A recent report published in the Straits Times showed that 1 in 3 Singaporeans have snoring problems and Obstructive Sleep Apnea (OSA).
Snoring and sleep apnea has always been my area of interest, so I have decided to write this comprehensive guide to help patients looking for information online.
This 2200-word post covers many questions that patients have asked me over the years, including:
- Treating obstructive sleep apnea in Singapore
- What a sleep clinic in Singapore does
- How to find the best CPAP machine for yourself in Singapore
Here's the TL;DR version:
- 70% of of patients with snoring and sleep apnea have palate obstruction as the main cause
- Your nose contributes to snoring as well
- Treating both your nose and palate at the same time will significantly improve your symptoms
- Obstructive Sleep Apnea patients require a holistic treatment approach, which includes weight loss, a healthy lifestyle, surgery, and close follow-up
What causes snoring?
Snoring is due to the vibration of tissues in your nose, mouth and oral cavity.
The vibration of excess tissue and the narrow airway leads to a collapse of these structures, which results in obstruction of your upper airway during sleep.
The presence of snoring is an ‘alarm’ that alerts one to the possibility of Obstructive Sleep Apnea.
Patients with snoring/sleep apnea can be divided into 3 main groups:
- those with a GLOBAL problem (patients with gross obesity, thick fat in the neck)
- those with a LOCAL problem (patients who are not obese but who might have big tonsils, a big tongue, a small jaw and/or a thick redundant palate)
- those who OVERLAP (patients who are obese and also have a local problem, like obesity or a thick neck.
What is obstructive sleep apnea?
Snoring and obstructive sleep apnea are different things. Obstructive sleep apnea is defined as occurences of interrupted breathing during sleep, usually accompanied with snoring and exhaustion during daytime waking hours.
What are the symptoms of obstructive sleep apnea during the night and day?
Upper airway obstruction causes stoppages in breathing (apnea) and low oxygen at night during sleep.
This results in:
- increased heart rate (as the heart is trying to compensate for the low oxygen), and
- increased blood pressure (hypertension).
Hence, the patient with obstructive sleep apnea has poor quality unrested sleep.
During the night
The most common symptom for patients with obstructive sleep apnea is snoring.
Most of my patients come to see me saying: “Hey doc, you know I snore; but you know what, it doesn’t bother me, it bothers my wife!”
Frequently, the bed partner prompts the patient to see a sleep doctor because of concerns over repeated choking at night/gasping/apneas (stoppages in breathing).
Patients may complain of frequent awakenings with a choking and gasping sensation, nocturia (frequently passing urine at night), or nightmares.
Many bed partners have witnessed their partners choking and holding their breaths during their sleep.
Patients with severe obstructive sleep apnea may be unable to sleep supine (on their back), as this causes the tongue to fall backwards resulting in obstruction of the airway.
During the day
Common daytime complaints include:
- Early morning tiredness and morning headaches (attributable to the repetitive nocturnal low oxygen levels).
- Morning dry mouth and throat are caused by mouth-breathing and snoring.
- Other symptoms include forgetfulness, depression, irritability and, less commonly, impotence.
Excessive daytime sleepiness is very common in patients with obstructive sleep apnea, and is caused by a combination of frequent arousals, sleep fragmentation, repetitive oxygen desaturations, and reductions in delta and rapid eye movement (REM) sleep.
Excessive daytime sleepiness can be measured by a simple questionnaire known as the Epworth’s Sleepiness Score (ESS).
How do you know if you have obstructive sleep apnea?
Many studies have shown that the symptoms of a patient alone are fairly useful in predicting if one has sleep apnea or not.
Many of my younger patients (between 30 to 40 years old) come to my clinic with severe symptoms of sleep apnea, and who are already on anti-hypertensive (high blood pressure) medication.
It is not normal for a young male to have high blood pressure; an underlying cause should be sought for.
There are some strong tell tale symptoms of sleep apnea.
- If you snore and have excessive daytime sleepiness, you have a close to 70% chance of having sleep apnea.
- If you snore, have excessive daytime sleepiness and your bed-partner noticed that you stop breathing (or noticed you gasping at night), you have an 80% probability of having sleep apnea.
- If you snore, have excessive daytime sleepiness, your bed-partner says you stop breathing at night, and you have high blood pressure (hypertension), you have a 90% chance of having sleep apnea.
An obstructive sleep apnea questionnaire
Some simple questions that you may ask yourself to see if you might have sleep apnea (If you answer “yes” to any 3 of these questions, there's a strong probability that you might have sleep apnea):
- Do you wake up in the morning tired and foggy, and unrefreshed?
- Do you have headaches in the morning?
- Are you very sleepy during the day?
- Do you fall asleep easily during the day?
- Do you have difficulty concentrating, and completing tasks at work?
- Do you feel in a daze, like you are not in your “body”?
- Have you ever arrived home in your car but couldn't remember the trip from work?
At night, while asleep:
- Do you snore loudly each night?
- Do you have frequent pauses in breathing while you sleep (do you choke or wake up choking)?
- Are you restless during sleep, tossing and turning from one side to another?
- Do you have to sleep sitting up or propped up by pillows, because you find that you are breathless sleeping flat?
- Do you have to get up to urinate (pass urine) several times during the night?
- Have you wet your bed?
- Do you have frequent nightmares?
Is snoring or obstructive sleep apnea dangerous?
Patients with sleep apnea do not live as long as people without sleep apnea.
Medical research has shown that patients with severe obstructive sleep apnea (patients who stop breathing more than 30 times per hour) have a mortality rate of about 3% per year.
It's been said that “Sleep apnea is the phantom cause of heart disease and sudden death”.
Sleep apnea patients have a 6 times higher risk of dying between midnight and 6 am, compared to normal non-apneic patients.
As patients with snoring and sleep apnea have numerous dips in their oxygen levels while asleep, they suffer from significant stress on the heart and brain during these low oxygen events.
This in turn leads to high blood pressure, lack of oxygen in the blood and hence, strokes, heart attacks and sudden death.
Who should you see if you suspect that you have obstructive sleep apnea?
In Singapore, obstructive sleep apnea patients are most commonly seen treated by ENT specialists.
At the clinic, you will have:
- Your weight and height recorded
- Body mass index (BMI) calculated
- Blood pressure taken, and
- Neck circumference measured.
Your doctor may also request for you to spend a night at the sleep clinic.
What happens at a sleep clinic in Singapore?
A sleep study is the gold standard for diagnosing snoring and sleep apnea. These are performed at sleep clinics.
It tracks your brain, heart, and eye activity, as well as the breathing and blood oxygen level patterns.
In patients who may have sleep apnea, the sleep expert will track episodes where breathing is shallow or stops for longer than 10 seconds.
In general, apnea is significant if more than five episodes per hour is reported.
If there are more than 15 episodes per hour, the condition is serious.
How do doctors determine what is the best treatment for your obstructive sleep apnea?
Treatment of snoring and sleep apnea may be conservative and/or surgical. The following factors determine your treatment:
- BMI, neck circumference
- Oral cavity adequacy
- Tonsil size
- Palate size / length
- Tongue size
- Upper airway assessment
- Nasal passage size
An ear, nose, and throat endoscopic examination of your upper airway is the most important step in determing treatment.
Here's what I'm able to check during the examination:
- Nose swelling – the nose is essential in breathing. Any swelling within the nose needs to be corrected in order for normal breathing to be restored.
- Tonsil size – the tonsils are assessed with regards to how obstructing they are. They are graded based on their size within the oral cavity.
- Tongue size – the tongue is very essential in the evaluation, as the tongue is the final “gate-keeper” to the opening of the lungs.
- Palate thickness – if your palate is too thick or redundant, it will not only cause loud snoring, but may also lead to obstruction of the airway and hence, sleep apnea.
- Lateral (side) throat wall thickening – many patients with obstructive sleep apnea have very thick and bulky lateral walls of the throat. These side walls actually cause collapse and obstruction of the upper airway during sleep, resulting in stoppages in breathing and low oxygen.
What are non-surgical treatments for obstructive sleep apnea?
In general, patients with obstructive sleep apnea are advised:
- a strict trial of weight loss,
- exercise regime,
- nutritionist consultation (dietary advise),
- regular close follow up and
- a nasal mask continuous positive airway pressure (CPAP) trial
1. Nasal CPAP
This is a non-invasive method of treatment.
It entails using continuous positive airway pressure (forced air) by a mask worn on your nose or the face throughout the night (it is sometimes compared to a “reverse vacuum cleaner”).
Do note that CPAP is only a control, and not a cure.
It is only effective when it is worn on the face. However, for most patients with obstructive sleep apnea, it is not easy to wear the mask throughout the entire night and for every night for the rest of his life.
Moreover, many patients wake up with the mask on the floor, and hence, would not use it the entire night.
Other common reasons for poor compliance with nasal CPAP include:
- nasal problems – nasal stuffiness, irritation, discharge, pain
- mask problems – poor fit, air leak, dry eyes, skin breakdown
- equipment problems – noisy, cumbersome, high air pressure, pressure-related arousals
- concept problems – failure to understand medical benefit
2. Oral appliances
Oral appliances (like dentures) are designed to bring your lower jaw and base of tongue forward, either by stabilizing the lower jaw position during sleep or by attempting to pull the tongue forward, in an effort to increase the posterior airway space.
Oral appliances are offered especially when you are a poor candidate for surgical intervention, or are unable to tolerate nasal CPAP.
Oral devices can be divided into two basic types:
- Mandibular (lower jaw) repositioning device – these are removable devices worn at night. They are affixed to the upper and lower teeth and are gradually adjusted to advance the mandible.
- Tongue-retaining device (TRD) – these come in the form of a soft suction cup that is placed in the mouth, creating a negative pressure to hold the tongue in a forward position during sleep.
These oral devices also have an issue with patient usage (compliance) because the lower jaw is held forward at night, which causes it to feel strain.
How can you find the best CPAP machine for yourself?
Here are some tips that I give to my patients:
1. Choose a CPAP mask and machine that fits your needs
There are many variations of masks. Just to name a few:
- Some masks have a brace that adds cushions to prevent marks on your face. Others are even designed to "float" on a cushion of air.
- Certain masks are large enough to cover both your nose and mouth, which can help to prevent dry mouth.
- There are even masks that cover your entire face, including your eyes.
2. Pick your correct size
Most patients are fitted with a mask sizing after the sleep study.
You should pick a mask that is large enough to allow adequate air delivery. Avoid over-sized masks that may be prone to shifting on your face, or excessive leaking.
Lastly, be sure to try it on while it's attached to a machine delivering your level of air pressure.
3. Use accessories that make compliance easier
Aside from getting the proper style and fit, you may also want to explore other CPAP accessories that make treatment easier to tolerate.
Some offerings are customisable headgears, chinstraps, heated humidifiers, and mask liners.
What are surgical treatments for obstructive sleep apnea?
The success rates of surgery depend on:
- type of patient selected for surgery – including height and weight, age, tonsil size, palate length, tongue size and nasal pathology
- type of palate surgery performed – including Uvulopalatopharyngoplasty (UPPP) and/or Lateral Pharyngoplasty,
- type of tongue surgery performed (if needed) – Tongue Reduction Surgery (minimally invasive tongue volume reduction surgery)
- whether nose, palate and tongue surgery is performed together
- severity of Sleep Apnea (disease) as noted on the sleep test
The severity of obstructive sleep apnea can be classified according to the AHI and lowest oxygen saturation level (LSAT).
The severity is usually graded as the worst of the two.
86% - 95%
75% - 85%
What types of surgical treatments are required for obstructive sleep apnea?
1. Nose surgery
Nose surgery is important for a few reasons:
- your nose represents 50% of the upper airway (the other 50% is the mouth), hence, having a clear nasal passage is important
- nose surgery alone (performed alone) is at best 20% to 30% effective in treating obstructive sleep apnea (should be done with other procedures, like palate surgery, if the patient has moderate or severe obstructive sleep apnea)
The type of nose surgery is dependent on your nose anatomy.
In general, the radiofrequency of the inferior turbinates are easy, simple, painless, quick and has minimal side-effects.
Other types of nose surgery:
- Nasal Turbinate Reduction - Laser, Radiofrequency, Micro-debrider, Coblation
- Nasal Turbinectomy – cutting of the turbinate
- Endoscopic Sinus Surgery – involves the use of endoscopes through the nose to correct anatomical deformities, reduce or remove nasal swellings and enlarge sinus openings (improving sinus drainage).
This new technique is minimally invasive surgery; it is safe, convenient and effective in treating sinus diseases.
2. Palate surgery
Palate surgery is important for many reasons:
- 70% to 80% of most snoring arise from the palate
- Surgery to the palate will reduce snoring and obstructive sleep apnea effectively
- Correct type of surgery to the palate is important to prevent complications (stenosis of the palate)
- Reconstruction of the palate is now the lastest method of surgery to the palate
Types of Palate Surgery
- Radiofrequency of the Palate
- Laser Palate Surgery
- Anterior Palatoplasty
- Coblator Palate Surgery
- UvuloPalatoPharyngoPlasty (UPPP)
3. Tongue surgery
Tongue surgery is important for a few reasons:
- the tongue contributes significantly in sleep apnea during an obstruction
- the tongue contains fat tissue as well (sizeable amount)
- the tongue can also be the cause of airway obstruction
Types of Tongue Surgery
- Tongue Reduction Surgery
- Minimally Invasive Tongue Suspension Suture (effective)
- Radiofrequency of Tongue Base
- Genioglossus Advancement Mandibulotomy
I hope that this article helps you to understand some of your options in treating sleep apnea and snoring.
The good news is that all your symptoms can almost always be completely treated!
Dr Kenny Pang is an ENT and snoring specialist. He is well versed in treating all forms of sleep disorders, including snoring, obstructive sleep apnoea, insomnia, sleepwalking, night terrors and bedwetting. He invented 2 very successful surgeries namely, the Expansion Sphincter Pharyngoplasty and the Anterior Palatoplasty.