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What you should know and what you can do about sleep-disordered breathing
Snoring and Obstructive Sleep Apnea (OSA) are the most common types of Sleep-Disordered Breathing (SDB).
In a recent global survey on snoring cities, Singapore was identified as one of the top three snoring cities in the world, after Dublin and Canberra that were ranked first and second, respectively.
Not only is snoring prevalent in Singapore, one in three has moderately-severe to severe OSA and is undiagnosed.
Undetected and consequently untreated severe OSA leads to:
Hence, snoring and Obstructive Sleep Apnea (OSA) are linked to unmet serious public health problems. The challenge is to gain public recognition for the need to diagnose the cause of snoring for the right treatment.
In this 'Ask the Specialist' Q&A forum, Dr Mimi Yow, Senior Consultant from the Department of Orthodontics at National Dental Centre Singapore (NDCS), a member of SingHealth group, answers questions on common causes for snoring and sleep apnea, when it is a concern and treatments available (non-interventional and interventional).
This Q&A forum is open from 1 Nov to 28 Nov 2022.
To post your question, please log in as a member. If you are not a member, you can register for a FREE membership here.
If you have problems posting your questions, please email your questions to marcom@healthxchange.com.sg
Kindly note: Your question will only go live / appear on this page after the doctor answers it
Hello, Are tongue exercises beneficial to mitigate against OSA and if so, can you provide a link to learn more about these exercises? Is Invisalign beneficial in improving OSA if the teeth alignment is narrow rather than rounded? What are the options for a patient wanting to improve the symptoms of OSA? CPAP would not be an option I would consider. Thank you.
Answered by Dr Mimi Yow, Senior Consultant, Department of Orthodontics, National Dental Centre Singapore (NDCS)
Hello Mr Guy. Thank you for your questions.
Research studies show that daily exercises involving muscles of the face, mouth, tongue and throat in orofacial myofunctional therapy can help to reduce snoring and the severity of OSA. This SGH video-link shows what orofacial myofunctional therapy looks like:-
https://www.sgh.com.sg/patient-care/conditions-treatments/Orofacial-Myofunctional-Therapy
Orthodontic bone-expanders broaden the palate (roof of the mouth), which is also the floor of the nose. Two outcomes are achieved by this bone expansion. Firstly, it opens up the nose to relieve nasal congestion for better breathing. Secondly, it increases space in the mouth for better placement of the tongue, which helps to reduce airway obstruction at the throat and the severity of OSA. The extra space can be used for alignment of teeth if they are initially crowded, or conversely, the extra space can cause teeth to become spaced. In either case, Invisalign removable braces or bonded braces can be used to align teeth or close the spaces between teeth in the wider jaw bone.
CPAP is by far the most effective treatment for OSA. It is understandable that not everyone can cope with daily use of CPAP and you are not alone. An audit at SGH showed that 60 to 70% patients reject or cannot tolerate CPAP treatment. There are non-surgical and surgical options to be considered after thorough examination and assessments by our sleep team doctors. Conservative or non-surgical treatment other than CPAP include:
Surgical treatment is not a substitute for conservative treatment but provides options where non-surgical treatment has not worked. The different types of surgery are:
All the very best to you as you explore the options on the best way to manage your condition to improve your health and quality of life.
Dear Doctor Mimi Yow,
I'm male 60 year old on medications for HBP, High Cholesterol, Blood Thinner and Diabetic.
I snores whenever I sleep and have Sleep Apnea. Is there cure for Sleep Apnea such as surgery and would it eradicate Sleep Apnea. Other than surgery, any other medical help or treatment Sleep Apnea.
Thank you very much.
Regards,Michael
Hello Michael. Thank you for our questions.
I can understand your concerns with your snoring, sleep apnea and multiple medical conditions. I trust that you have seen a doctor and had a sleep study to confirm you have sleep apnea. Sleep apnea is a disorder that is treatable but not curable except for very mild sleep apnea. There are three different types of sleep apnea:
Diagnosis is important as it determines the type of treatment for you.
In Singapore, sleep studies reveal one in three of the community has moderately severe to severe OSA. More than 90% are unaware they have OSA and remain untreated.
Individuals with untreated sleep apnea are at risk for multiple medical conditions with serious health and daily life consequences: hypertension, coronary artery disease, angina, heart attack, irregular heart rhythm, stroke, sudden death, diabetes, glaucoma, impaired neurocognition, depression, interrupted sleep, fatigue, daytime sleepiness, lack of vigilance at work or school, and increased risk of road traffic accidents by falling asleep at the wheel while driving.
There are several non-surgical ways of treatment:
It is best for you to have a thorough examination by a sleep-trained doctor who can help you to determine the type and severity of sleep apnea you have and the appropriate treatment or combination of treatment that is best suited for your condition. All the very best to you in finding the best solution to manage your health and quality of life.
How to prevent snoring?
Hello Mr RichardAQP. Thank you for your question.
Snoring is caused by soft tissue vibrations in the upper airway. It can be due to a small and narrow airway or loose soft tissues in the airway or both. Narrowing of the nose and upper airway may be due to a number of reasons that may overlap: nasal allergy, swellings or polyps in the nose, deviated nasal septum, enlarged tonsils and/or adenoids, long and thick soft palate, big tongue, reduced muscle tone of the airway and tongue, and small jaws.
Taking alcohol, antihistamines, sedatives and tranquillizers, smoking and nasal congestion can make snoring worse. To reduce snoring, avoid taking substances that make it worse, especially alcohol, in the evening and before going to bed. Sleep on the side rather than on the back, stop mouth breathing by clearing up nasal congestion and strengthen the tongue and throat muscles by daily myofunctional exercises. See a doctor to check if there is anything blocking your nose or pharynx (the airway behind the nose and tongue).
Listen out for family and friends who snore, it is a sign that they may need medical help. Before trying out self-remedies for snoring, it is important to check with a doctor to determine if snoring is a symptom of sleep apnea.
Prevention is certainly better than cure and I wish you the best of health.
My ENT doctor believes I have sleep apnea and advises me to do a sleep apnea test. It is very expensive so I am not sure if it is really necessary. How would the test help me?
Hi Nezlo, your doctor is right. It is necessary to have a sleep study to confirm sleep apnea.
A sleep study measures what happens to you while you sleep:
A home-based sleep study is less expensive and costs a few hundred dollars. However, it does not provide as much information as an in-hospital sleep study. If a home-based sleep study cannot rule out that you do not have sleep apnea, you may need to attend an in-hospital sleep study, which is the best available test to diagnose sleep apnea and any overlapping sleep disorder. An in-hospital sleep study can cost a few thousand dollars. If you have medical insurance or qualify for government subsidy, it can help to defray the cost of either a home-based or in-hospital sleep study.
Individuals with untreated sleep apnea are at risk for multiple medical conditions with serious health and daily life consequences such as hypertension, coronary artery disease, angina, heart attack, irregular heartbeats, stroke, sudden death, diabetes, glaucoma, impaired neurocognition, depression, interrupted sleep, fatigue, daytime sleepiness, lack of vigilance at work or school, and increased risk of road traffic accidents by falling asleep at the wheel while driving. Appropriate treatment and adequate follow-up are only possible with proper identification and confirmation of your condition.
I wish you good health and may it be a priority in your life.
Question posted by Andrew
Hi Doctor,
How can I be sure that I have OSA? I do have the symptoms mentioned. Thanks.
Hello Andrew, you are indeed a wise man who listens to his body.
You can determine the level of risk you have for OSA by self-screening using the STOP-BANG questionnaire. Screening establishes the level of suspicion for OSA but it does not replace the need for a sleep study. If you want to be absolutely sure if you have or do not have OSA, a sleep study is necessary.
Screening questionnaire:
S – Do you snore loudly?T – Do you often feel tired or sleepy during the daytime?O – Has anyone observed that you have stopped breathing/choking/gasping for breath during sleep?P – Pressure: do you have high blood pressure?B – Body mass index (BMI) of more than 35kg/m (weight divided by the square of height)A – Age older than 50N – Neck circumference of more than 40cmG – Male gender
If you have 3 to 4 "yes" answers, it is suggested that you see a doctor for further assessments to confirm if you have sleep apnea.
If you have 5 or more "yes" answers, it indicates you are at high risk of sleep apnea. You are strongly advised to see a doctor to confirm the diagnosis of sleep apnea and treatment needed.
All the best of health to you.
Question posted by Angela
Dear Doctor,
I have been wanting to see a doctor for my sleeping disorder and have it diagnosed and treated but I don't know where to start. I am experiencing the signs of snoring, constant tiredness that are mentioned.
Hello Angela. Good on you - you have taken the first step to find out what is the problem behind your snoring and constant daytime tiredness.
Snoring is caused by soft tissue vibrations due to airflow in a small airway or loose soft tissues in the airway. Narrowing of the nose and upper airway can be caused by many factors: nasal allergy, swellings in the nose, deviated nasal septum, enlarged tonsils and/or adenoids, long and thick soft palate, big tongue or loose airway and tongue muscles, and small jaws.
A detailed examination of your nose, mouth, throat and jaws will be done to determine the possible causes of snoring where the airway is narrow. A sleep study will be necessary to confirm if the snoring and daytime sleepiness are associated with sleep apnea. The appropriate treatment will depend on the sleep study results and clinical assessments.
You can see your own family doctor or a polyclinic doctor for a referral. An appointment can be made through Health Hub for the Singapore General Hospital, Changi General Hospital or Sengkang General Hospital Otolaryngology (ENT) Service.
All the best to you on your journey to good health.
Dear Doctor
My sleeping problem is rather disturbing as I can only sleep soundly on my left side. For years I am unable to sleep on my right side as I would choke on my saliva or something else irritating my throat and would cause me to cough badly.
If I sleep face up the cough would also happen or otherwise I would snore after I fall asleep from exhaustion. This happens to me every night and for years.
I have an upcoming health screening at Changi General Hospital next month so am I able to get a referral from the health screening doctor?
I look forward to your reply.
Hello Angela.
From what you describe, you seem to be choking in your sleep from upper airway obstruction. Yes, you can get a referral to the Integrated Sleep Service (ISS), which is also at the Changi General Hospital (CGH) where your health screening is done.
The ISS at the CGH Specialist Clinics is a one-stop multidisciplinary clinic for comprehensive services to manage different types of sleep disorders including snoring, sleep apnea and insomnia by specialists from:
Good to know that you are getting the medical help you need.
Question posted by Mike
Hi Dr Yow,
I was diagnosed with severe sleep apnea a few years ago, in my early 20s. I have more than 30 apnea events each hour when left untreated. To treat it, I am required to use a CPAP machine.
Unfortunately, I am not the best patient - I constantly fail to use it at night, and on average only put it on once a week. Is there any point of me using a CPAP machine if I am not compliant? What would the long term effects be if I still continue to use it this infrequently?
Hello Mike. You have severe OSA and that is worrying.
If you have untreated or inadequately treated sleep apnea, you are at risk for multiple medical conditions with serious long-term health and daily life consequences such as: hypertension, coronary artery disease, angina, heart attack, irregular heart rhythm, stroke, sudden death, diabetes, glaucoma, impaired neurocognition, depression, interrupted sleep, fatigue, daytime sleepiness, lack of vigilance at work or school, and increased risk of road traffic accidents by falling asleep at the wheel while driving.
Try your best to get used to sleeping with the CPAP device as it is proven to be the most effective among all the available treatment for OSA. Ideally, the CPAP device should be used for the entire duration of your sleep. Sleeping with the CPAP device for 4 to 5 hours improves daytime sleepiness but in order to reduce cardiovascular risks and hypertension associated with OSA, up to 6 hours of sleep with the CPAP device is advised.
If you cannot use the CPAP device, there are other conservative, non-surgical ways to manage OSA:
There are also surgical options where conservative treatment does not work:
Please take your health issues related to OSA seriously as you are still young. Do take action to treat the severity of your OSA. I wish you a long life ahead with many healthy years.
Question posted by Erik
Dear Dr Mimi,
Good day.
I read with interest about SDB, whether snoring or OSA and in particular the Non-invasive treatment.
Would appreciate your sharing about the non-invasive treatment:
Hello Erik. Thank you for your questions.
There are different types of non-invasive treatment to manage sleep-disordered breathing. Being non-invasive, there is no surgery involved. Non-invasive therapies include:
Invasive treatment to manage sleep-disordered breathing requires surgery with general anaesthesia. Surgery is not a substitute for non-invasive therapies but provides options where conservative treatment has not worked. There are different types of surgery:
The success of treatment varies as OSA can be due to different causes that require a combination of treatment. Individual compliance and response to treatment are also unpredictable factors that affect treatment outcomes.
The cost for devices varies as they are supplied by different vendors. This will be discussed at the time of assessment and selection of the appropriate device.
For invasive treatment, assessments by the surgeon are necessary to determine the risks and benefits of surgery compared with other non-surgical management of your condition. The cost of surgical intervention depends on the indications of the type or combination of surgical procedures, choice of ward and duration of hospitalisation. The attending surgeon will discuss this with you after an assessment of your condition during the consultation.
Good health to you, take care and stay well.
Question posted by Shawn
Hi Dr,
Can you talk about Inspire sleep apnea implants? Is it approved in Singapore and if yes, what is the cost like.
I did surgery for OSA years ago and it came back in two years. I am very interested in the Inspire implants.
Hi Shawn. Thank you for your question. It is good to know that you are keeping checks on your condition, which can worsen by aging, weight gain from increased body fat and loss of muscle tone.
Yes, the Inspire device is approved in Singapore for use in selected patients with OSA. SGH is currently the only public health institution with ENT surgeons accredited to perform Inspire implant surgery.
The Inspire hypoglossal nerve stimulator (HGNS) device delivers electrical stimuli to the nerves in the tongue by sensing respiratory effort. The tongue is activated to move forward together with other muscles in the throat to open and stabilise the airway.
A thorough assessment by the surgeon is necessary to determine the risks and benefits of the implantable sleep apnea device and whether it is suitable for you. The cost depends on indications of the device, the surgical procedure, choice of ward and duration of hospitalisation. This will be discussed with you by the attending ENT surgeon.
All the very best of health to you.
Follow-up question posted by Shawn
Thank you for your reply Dr Yow.
Can you let me know about your experience with this?
How are the patients doing after the surgery?
Are there significant improvements in sleep quality and snoring?
Assuming the surgery is performed and staying in a class B ward, what is the ballpark figure on the cost?
How can I schedule an appointment with ENT for this?
Hello Shawn. Thank you for your questions.
The Inspire implant accredited ENT surgeon is the best person to answer your questions and advise you. To schedule an appointment as a private patient, you can contact the SGH Patient Liaison Service, by email: pls@sgh.com.sg or by phone: (65) 6326-5656. Should you wish to be seen as a subsidised patient, please make an appointment with a doctor at any Polyclinic who can assess you before referring you to the SGH ENT Centre.
All the very best to you.
Question posted by Irene
Dear Dr,
I was diagnosed by an ENT surgeon in SGH as having mild to moderate OSA about 7-8 years ago.
Upon her advice I bought a CPAP but I didn't really like to use it because it limits my movement, that is turning to the right or left. I cannot be lying in a recumbent position. Because of this restriction, I used the device about 4- 5 hours nightly.
The question I would like to ask is would seeing a Dental Surgeon help with the OSA? I would be happy if I don't have to use the device.
Hello Irene. I am very sorry to learn of your frustrations in sleeping with the CPAP device. It is understandable that not everyone can cope with the daily use of CPAP and you are not alone. An audit at SGH showed that 60 to 70% patients reject or cannot tolerate CPAP treatment.
The most effective treatment for OSA is CPAP. Ideally, the CPAP device should be used for the entire duration of sleep. Sleeping with the CPAP device for 4 to 5 hours improves daytime sleepiness but in order to reduce cardiovascular risks and hypertension associated with OSA, up to 6 hours of sleep with CPAP device is advised.
Do try out the newer, smaller and softer models of CPAP straps/nose mask or nasal pillows for side-sleepers or active sleepers, to see if they work for you. However, if you really cannot sleep properly with the CPAP device, you can explore other options of treatment or combinations of treatment.
The conservative, non-surgical ways to manage OSA other than CPAP are:
It is best for you to have a thorough examination by a sleep team who can help you to determine the appropriate treatment or combination of treatment. All the very best to you in finding the best solution to manage your condition for good sleep and good health.
Question posted by Wongfam
Good evening Dr,
My husband snores really loud and it's affecting my sleep. We have changed so many pillows thinking that might be the problem. But apparently not.
Sometimes after a period of snoring loudly, he quietens down, and seems like he's not breathing. Then after a few seconds, he starts snoring again. It's something I observe when I can't sleep. He refuses to see a doctor about it. Please advise. Thank you.
Hello Wongfam.
It must be distressing for you to witness your loved one suffering from sleep-disordered breathing. What you have observed is partial collapse of the upper airway that limits airflow and causes snoring. When the upper airway collapses completely there is no noise as there is no airflow - what follows is the brain waking up briefly to restore airflow.
Snoring is common but just because it is common does not mean that it is normal. Snoring, with or without sleep apnea, is harmful. To the person who is snoring, he is unaware of it as he is unconscious. To you the bed-partner, the noise from snoring keeps you awake. If this happens night after night, you become sleep deprived. Loud snoring can be more than 100 decibels in intensity – similar to the sound level at a rock concert or from the car speaker that is at maximum volume. Loud sounds create powerful vibrations. Recurrent strong vibrations inflict damage to the snorer’s soft palate and pharynx (the airway behind the nose and tongue). Repeated trauma causes inflammation and swelling of the soft palate and pharynx, which are prevented from healing by constant vibrations from the snoring. The damaged pharynx becomes collapsible and prone to snoring and sleep apnea.
It is good that you know what is happening and can help him. He may be unaware or fearful of the health consequences or both. Give him plenty of support and time to understand that snoring is a health issue for the both of you. If your sleep is fragmented by the noise and you are experiencing symptoms of sleep deprivation - excessive daytime tiredness, headaches, irritability, reduced vigilance with daytime tasks or have problems thinking and remembering, please see a doctor and ask your husband to accompany you. The doctor can advise him on how to help you by getting treatment.
All the best of health and happiness to you and your husband.
Question posted by Chris
Hi Dr Yow
I have done sleep study (which I didn’t slept well) which shows AHI of 5.7. Sleep Doctor say I have no sleep apnea (at least of no concern) and only insomnia and delay sleep syndrome and given some pills to help with falling asleep.
However, I still feel unrefreshed and on several occasion noticed I can’t breath and the tongue is blocking my airway when I’m half awake. It gets worse when I am tired and on my back.
Is there any other discipline which I can request to check on my condition if I am told do not fit into the AHI / sleep apnea model but still feel tired and lack of oxygen/unrefreshed?
Hi Chris. I can understand your concerns with sleep-disordered breathing, unrefreshing sleep and daytime tiredness.
You are right in that there are some individuals with upper airway resistance who have sleep apnea type symptoms but the sleep study does not confirm sleep apnea. If you still do not breathe or sleep well, you should have another assessment and do take your sleep study report along to have it reviewed by a sleep-trained doctor.
To schedule an appointment as a private patient, you can contact the SGH Patient Liaison Service, by email: pls@sgh.com.sg or by phone: (65) 6326-5656. Should you wish to be seen as a subsidised patient, please make an appointment with a doctor at any Polyclinic who can assess you before referring you to the SGH ENT Centre. All the very best.
