name a few
  5. Surgery– different types of surgery are done, this depends on the obstructed site. In children, the most common cause for snoring is the enlarged tonsils and sometimes coupled with enlarged adenoids. Most of the kids get total relief of snoring after surgery (see previous article )
To conclude, snoring shouldn’t be taken lightly. It is not simply a social problem, it is a warning sign for us to avoid the hidden disease behind it. Yes, it is a siren that sounds when you sleep, and it is calling us to seek help. Please do.

Dr Ahmad Nordin is an Ear Nose and Throat surgeon currently working in Sabah. Find out more about him on The Team page.

References
2. Clinical Guideline for the Evaluation, Management and Long-term Care of Obstructive Sleep Apnea in Adults J Clin Sleep Med 2010 June 15 6(3)

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