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Insomnia and Snoring

It’s a bigger problem than you think

A good night’s sleep is not a luxury but an integral aspect of good health and quality of life.  There is now increasing evidence that poor sleep has an adverse effect on health, especially cardiovascular health.

There are a myriad of sleep disorders, of which the most recognisable are insomnia and snoring. Almost everyone has experienced it sometimes, but the actual incidence of problematic insomnia is not known. There is little data on snoring as well. But a local study in 1999 found that 24% of local adults snore and 15% have obstructive sleep apnoea. This is a condition where there is not only snoring, but also a blockage of the air passage during sleep, leading to repeated drops in oxygen level and poor sleep quality.

 Insomnia

Most causes of insomnia are related to mental and psychological well-being, like anxiety, stress, and depression. Sometimes, the causes are physical, like pain from other medical conditions; diseases, like an overactive thyroid gland; or medications, like decongestants that excite the body. Poor sleeping habits may also contribute, such as irregular sleep times or engaging in stimulating activities before sleep, including exercise and computer games.

Diagnosis

To improve insomnia, the most important step is to identify the cause. Your doctor will take a detailed history of your daily activities and sleep pattern. It is a good idea to keep a daily activity and sleep pattern diary over a few weeks so that this information will be available during your consultation. Tests are rarely necessary, but if there is a suspicion of a medical problem like thyroid disease, a blood test may be ordered. Other problems that keep you awake or wake you up at night, like chronic pain, frequent urination, blocked nose, etc, may require input from other specialists. A sleep study, either in the hospital or at home, may be necessary if other sleep disorders are suspected.Untitled-1

Treatment Options and Medication

The most important step in treating insomnia is to adopt good sleeping habits. These are:

  • Maintaining a regular sleep pattern
  • Avoiding stimulating activities just before sleeping
  • Not using the bed for other activities like reading or watching TV, etc
  • Avoiding stimulants like caffeine or decongestant medications
  • Sufficient physical activity, preferably early in the day
  • Not lying in bed for a long time if unable to fall asleep

Other behavioural methods like relaxation techniques and minimising stressors are usually helpful as well.

Medications for insomnia include sleeping pills and those that induce sleepiness, like anti-histamines. These may be helpful in the beginning, to break the cycle of insomnia and allow for a good sleep pattern to be established. But these should not be used long term, especially sleeping pills, as there is a potential for addiction.

 Snoring and Obstructive Sleep Apnoea

Snoring is more than a social problem that affects your sleeping partners. It may be a sign of a more serious problem of obstructive sleep apnoea (OSA). This is when the airway blocks up during sleep, leading to repeated drops in oxygen and poor sleep quality. Research has found a strong link with cardiovascular diseases like high blood pressure, heart disease, and strokes. In fact, for patients with severe OSA, their risk of heart attacks and strokes may be more than three times higher than normal. A study in Singapore found that above 65% of patients suffering from heart attack had undiagnosed moderate to severe OSA. In children, OSA may lead to poorer school performance and difficulty concentrating and learning. It also increases the risk of developing cardiovascular disease and diabetes in future.

Diagnosis

You should seek an opinion of an ear, nose and throat (ENT) surgeon or sleep physician if you have the following symptoms on top of snoring:

  • Your sleeping partner notices that you sometimes stop breathing during sleep
  • Excessive sleepiness in the day
  • Waking up at night with shortness of breath or a choking feeling
  • Morning headaches
  • Irritability, difficulty concentrating and poor memory
  • Frequent urination at night or bedwetting in children

Your doctor will order a sleep study to determine if OSA is present. This may be performed in the hospital or even at your own home. You will also require a simple outpatient endoscopy to look at the points of obstruction. This may occur either in the nose, at soft palate, or at the back of the tongue. In the nose, blockage may be caused by soft tissue swelling or a bent nasal septum, the divider in the middle. The soft palate and tonsils may cause obstruction at the second level. At the lowest level, the back of the tongue may fall backwards causing obstruction as well.

Treatment Options

The sleep study will assess the severity of your OSA. Based on that and the findings on outpatient endoscopy, treatment can be recommended. In children, the first line of treatment for OSA is removal of the tonsils and adenoids, and sometimes nasal soft tissue reduction, if required.

Treatment for adults is more complicated. For mild OSA, simple procedures to open up the airway, like radiofrequency to reduce soft tissue in the nose and stiffen up the soft palate, or oral appliances to bring forward the jaw or retain the tongue, may be sufficient.

For moderate to severe OSA, use of a continuous positive airway pressure (CPAP) device gives the best results. It consists of a pump that pressurises air via a mask strapped to your face when sleeping. The problem with CPAP is that most patients are not willing to use it. In that case, surgery is the next best option. It should be tailored to the points of obstruction.

Surgery

As the majority of OSA patients have multi-level obstruction, multi-level surgery is usually necessary to achieve the best chance of cure. Nasal and soft palate surgery are most commonly performed, but may not be sufficient. Traditional surgery for tongue base obstruction requires sawing and moving part of the jaw forward and has poor patient acceptance. Robotic surgery using the da Vinci surgical robot is now available to allow qualified surgeons to remove part of the tongue base blocking the airway. This is performed through the mouth and does not require any skin incisions or bone work. Patient acceptance of this minimally invasive surgery is much higher and results are better than conventional surgery.

Seek Medical Opinion Early

In conclusion, insomnia and snoring may be heralds of a bigger medical problem. If insomnia does not improve with sleep hygiene, or if snoring is accompanied by other symptoms listed above, a medical opinion should be sought.

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Adjunct Assistant Professor Tay Hin Ngan is the Director of HN TAY ENT | Head & Neck | Thyroid | Sleep ROBOTIC SURGERY at Mount Elizabeth Hospital.
Posted by ezyhealth on Jun 10 2014. Filed under 20s–40s. You can follow any responses to this entry through the RSS 2.0. Both comments and pings are currently closed.

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