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Snoring and sleep apnoea

‘He’s such a sound sleeper that he snores !’ Nothing can be further from the truth; snoring and sound sleep is almost oxymoronic.

Snoring is the variable sound produced during breathing while asleep. The volume varies- from very soft to a huge locomotive breath (apologies to Jet Thro Tull). Often its apparent during the deepest duration of sleep when there is maximal muscle relaxation such as after strenuous physical activity or after an alcoholic binge. Simple snoring disturbs the sleeping partner and sometimes the roommate, co passenger etc as the case may be. In extreme cases marital discord and social issues could crop up.

On the other hand snoring with obstructive sleep apnoea is a disease with far reaching effects and calls for awareness, recognition, diagnosis and treatment. Snoring occurs because the loose tissue of the palate, throat and tongue vibrate during sleep due the suction effect produced by tongue fall or obstruction at other sites-nose, palate, tongue, larynx during deep sleep. If this is accompanied by significant periods of cessation of breathing despite inspiratory effort, for periods of 10 seconds or more, that person is said to obstructive sleep apnoea (OSA).

Patients with OSA snore heroically, sleep as soon as they hit bed and typically have daytime sleepiness. This is elegantly illustrated in the Epworth Scale which attempts to quantify severity of OSA. Since oxygenation during sleep suffers, blood pressure and heart trouble is common. Sleep fragmentation leads to poor concentration, workplace or school issues, headaches, psychological mal-adjustment and sexual dysfunction.

Most patients with moderate OSA are obese. In fact collar size more than 17 inches and BMI more than 28 is often the case. Examination must identify tonsil and adenoids especially in children and adolescents. Syndromic children eg Downs, Pickwickian etc must be identified. In adults the nose, larynx, throat, windpipe and chest must be examined for obstruction. Thyroid and other gland disorders may cause a person to snore.

A detailed history and examination is invaluable in making a diagnosis in OSA. Blood tests for diabetes, cholesterol, thyroid, kidney and liver function are useful. A detailed sleep study or POLYSOMNOGRAHY is the gold standard of diagnosis. At least nine parameters eg. oxygen levels, chest movement, body position, heart and brain functions are measured across the entire night. This test can be performed in the comfort of your home in your own bed. Infrequently, CT Scan and dynamic MRI for the head and neck may be necessary.

Treatment of sleep disordered breathing depends on severity of symptoms, age, presence of other co-morbid issues like diabetes,heart and lung disease and blood pressure. Most patients are obese and a strict regimen of diet, exercise and avoidance of alcohol and other such drugs is absolutely essential. An obvious cause eg. tonsil and adenoids in a child, or nasal and sinus polyps in an adult or hypothyroidism must be addressed appropriately.

Snoring without significant OSA will respond to changes in lifestyle and change in sleep habits. Yoga helps. In patients with a small lower jaw a specialised dental appliance can be useful. In patients who snore despite conservative means, minor surgical procedures to stiffen the palate, reduce the volume of the tongue and parts of the nose may help.

Continuous Positive Airway Pressure or CPAP should be first offered to all patients of OSA without an obvious local cause. A small machine drives in air into the windpipe, splinting it, and effectively abolishes snoring, low oxygen levels and daytime sleepiness. A variety of sophisticated machines are available as are masks of various materials to enhance wearer comfort.

A small percentage of patients may not be able manage CPAP and some don’t get adequate benefit with it. Several surgical procedures on the nose, palate, tongue, throat and jaw are described. The very fact that so many surgeries have been described means that that all of them have imperfections that the other tries to overcome. In morbid obesity, bariatric surgery has real value.

Snoring, OSA and other sleep disorders have huge physical and mental health impacts. If simple means of lifestyle modification and change in sleep habits don’t help it’s worth seeing a sleep specialist.

Prabodh Karnik

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