More to snoring than meets the eye

Mr A, a 31 year old gentleman saw me recently for loud snoring that his wife had complained for a few years. He also complained of dozing off easily during meetings and sometimes while driving too! As far as he can remember, he has always had nasal allergies with a constantly blocked nose which failed to improve much with nasal steroid sprays or decongestants. This resulted in mouth breathing, dry mouth and occasionally bad breath.

On examination, his tonsils were severely enlarged (also known as “kissing tonsils”- Figure 1). A nasoendoscopy (scope through his nose and throat region) showed enlarged turbinates and a deviated nasal septum (Figure 2) in his nasal cavity. He was overweight with a Body Mass Index (BMI) of 28. An overnight sleep study showed that his Apnoea Hypopnoea Index (AHI) was 25/hour (meaning his upper airway collapses on average 25 times in 1 hour!). This reading was consistent with moderate obstructive sleep apnoea (OSA).

Figure 1 – Severely enlarged tonsils (“kissing tonsils”) at the back of Mr A’s throat

Figure 2 – Deviated nasal septum to the left, blocking most of Mr A’s left nasal cavity.

Mr A was advised to undergo Continuous Positive Airway Pressure (CPAP) therapy which involves using a machine that pumps air through a nose or face mask to splint the upper airway open during sleep. He was also advised to undergo a weight loss program. Unfortunately, Mr A was not able to tolerate CPAP therapy and chose to undergo surgical interventions to widen his upper airway space. He underwent septoplasty (surgery to straighten his nasal septum), surgical reduction of his turbinates (turbinoplasty) and surgical removal of his tonsils (tonsillectomy). His postoperative recovery was uneventful.

On review about 1 month after his surgery, Mr A was happy that he no longer snores, is breathing better and does not doze off easily anymore. Mr A was also advised to continue losing weight which will help improve his chances of cure from OSA. He will need a repeat sleep study 6 months after surgery to help determine if the surgery and weight reduction has reduced or cured his OSA.

OSA is a condition in which the sufferer experiences repeated episodes of upper airway collapse (similar to “choking episodes”) during sleep. The most common symptom is loud snoring which many patients may put off as just a simple nuisance. However, if untreated, moderate and severe OSA have been shown to have an increased risk of:

1. Cardiac complications (e.g. high blood pressure, heart attack, heart failure, irregular heart beats etc)
2. Brain complications (e.g. low or poor concentration, stroke etc)
3. Behavioural and growth disturbances in children
4. Diabetes
5. Low libido and erectile dysfunction

The first line treatment for patients with severe OSA is Continuous Positive Airway Pressure (CPAP) therapy. However, for patients with known anatomical risk factors for upper airway obstruction (e.g. large turbinates, deviated nasal septum, large adenoids and tonsils etc) surgery is a good alternative. One of the most common surgery to widen the upper airway space is known as uvulopalatopharyngoplasty (often known as “UP3”).

In this procedure, the back part of the throat is reconstructed after removal of the tonsils to create a “rectangular-shaped” opening. Although the option of having this procedure performed in addition to tonsillectomy was discussed with Mr A for better result, he decided to take a more conservative approach. This is reasonable in patients with very large tonsils. Studies have shown that tonsillectomy alone in OSA patients with very large tonsils can reduce the number of times the upper airway collapses during sleep. In fact, for children with OSA, tonsillectomy and adenoidectomy (removal of the adenoids) are often the first line treatment. There is no “one size fit all” approach in the treatment of snoring and OSA and it is best to have a detailed assessment and discussion with your ENT Specialist in Singapore.