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SNORING & SLEEP APNEA

SNORING FAQ

What is snoring?
Snoring is noise produced during inspiration when one is asleep. It is due to the vibration of the soft palate, uvula base of tongue and other soft tissues in the throat when one inhales. Snoring implies an increased resistance to the inflow of air during breathing at the level of the upper airways.

As much as 30% of the adult population, or 60% of men over 40 years of age snore.

Is snoring an illness?
Snoring itself is not an illness, but it can be a potential problem, especially if it disturbs other people’s sleep. The snorer may be the target of irritation or anger, may even strain household or marriage relationships.

Snoring if associated with symptoms of tiredness, poor concentration, daytime sleepiness, choking sensation at night, may be a sign of a potential serious medical problem – Obstructive Sleep Apnoea (OSA).

Is snoring dangerous?
Snoring is dangerous if it is associated with daytime tiredness, morning headaches, nighttime choking / gasping or difficulty in breathing. Snoring and Sleep Apnea can lead to heart attacks heart failure, high blood pressure, strokes and sudden death while sleeping.

Where is it generated?
NOSE, PALATE, TONSILS/ADENOIDS, TONGUE

Huge Tonsils blocking the Air Passage

Can it be cured?

YES.

There are a number of different treatment options, the efficacies of which are pretty similar. The majority of snoring is due to nose block and palate vibration / flutter. Thus, treatment is directed at opening up the nose passage and stiffening and strengthening the palate. The theory is that the stiffer the palate the less likely the palate would vibrate and hence, no more obstructions and better oxygen levels at night during sleep, therefore better rested sleep.

Figure showing palate and tongue collapse during sleep (on the right). The collapse of palate and tongue, results in obstruction of the airway and hence, LOW oxygen, stress on the brain, heart and other organs. Sudden Death during sleep is a feared event.

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SNORING IN KIDS

Does your child snore? Did you know that as high as 20% or 1 in 5 children snore nightly and 30% or more snore occasionally? This may be caused by: nasal congestion blocked nose allergic rhinitis enlarged adenoid enlarged tonsils

CHILDREN WHO SNORE OR STRUGGLE TO BREATHE WHILE SLEEPING MAY SUFFER FROM OBSTRUCTIVE SLEEP APNEA (OSA).

In these cases you may hear a snort or gasp for air as they snore and their chest may appear to “suck in”. OSA is described as cessation of breathing while asleep. The stoppages in breathing are usually caused by the airway being partially or completely collapsed during sleep.

How do I know if my child’s snoring is serious?
Children with OSAS will typically experience some difficulty sleeping at night and behavioral problems during the day. Undiagnosed OSA has physical, mental and social impact on the child. The child may encounter problems in school; poor school results, delayed growth and development, and even heart failure.

Children who have sleep apnea may seem sluggish and may perform poorly in school. Sometimes they are labeled “slow”, “lazy”, or children with “learning problems”.

Because some of these symptoms are similar to those described in children with attention deficit hyperactivity disorder (ADHD), some children are misdiagnosed as having ADHD when they are actually suffering from OSA. These can be treated and patients will recover well.

How do I know my child has Sleep Apnea?

1. Frequent loud snoring
2. Short periods of stoppages in breathing during the night
3. Difficulty waking up, even though it seems that he/she has had adequate sleep
4. Headaches in the morning, or often during the day
5. Falling asleep or excessive daydreaming
6. Irritable, aggressive
7. Poor school results, performance

Treatment of OSA

For most children with OSA who have enlarged tonsils and adenoids, treatment is curative with an adeno-tonsillectomy.

Children with allergic rhinitis are also treated aggressively with allergen avoidance, topical nasal steroid sprays and antihistamines (if necessary).

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SLEEP APNEA

Type of Sleep Apnea

Central and Obstructive (Peripheral)

Central Sleep Apnea – is when the brain “forgets to breathe”. This happens in patients with disorders in the brain itself. For example, patients with brain tumours or patients with too much carbon dioxide in the blood, this would lead to suppression of the breathing centers in the brain.

Obstructive Sleep Apnea – OSA is a disorder that is characterized by repeated episodes of airway blockage that occur during sleep, and usually associated with snoring and reduction in blood oxygen level.

Apnea is defined as an absence of breathing for 10 seconds or longer.

Severity of OSA is measured in terms of the number of stoppages of breathing per hour at night during sleep. Patients with severe sleep apnea can stop breathing as often as once every minute, over the entire night’s rest.

Diagnosis of OSA requires a thorough clinical examination, a flexible nasoendoscopy and an overnight sleep study (polysomnogram).

Do I have Obstructive Sleep Apnea (OSA)?

Symptoms of OSA: During the day:

During the night:

Is OSA dangerous?

Obstructive Sleep Apnea can lead to heart attacks heart failure, high blood pressure, strokes and sudden death while sleeping.

IN SINGAPORE, AN AVERAGE OF 300 PEOPLE DIE PER YEAR FROM SUDDEN DEATH IN THEIR SLEEP. (Sunday Times, Nov 2006)

Associated diseases

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SLEEP TESTS

Do I need a sleep test?
Yes, for most patients who have snoring and are having un-refreshed sleep should have a sleep test done.

Do I need to stay hospital stay?
No. There are newer home based monitoring options that are just as accurate and reliable as the hospital overnight sleep test. The home based devices are also better, as the patient sleeps at home, in his natural regular environment; hence, the sleep is more physiological and would yield a more accurate result.

The current Watch PAT device has been shown to be effective and up to 93% accurate and reliable compared to the overnight full polysomnogram.

Photo of an overnight sleep test, done in hospital or at home (difficult to sleep with all the wires). May not be physiological, and test might not be accurate or reflective of a normal night sleep.

The Watch PAT device worn on the hand. Comfortable for the patient, sleep better and might be more reflective of a normal night’s rest.

Article Written by Dr Kenny Pang on Screening Devices in Sleep Apnea, Published in the Prestigious American Journal of ENT 2005

Article Written by Dr Kenny Pang on the Sleepstrips in Sleep Apnea, Published in the Prestigious American Journal of ENT 2006, it was found to lack accuracy.

Article Written by Dr Kenny Pang on the WatchPAT in Sleep Apnea, Published in the Prestigious American Journal of ENT 2007, it was found to be very accurate and reliable.

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TREATMENT OPTIONS

Are there any conservative options?
A healthy lifestyle, regular exercise and some weight loss would be helpful. If the patient was over-weight, weight loss would be certainly important.

In general, dietary measures are important and mandatory for obese patients.

Sleeping on the side might be helpful, in order to prevent the tongue from falling back and obstructing the airway.

What is Nasal Continuous Positive Airway Pressure (nCPAP)?
This is a non-invasive method of treatment, it entails using continuous positive airway pressure by a nasal mask worn by the patient throughout the night. CPAP is the most effective and frequently used treatment for OSA, but the issue of compliance is a major problem.

As the patient does not use the mask the whole night, it would not be effective.

What are Oral Appliances (OA)
These are mouthpieces that are worn while sleeping to prevent the airway from collapsing. It works by repositioning the tongue or mandible forward.

Does surgery work?
Yes. It would work for selected group of patients with identifiable nose, palate or tongue obstruction and/or narrowing. (see below)

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CPAP

What is nasal CPAP?
This is a non-invasive method of treatment, it entails using continuous positive airway pressure by a mask worn by the patient on the nose or the face throughout the night. CPAP is the most effective and frequently used treatment for OSA, but the issue of compliance is a major problem.

It only works if the patients the mask, it would not work if it was kept in the closet.

As the patient does not use the mask the whole night, it would not be effective.

Picture: CPAP mask treatment

How many types of CPAP are there?
CPAP machines come in the (a) manual and the (b) automatic.

1. Manual – this machine delivers a fixed pressure of air, pre-determined by your sleep specialist based on either an overnight sleep study with the CPAP on, or an average recording of the automatic CPAP use over a month. This machine may be cheaper than the automatic version but require closer monitoring and follow up by the sleep specialist.
   
   
2. Automatic – this is a dynamic machine that will titrate and adjust the amount of pressure required by the patient (user) based on each breath to breath variation. This machine records the average duration of use by the patient every night, records the average pressure required by the patient, records the leak of air between the patient’s nose/mouth and the mask, and provides an AHI reading, which tells the doctor how many times per hour the patient still stops breathing (if at all) while on the machine. This machine may be slightly may expensive but is probably more user friendly for the patient and more comfortable for usage.

Failure of CPAP

The CPAP machine is very effective provided the patient can tolerate it the entire night. Compliance is the main problem. Most people do NOT use the machine the entire night and every night of the week. Hence, the treatment effectiveness is based entirely on the patient’s use.

Long term follow up and research done on over 20,000 patients on CPAP and those who underwent surgery. This study was published in the American Otolaryngology Journal in 2006, showed that patients who underwent surgery LIVED LONGER on average than patients who were using CPAP.

Article Published in 2004, in an American Journal of ENT, showing that patients who underwent surgery for sleep apnea had better survival rates than patients on nasal CPAP mask.

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SURGERY

The key to surgical success is patient selection

The most important role for the sleep surgeon is to

a. select the correct patient
b. for the correct surgery, and
c. be able to perform this surgery.

Surgery is divided into surgery for the Nose, Palate and Tongue.

NOSE

Nose surgery is important for a few reasons:

1. the nose represents 50% of the airway (the other 50% is the mouth), hence, having a clear nasal passage is important.
   
   
2. a clear nose is important for a patient who is using the CPAP machine, helps usage and improves compliance
   
   
3. nose surgery also helps reduce snoring and obstructive sleep apnea to a good extent (if done together with other procedures, like palate or tongue)
   
   
4. nose surgery alone (performed alone) is at best 20% to 40% effective in treating obstructive sleep apnea (should be done with other procedures, like palate or tongue, if the patient has moderate or severe obstructive sleep apnea)

Picture showing a patient with a nose mass blocking the nasal passage.	Endoscopic picture of a patient with nose polyps, blocking the entire nose.

Types of nose surgery

1. Nasal Turbinate Reduction - Laser, Radiofrequency, Micro-debrider, Coblation
2. Nasal Turbinectomy – cutting of the turbinate
3. Endoscopic Sinus Surgery – involves scopes through the nose to reduce nasal swellings and enlarge sinus openings

Nasal Turbinate Reduction with the Radiofrequency is effective

1. 10 minute procedure
2. Local anaesthesia
3. PAINLESS procedure
4. Done in the clinic / office
5. Outpatient basis
6. Good Results

Radiofrequency of the Nose, done under local anaesthesia (painless procedure).

PALATE

Palate surgery is important for many reasons:

1. 70% to 80% of most snoring arise from the palate
   
   
2. Surgery to the palate will reduce snoring and obstructive sleep apnea effectively
   
   
3. Correct type of surgery to the palate is important to prevent complications (stenosis of the palate)
   
   
4. Reconstruction of the palate is now the LATEST method of surgery to the palate
   
   
5. The Expansion Sphincter Pharyngoplasty technique has been shown to be 86.2% effective in patients with sleep apnea (Invented by Dr Kenny Pang, 2006)

Surgery Invented by Dr Kenny Pang on the Expansion Sphincter Pharyngoplasty for Sleep Apnea, Published in the Prestigious American Journal of ENT 2007.

Types of Palate Surgery – For Snoring and Mild Sleep Apnea

1. Radiofrequency of the Palate
2. Pillar Implant Palate Procedure – MultiCenter Trial in United States done by Dr Kenny Pang
3. Laser Palate Surgery
4. Cautery Assisted Palate Surgery – Invented by Dr Kenny Pang
5. Coblator Palate Surgery

Pillar Implants for the Palate (Multi-center Trial in USA conducted by Dr Kenny Pang

Palate Surgery For Snoring and Mild Sleep Apnea is effective

1. 10 minute procedure
2. Local anaesthesia
3. PAINLESS procedure
4. Done in the clinic / office
5. Outpatient basis
6. Good Results

A patient with huge obstructing tonsils, causing narrowing of the airway and severe obstructive sleep apnea	The same patient after surgery of the Palate, notice the large space created after surgery, the patient breathes better now.

Types of Palate Surgery – For Moderate and Severe Sleep Apnea
Traditional UvuloPalatoPharyngoPlasty (UPPP) – for selected group of patients, average results from 3,000 over patients showed UPPP at best results were 59% after very careful and prudent selection of patients

Z-PharyngoPlasty (ZPP) – good for patients with narrow palate and absent tonsils

Expansion Sphincter Pharyngoplasty (ESP) – very useful technique, have shown to be 86% successful in a controlled trial (Invented by Dr Kenny Pang)

TYPES OF SLEEP APNEA PATIENTS
60% OF PATIENTS WITH SLEEP APNEA HAVE PALATE OBSTRUCTION AS THE MAIN CAUSE (WILL NEED PALATE SURGERY)
40% OF PATIENTS WITH SLEEP APNEA HAVE BOTH PALATE AND TONGUE OBSTRUCTION AS THE MAIN CAUSE (WILL NEED PALATE AND TONGUE SURGERY)

Patients with palate and tongue obstruction who only have palate surgery done alone, will not be cured of their sleep apnea (will not have good result).

Patients with palate and tongue obstruction will NEED both palate and tongue surgery done together for a good result.

TONGUE

Tongue surgery is important for a few reasons:

1. the tongue contributes a lot in sleep apnea during an obstruction
2. the tongue needs to be treated if the patient wants a good result
3. the tongue is the culprit in at least 40% of patients with sleep apnea
4. not treating the tongue, will lead to FAILURE on surgery

A patient with a BIG tongue causing small air passage and obstructive sleep apnea at night.

Types of Tongue Surgery

1. Tongue Reduction Surgery / Excision
2. Minimally Invasive Tongue Suspension Suture (Introduced by Dr Kenny Pang into Asia, 2005)
3. Tongue Radiofrequency of Tongue Base
4. Minimally Invasive Midline Submucosal Tongue Excision (SMILE technique)

The Tongue Suspension Suture to hold the tie forward, so that it does not fall back and block the airway at night. Introduced into Asia by Dr Kenny Pang in 2004.

TYPES OF SLEEP APNEA PATIENTS
60% OF PATIENTS WITH SLEEP APNEA HAVE PALATE OBSTRUCTION AS THE MAIN CAUSE (WILL NEED PALATE SURGERY)
40% OF PATIENTS WITH SLEEP APNEA HAVE BOTH PALATE AND TONGUE OBSTRUCTION AS THE MAIN CAUSE (WILL NEED PALATE AND TONGUE SURGERY)

Patients with palate and tongue obstruction who only have palate surgery done alone, will not be cured of their sleep apnea (will not have good result).

Patients with palate and tongue obstruction will NEED both palate and tongue surgery done together for a good result.

THE TONGUE NEEDS TO BE TREATED AND OPERATED ON IF IT IS LARGE OR OBSTRUCTING THE AIRWAY, IF NOT, SURGICAL FAILURE IS LIKELY.

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SUCCESS RATES OF TREATMENT

The key to surgical success is patient selection

1. type of patient selected for surgery – including height and weight of patient, age of patient, tonsil size, palate size, tongue size and nose problems
2. type of surgery performed – including UPPP, ESP, Z-Plasty
3. whether nose, palate and tongue surgery is performed together
4. type of tongue surgery performed
5. severity of Sleep Apnea (disease) as noted on the sleep test
   

sleep well & breathe easy

Thick Uvula and Palate

After Surgery, air space enlarged.

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SAFETY OF SURGERY

Multi-level sleep surgery has been shown to be safe and effective in patients with multi-level obstruction (including nose, palate and tongue surgery together).

Research done and International review by Dr Kenny Pang showed that patients who had nose, palate and tongue surgery done together had no severe problems / side effects / complications.

Monitoring of patients who just had sleep apnea surgery was also researched by Dr Kenny Pang, this showed that patients who have sleep apnea surgery needs special monitoring post-operatively.

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