Snoring, when associated with choking, unrefreshing sleep or daytime sleepiness, can be a symptom of obstructive sleep apnoea (OSA). The Department of Otolaryngology from Singapore General Hospital (SGH) discusses its causes and treatment options.
What is obstructive sleep apnoea (OSA)?
A symptom of
obstructive sleep apnea (OSA) is snoring associated with choking, unrefreshing sleep, daytime sleepiness or fatigue.
This is a condition where there is repeated upper airway collapse during sleep. This causes breathing to stop and the brain needs to wake up temporarily to open the airway to breathe again before falling back to sleep. On returning to sleep the obstruction occurs again and this cycle repeats. This causes poor sleep quality.
Lifestyle changes to manage mild obstructive sleep apnoea (OSA)
For mild cases of obstructive sleep apnoea (OSA), you can try making simple lifestyle adjustments such as:
Sleep on your side to reduce the incidence of apnoea during sleep
Lose weight if you are obese
Exercise regularly
Quit smoking (if you haven't)
Avoid consuming alcohol at night. Alcohol causes relaxation of the upper airway muscles.
Avoid sleeping pills / sedatives as these may cause relaxation of the upper airway muscles.
Treatments for obstructive sleep apnoea (OSA)
Watch this video on sleep apnoea treatment by the SingHealth Duke-NUS Sleep Centre.
1. Continuous Positive Airway Pressure (CPAP)
The most common way of delivering positive airway pressure (PAP) is via the CPAP (continuous positive airway pressure). It is considered the
gold standard treatment for obstructive sleep apnoea (OSA). CPAP is safe, generally well-tolerated and highly effective.
PAP is positive pressure delivered by a machine that blows out air and is connected to a mask (via a hose) worn during sleep. This column of air pressure prevents the airway from collapsing.
It may take a while to get used to CPAP treatment, but it is important to persevere to reap the benefits of your treatment. Minor troubleshooting may be required, and it may take time to find the right device settings for you.
OSA sufferers who start using CPAP report sleeping better and feeling more energetic and less sleepy during the day. Some report feeling better after the first day of treatment while for others, the improvement may only become apparent after a few weeks of sustained use.
2. Oral appliance (OA) or dental splints
An oral appliance (OA) or a dental splint is an alternative to the CPAP in managing snoring and mild to moderate obstructive sleep apnoea (OSA). OA looks like the removable functional braces worn by children, or mouth guards that protect the teeth during sports. Proper examination and diagnosis are needed to determine the jaw structure and nature of airway obstruction, before prescribing an OA.
Another form of an OA, is the Tongue Stabilising Device (TSD). It is a silicone suction cup that clips over the front of the tongue. Lip shields protrude from the device to keep the tongue positioned outside the mouth. The tongue guard holds onto the tongue and prevents it from falling backwards into the airway during sleep.
Dental splints are different from an oral appliance as it is used to protect the teeth from bruxism (tooth grinding). Dental splints, also worn during sleep, protrude the lower jaw by keeping the lower teeth in a more forward position. By maintaining the lower jaw in a protruded position,this also helps to enlarge the air space behind the tongue and puts the air passage tissues in greater tension. This decreases the tendency for the airway walls to collapse.
3. Surgery
Surgery for OSA remains a last resort when first-line treatment, such as behavioural and lifestyle modifications, CPAP therapy as well as dental appliances, have failed. Surgery may also be recommended, when there are easily correctible abnormalities of the upper airway, such as enlarged tonsils and adenoids.
Types of surgery for obstructive sleep apnoea (OSA) include:
a) Nasal surgery
Surgical options to relieve nasal airway obstruction are:
Reducing the size of the turbinates
Straightening the deviated nasal septum
Removing enlarged adenoids
Endoscopic sinus surgery to treat nasal polyps and sinusitis
b) Palatal surgery
The area behind the soft palate is the most common site of obstruction, contributing to snoring and OSA.
For those with snoring and mild or moderate OSA, radiofrequency ablation of the soft palate may be performed under local anaesthesia, to reduce the floppiness and bulkiness of the soft palate.
Alternatively, tonsillectomy and uvulopalatopharyngoplasty (UPPP) or one of its many variations can be performed under general anaesthesia to increase the airway dimensions behind the soft palate.
c) Hypopharyngeal and base of tongue surgery
The base of the tongue and lingual tonsils (lymphoid tissue at the base of tongue) may be enlarged, contributing to upper airway obstruction during sleep.
The epiglottis (cartilage situated behind and below the base of the tongue) can also cause airway obstruction during sleep. Some people may have a small lower jaw that leaves less room for the tongue, resulting in posterior displacement of the tongue, reducing the size of the upper airway.
Options to treat obstruction, include both soft tissue surgery as well as bony skeletal surgery.
d) Maxillomandibular advancement surgery
Maxillomandibular advancement (MMA) is a more invasive but effective surgery, with up to a 90 percent success rate.
This procedure is performed in severe OSA cases when nasal, palate and tongue base surgeries are not effective enough. It is a major surgical procedure where both the upper and lower jaws are surgically advanced using orthognathic surgery techniques, increasing the space behind both the palate as well as the tongue base.
It is done in conjunction with fixed orthodontic braces to shift the upper and lower teeth into a good bite after the surgery.
e) Hypoglossal nerve stimulation
Hypoglossal nerve stimulation is achieved by implanting a device beneath the skin in the chest. This device is switched on by the patient just before sleep, and it applies mild stimulation to the hypoglossal nerve that supplies the tongue. This achieves optimal tongue protrusion required to prevent tongue base obstruction during sleep.
For more detailed explanations with diagrams of various sleep apnoea treatments, visit the SingHealth Conditions and Treatments page here.
Common causes of obstructive sleep apnoea (OSA)
Abnormal shape of the facial bones, inherited or developed over time (this may include nasal problems that narrow the nose passage).
Tonsils
Adenoid enlargement
Obesity
Increasing age (when tissues in the air passage become more lax).
The Otorhinolaryngology - Head and Neck Surgery department at Singapore General Hospital (SGH), a member of the SingHealth group, offers a complete range of ENT clinical and paraclinical services dealing with problems of the ear, nose and throat.
The Sleep Centre adopts a multi-disciplinary approach in the treatment of sleep disorders, with specialists from Respiratory Medicine, ENT, Neurology as well as Psychologists and Psychiatrists.
Ref: I23 (ed)
More sleep articles you may be interested in:
8 Easy Exercises to Stop Snoring
8 Tips to Stop Snoring
When is Snoring Considered Obstructive Sleep Apnoea (OSA)?
Obstructive Sleep Apnoea (OSA): How to Manage
Obstructive Sleep Apnoea (OSA): Why It Increases Heart Disease Risk
