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Snoring: The Tip Of The Iceberg In Obstructive Sleep Apnea

Did you know that if you snore, the snoring noises actually mean that there is a considerable degree of airway obstruction happening during your sleep? As an ENT specialist in Singapore who looks after many snoring patients, we find that quite often, snorers already suffer from underlying obstructive sleep apnea, a serious and potentially dangerous condition which leads to recurrent drops in the blood oxygen levels during sleep. Such oxygen desaturations may happen as frequently as up to 200 times a night in severe sleep apnea cases, where patients suddenly stop breathing for repeated lengths of time, sometimes as long as up to 2 minutes! So this results in poor quality disrupted sleep, which then leads to daytime tiredness, memory issues, low energy and mood disturbances. Quite often, it is the spouse or sleep partner who notices the disturbed sleep pattern, and highlights it to the snorer, because the snorer may not be aware this is happening in their sleep at all. Jo Koy, a famous American comedian, suffers from obstructive sleep apnea but he was not aware that this was completely abnormal until his mother videotaped him asleep to show him how he was struggling to breathe in his sleep, suffering “mini-deaths” when he stopped breathing for prolonged periods. You can see his skit on OSA here.

Snoring may be the tip of the iceberg of underlying obstructive sleep apnea, a serious life-threatening condition with persistent dips in oxygen levels in the snorer. If sleep apnea continues untreated, then there are increased risks of potentially life-threatening conditions such as heart disease, stroke, irregular heart rhythms (arrhythmias), hypertension, abnormally elevated blood glucose levels, gastro-oesophageal acid reflux and persistent weight gain. Weight gain in patients with obstructive sleep apnea is explained by the fact that poor quality disrupted sleep leads to hormonal imbalances in the brain, mainly with the leptin and ghrelin hormones which control your appetite and metabolic rate. If you suffer from airway obstruction during obstructive sleep apnea, your oxygen levels tend to vary considerably and may fall again and again throughout the night. This means that your poor heart now has to work harder by beating faster and your blood pressure rises at night, when it really should be lower usually.

Did you also know that obstructive sleep apnea is associated with low testosterone levels in men? Testosterone is an important hormone in males and testosterone deficiency will lead to low libido and poor sexual performance, in addition to low energy and low muscle mass, with mood disturbances.

Although many patients who snore and suffer from obstructive sleep apnea are male, we do see a few female snorers as well. The common risk factors for snoring are weight gain, smoking and alcohol but in the Asian population, it is very often caused by structural areas of narrowing or blockage inside the nose, throat and airway.  Some snorers have difficulty breathing clearly through their nose which may become congested due to a deviated or crooked nasal septum inside: The septum divides the right and left nasal passages and is made of bone and cartilage plates. Other causes for nasal congestion may be due to enlarged swollen inferior turbinates related to nasal allergies, sinusitis/sinus infections and/or the formation of nasal polyps, benign growths related to poorly-controlled allergic rhinitis.

Many snorers have an “overcrowded” throat anatomy whereby they have huge swollen tonsils which constrict their airway. They also have low-lying soft palate structures called the uvula, which fall backward to close off the back of their throats when asleep.  The uvula then vibrates repeatedly, producing most of the snoring noise when the snorers breathe through their mouths to allow abnormal turbulent airflow to enter. Your mouth is not meant to be the main breathing organ for airflow to enter and indeed, you should use your nose to take in air during respiration. Some snorers may have large floppy tongues which fall backwards into their throat to block their airway off when they lie flat on their backs when asleep.

Now that you realise the true potential health risks associated with obstructive sleep apnea, the way to diagnose sleep apnea is by having a sleep study performed. For most patients, this is similar to wearing a fancy Fitbit tracking device on your wrist, in the comfort of your own home for one night. The sleep study analyses the number of times you stop breathing during your sleep, called an “apnea”, and also looks at any other type of abnormal breathing event, called a “hypopnea”. The sleep study will count the number of times your blood oxygen levels fall and how low these levels may reach. It analyses your breathing pattern according to your body position, heart rate, sleep stage and loudness of your snoring too. Then the magic number, the Apnea Hypopnea Index (AHI), is used to determine if you do indeed suffer from obstructive sleep apnea and how severe the condition actually is.

If you have been diagnosed with obstructive sleep apnea or you are considering different options of treatment for your snoring symptoms, then it would be useful to read about patients’ journeys as they progress with their treatment. We have 2 featured articles/case studies on Dr Annabelle’s website that has more information which you might find helpful, including a  patient who was kind enough to allow an interview about his obstructive sleep apnea treatment. Another article on the Media page highlights a real-life patient case study but anonymous was published in December 2022 with a different slant towards the association of obstructive sleep apnea and acid reflux (gastro-oesophageal reflux GERD).