Tuesday, 26 July 2011

Snoring and Sleep Apnoea

Published in Panorama

Snoring away to ill-health !!!

45% of normal adults snore at least occasionally, and 25% are believed to be habitual snorers. Problem-snoring is more frequent in males and overweight persons, and it usually grows worse with age. Though snoring is a common problem affecting all ages of people and both genders, three times more men than women snore. There are millions of people with the problem but that does not mean that snoring should be taken lightly and simply considered a source of disturbance and irritation to those around the snorers. It disturbs sleeping patterns and deprives the snorer of appropriate rest. When snoring is severe, it can cause serious, long-term health problems, including obstructive sleep apnea. However, the problem can be helped by sensible alteration in lifestyle emphasizes Dr.Sunil Narayan Dutt, ENT Specialist and Departmental Coordinator, Canadian Specialist Hospital, Dubai.

The noisy sounds of snoring occur when there is an obstruction to the free flow of air through the passages at the back of the mouth and nose. All body muscles become less active and floppy during sleep and in most parts of the body this helps one to relax and sleep comfortably. The only floppy segment of the airway is between the back of the nose and the entrance to the voice box including the throat or the gullet. When the muscles that help hold open the throat behind the tongue relax, there is partial collapse and narrowing of the airway resulting in vibrations that is heard as a ‘snore’. The noise is generated by the soft palate at the level of the roof of the mouth or by the back of the tongue or both, explains Dr.Dutt.

What causes snoring and why is it that some people snore while others don’t?
People who snore may suffer from poor muscle tone in the tongue and throat. The muscles themselves may be too relaxed, either from alcohol or sedative drugs like sleeping tablets or sedative antihistamines.

Excessive bulkiness of throat tissue, that is extra fat in the neck, squashes the throat from outside, especially when the throat muscle become floppier with sleep. It is natural that obese and overweight individuals are predisposed to snoring. Men snore three times more than women since they tend to have fatter necks and there may also be a hormonal factor involved, reveals Dr.Dutt. Children with large tonsils and adenoids often snore.

Individuals with long palate and uvula have a tendency to snoring and sleep apnoea. A long palate narrows the opening from the nose into the throat. As it dangles, it acts as a noisy flutter valve during relaxed breathing. The situation is worse still in the case of a long uvula. Any condition which narrows the nasal airway may predispose the individuals to snoring and possibly, sleep apnoea, explains Dr.Dutt. These include stuffed nose due to allergy, nasal polyps and tumours.

Also, deformities of the nose or nasal septum, such as a deviated septum, the wall separating one nostril from the other can cause such an obstruction and consequently expose the individuals to the risk of snoring.

A lot of children snore. Are the reasons, causes or risk factors the same for children and adults? Dr.Dutt is emphatic, “No. The causes for snoring in children are very different from those in adults. Some of the very common causes of snoring in children are large adenoids or tonsils or both. Some children born with congenital malformations of the skull and facial skeleton (Eg: Treacher Collins syndrome, Down’s syndrome, Crouzon’s syndrome etc) may suffer from snoring and sleep apnoea. The commonest reason that adults snore is obesity.”

Is snoring a cause for concern? It disturbs sleeping patterns and deprives the snorer of appropriate rest. When snoring is severe, it can cause serious, long-term health problems, including obstructive sleep apnea, reveals Dr.Dutt.

What is Obstructive Sleep Apnoea? Does every person who snores also have OSA? When loud snoring is interrupted by frequent episodes of totally obstructed breathing, it is known as obstructive sleep apnea. There is a cessation of breathing during sleep due to the obstruction and/or collapse of the upper airway, usually accompanied by a reduction in blood oxygen saturation, and followed by an awakening to breathe. The person takes a few deep breaths and then returns to sleep. This obstruction and waking may become a continuous cycle that can go on several times each night, explains Dr.Dutt.

Serious episodes last more than ten seconds each and occur several times per hour. These episodes can damage your health because they reduce blood oxygen levels, causing the heart to pump harder. After many years with this disorder, elevated blood pressure and heart enlargement may occur. There may be abnormalities of the heart rhythm and in severe cases, even congestive cardiac failure. The immediate consequence however is that patients who snore and wake up to breathe, may not be aware of the number of times they are up and how often their sleep is disturbed because of the apnoeic episodes. Consequently, they are likely to feel extremely tired even as they wake up in the morning and may tend to doze off frequently during the day. This is termed excessive daytime somnolence or sleepiness. Besides being a nuisance, this may be potentially dangerous to individuals working in the shop floor with machinery and while driving, explains Dr.Dutt.

What about sleep apnoea in children? Does it happen? If yes, can it be prevented? Else, what is the treatment? Sleep apnoea in children does happen explains Dr. Dutt: “As mentioned earlier, tonsillar and adenoidal enlargement can be so large that they can cause sleep apnoea. Frequent infections of the tonsils and adenoids make the condition worse. It is possible to limit the number of infections with the use of long term antibiotic prophylaxis; there are also immune related treatments available including ayurvedic and homeopathic medications. However, these forms of treatment are contentious. Surgery in the form of adenoidectomy or tonsillectomy or both is perhaps the best option.

Certain congenital craniofacial syndromes may be associated with sleep apnoea. In these, the use of nasopharyngeal airways to keep the airway patent or a CPAP machine at night may be advised.”

How is sleep apnoea diagnosed? There is a lot of information gleaned from the history that a patient gives us. There is usually valuable information given to us from the parents of children who snore and from the partner of a snoring patient! They can tell us if there are breath-holding spells during sleep associated with snoring. There are other classic features and effects of sleep apnoea such as excessive daytime sleepiness, poor work performance. et al, explains Dr.Dutt.

The nasal passage and the upper respiratory tract should be examined to exclude the possibility of swelling within the nose or oropharynx, deviated nasal septum or tumour.

A simple diagnostic sleep study performed overnight either in the hospital or at home can tell us if there is sleep apnoea and if that is significant. This would involve a night’s hospitalization of the patient who would be hooked on to the polysomnography apparatus. This machine would record values such as the patient’s pulse rate, ECG, oxygen levels in the blood, snoring and the number of episodes of apnoea among other things. Oxygen levels in the blood are continuously measured from a clip on the finger and the rest of the parameters assessed using a belt on the chest or belly or by wearing a nasal mask. In some cases, an EEG may be done to measure the sleep quality and the activity of the brain during sleep, explains Dr.Dutt. Excessive sleepiness during the day may be assessed using the Epworth Sleepiness Scale.

How can the problem of snoring and sleep apnoea be dealt with? Treatment of the problem depends on its cause, emphasizes Dr.Dutt.

Overweight individuals should undertake diet and exercise regimen sensibly to bring down their weight. This may make the snoring problem tolerable and even make it disappear in some cases.

Even small quantities of alcohol will aggravate the problem. It is therefore best to abstain from any form of alcohol.

Avoid taking tranquilizers and sedatives close to bedtime.

If snoring is worse when lying on your back, try to sleep on your side.

If you have a nose block, clear this with appropriate medication or surgery, depending upon the cause of the blockage. This will help about half the individuals suffering from snoring.

If none of the above measures work, you may be a candidate for a surgery on the soft palate. Excess redundant soft tissue in the back of the throat can cause mild to severe snoring and sometimes certain degrees of sleep apnoea. This surgery is indicated when a sleep study shows snoring alone with very little or no sleep apnoea. However, this surgery does not always work, may be painful for nearly two weeks after surgery and it involves some inherent complications such as transient nasal regurgitation of food and drink and if you put on additional weight after surgery, the snoring problems returns.

If your problem is one of sleep apnoea and not just snoring, you may require other treatment modalities. Your condition may be improved by going to sleep every night with a nasal mask that delivers air pressure into the throat through an apparatus called continuous positive airway pressure or CPAP. This keeps the pressure in the throat higher than the atmospheric pressure so that the throat is not pressed closed. This works so well at preventing breathing pauses and snoring that they are no longer sleepy during the day, explains Dr.Dutt. However, CPAP therapy does not actually cure the problem and the patient should still make an effort to lose weight.

How safe is surgery for the problem? Dr.Dutt reveals, “It depends on the type of surgery that we are talking about. Nasal surgery for obstructions such as polyp removal and septoplasty for deviated nasal septum are fairly safe procedures. The surgery for the soft palate, Uvulopalatopharyngoplasty (UPPP) or laser assisted uvulopalatoplasty (LAUP), is quite safe as well but the long term results are not very satisfactory in terms of snoring alleviation. There are other heroic surgeries available for the jaws and tongue; in my personal opinion, these are perhaps unsatisfactory procedures both in terms of results and safety.”


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