In most homes snoring is a subject for jokes. Yet the sudden silences that break up the snoring, followed by a deep, choked breath, are often the sign of a condition that goes unnoticed: sleep apnea.
Simple snoring and sleep apnea are not the same thing. Snoring is a bothersome noise; sleep apnea is a medical condition in which breathing stops again and again and which affects heart and blood vessel health. Telling the two apart determines where treatment begins.
What is sleep apnea?
Sleep apnea is the interruption of breathing during sleep caused by the upper airway narrowing or closing completely. The most common type is obstructive sleep apnea syndrome (OSAS).
When breathing stops, the oxygen level in the blood drops. The brain senses this drop and wakes the person very briefly so that they breathe. These awakenings are usually not remembered, but they are repeated dozens of times through the night, and hundreds of times in severe cases. As a result, sleep is fragmented and loses its restorative quality.
This is why people with sleep apnea wake up tired even after eight hours in bed.
What is the difference between snoring and sleep apnea?
Snoring is produced by the soft tissues of the throat vibrating as air passes. In simple snoring, breathing continues without interruption and the oxygen level in the blood does not fall.
In sleep apnea the picture is different. The snoring gets steadily louder and is then followed by a sudden silence; that silence is the moment breathing stops. After some seconds, sometimes more than a minute, the snoring starts again with a deep, choked breath. This cycle repeats throughout the night.
Not everyone who snores has sleep apnea. However, almost everyone with sleep apnea snores. For this reason regular snoring should not be seen as a habit and should at least be evaluated.
What are the symptoms of sleep apnea?
Night-time symptoms
- Loud, irregular snoring
- Pauses in breathing noticed by a partner or family member
- Waking up choking or gasping for air
- Frequent urination at night
- Dry mouth and night sweats
Daytime symptoms
- Waking up unrefreshed in the morning
- Morning headache
- Falling asleep during the day, particularly while driving
- Poor concentration and forgetfulness
- Irritability and mood swings
The most dangerous of these symptoms is daytime sleepiness. A description of falling asleep while waiting in traffic or while driving is a finding that needs to be evaluated without delay.
What causes sleep apnea?
Sleep apnea does not have a single cause. Usually more than one factor is present at the same time.
- Excess weight. Fatty tissue around the neck narrows the airway from the outside.
- Nasal obstruction. A deviated septum, enlarged turbinates and allergic rhinitis are the most common causes.
- Large tonsils and adenoids. The main cause of sleep apnea in childhood.
- Jaw structure. A small or set-back lower jaw narrows the airway.
- Age and sex. It is more common in men and at older ages.
- Alcohol and muscle-relaxant medication. These relax the throat muscles and make obstruction easier.
What role does nasal obstruction play in sleep apnea?
The nose is the entrance to the airway. A person who cannot breathe comfortably through the nose sleeps with the mouth open. When the mouth is open during sleep, the lower jaw slides back and the base of the tongue narrows the airway even further. So although nasal obstruction does not create sleep apnea on its own, it makes the existing condition worse.
The causes most often found in an ENT examination are a deviated septum and enlarged turbinates. If nasal congestion has been going on for months, sleep quality should be questioned as well.
How is sleep apnea diagnosed?
A definite diagnosis is made not by examination but with a sleep study (polysomnography). The patient sleeps for one night in a sleep laboratory while breathing, blood oxygen level, heart rhythm and brain waves are recorded simultaneously.
From the test, the apnea-hypopnea index (AHI) is calculated. This value shows how many times per hour breathing stops or becomes shallow:
- 5-15: mild sleep apnea
- 15-30: moderate sleep apnea
- 30 and above: severe sleep apnea
An ENT examination does not replace the sleep study; it complements the result. The examination determines the level of the obstruction (nose, nasopharynx, palate or tongue base), and the treatment plan is shaped accordingly.
How is sleep apnea treated?
Lifestyle changes
Losing weight can bring a marked benefit on its own in mild and moderate sleep apnea. Sleeping on your side instead of your back and avoiding alcohol in the evening are also changes with a measurable effect that lower the AHI.
CPAP device
In moderate and severe sleep apnea the gold-standard treatment is CPAP. The device delivers continuous positive airway pressure through a mask and prevents the airway from closing. With regular use, daytime sleepiness and cardiovascular risks are reduced considerably.
The most common problem in CPAP treatment is not the device itself but the patient being unable to adapt to it. A person with a blocked nose cannot tolerate the mask and may give up treatment within a short time.
Oral appliances
Appliances that widen the airway by bringing the lower jaw forward are an alternative in mild and moderate sleep apnea or for people who cannot use CPAP. They are planned together with a dentist.
Surgical treatment
Surgery comes into consideration when the obstruction has an anatomical cause. Septoplasty and turbinate (concha) surgery can be performed for obstruction inside the nose, tonsillectomy for large tonsils, and palate surgery for laxity at the level of the palate.
Does nasal surgery cure sleep apnea?
Nasal surgery alone does not eliminate sleep apnea in most cases. This is the most commonly misunderstood point on the subject.
Nasal surgery makes breathing easier, can reduce the loudness of snoring and improves sleep quality. But if the obstruction is at the level of the palate or tongue base, the apnea continues. The real contribution of nasal surgery to sleep apnea treatment is this: it makes CPAP use possible. A patient whose nasal airway has been opened can tolerate the mask, uses the device regularly and benefits from the main treatment.
For this reason it is wise to be cautious about any claim that sleep apnea will disappear completely with nasal surgery alone, and to get a second opinion.
What happens if sleep apnea is left untreated?
Sleep apnea is not just a sleep problem. When left untreated, the repeated drops in oxygen through the night put a strain on the heart and blood vessels. The risk of high blood pressure, heart rhythm disorders, heart attack and stroke increases, and diabetes becomes harder to control.
It is also known that the risk of traffic accidents related to daytime sleepiness increases. For this reason sleep apnea should not be regarded as a cosmetic complaint.
Which doctor should you see for sleep apnea?
The first visit can be to an ear, nose and throat (ENT) specialist or a pulmonologist (chest diseases). The ENT examination determines the level of the obstruction and, if considered necessary, a referral is made for a sleep study. It is worth noting that the process usually requires more than one specialty working together.
For an examination in Antalya, Turkey, you can contact Op. Dr. Ümit Küçüktepe.
This text has been prepared for information purposes only. Please consult your physician for diagnosis and treatment.
Frequently Asked Questions
Obstructive sleep apnea is not a condition that goes away on its own. However, if it developed because of excess weight, it can ease considerably with weight loss. In children, if it is caused by enlarged adenoids and tonsils, it can resolve completely once these tissues are treated.
Polysomnography is a painless test. You sleep for one night in a sleep laboratory; sensors attached to the body record breathing, oxygen level, heart rhythm and brain waves. There are no needles or incisions.
Yes. Although excess weight is the most common risk factor, it is not the only cause. A small or set-back lower jaw, large tonsils, nasal obstruction and a bulky tongue base can lead to sleep apnea in thin people as well.
An evaluation is recommended if you have daytime sleepiness, morning headaches or wake up unrefreshed. Pauses in breathing are usually not noticed by the person themselves and can be missed entirely in people who live alone.
CPAP does not eliminate the condition; it keeps it under control for as long as it is used. The need may decrease in situations such as weight loss or surgical correction of an anatomical obstruction; this decision is made with a follow-up sleep study.
Regular snoring in children is not considered normal. The most common cause is enlarged adenoids and tonsils. Because it can lead to growth delay and attention and behavior problems when left untreated, an ENT examination is recommended.
