When Is Snoring More Than Just Being Tired?


Humans have been snoring for centuries. Even some animals snore too. A common belief in our society is that males tend to snore in the night because they are more tired after a hard day’s work. It was traditionally viewed as a sign of diligence and manliness.

As a result, family and loved ones accept snoring and bear with it for life. This is especially true in Asian countries, where our culture believes that issues in the bedroom are akin to dirty linen that should not be aired in public.

Through my years of dealing with families with snoring problems, these are some of the myths I often hear:

  1. I have been snoring since young so it should be normal.
  2. I feel fine despite the snoring and poor sleep, so there is no need to worry.
  3. Waking up 2-3 times every night to visit the bathroom is normal.
  4. My grandfather, father and brothers snore as well, so I am normal.

So what exactly is snoring? Snoring is basically “noisy” breathing.  It is analogous to a plane flying through turbulent air currents. When the airway is abnormally reduced in caliber and in the presence of pliable surrounding soft tissue, the tissues of the throat are exposed to turbulent airflow during breathing. The vibrations generate the sound heard during snoring.  Although simple snoring is a social problem, it may actually be a symptom to a more sinister condition called Obstructive Sleep Apnoea.

Obstructive sleep apnea

Obstructive Sleep Apnoea

In the last two to three decades, a chronic medical condition called Obstructive Sleep Apnoea (OSA) has rapidly gained attention in the medical community. It is a sleep disorder that has serious medical and quality-of-life consequences if left untreated. With OSA, there are periods of complete airway obstruction (apnoea) and partial airway obstruction (hypopnea). The result is a reduction of oxygen in the bloodstream (oxygen desaturation). This reduction in oxygen level triggers receptors in the body, which lighten the depth of sleep in order to regain muscle tone and terminate the collapse in the throat. This whole cycle, also known as an “event”, may repeat tens to hundreds of times per night, causing sleep fragmentation and reduced sleep restfulness.

The condition’s severity is categorized by the frequency of events, as well as the amount of oxygen reduction. During a sleep study, which can be conducted either at home or in a hospital, the various aspects of sleep are measured. The number of obstructive events that occur during sleep are also recorded. If the number of events per hour, also known as the Apnoea-Hypopnea Index, is >5 but <15, mild OSA is present. If the AHI is >15 but <30, moderate OSA is present and if the AHI is >30, severe OSA is present.

Consequences and Complications of OSA

As OSA continually gains prominence, research into this condition has uncovered wide-ranging consequences. In a classic study done in the 1980s, it was revealed that if severe OSA is left untreated, the mortality rate is 37% in 8 years. The main reason behind this dire consequence is the chronic lack of oxygen to the heart and the brain. Research revealed definitive evidence that OSA leads to high blood pressure, heart attacks and strokes.

Recent research was even more alarming. OSA could contribute to the development of diabetes and even cancer through chronic inflammation. In children, it adversely impacts their physical, mental and cognitive development and ability to perform at school.  In fact, a significant percentage of kids with poor sleep and OSA are wrongly diagnosed as having Attention Deficit Hyperactive Disorder (ADHD). In adults, sleep fragmentation and sleep deprivation lead to Excessive Daytime Sleepiness (EDS), which manifests as reduced productivity and falling asleep during work. Even worse, having EDS while driving accounts for a sizeable number of road traffic accidents, of which some were fatal. Interestingly, it is believed that “sleepy” driving may be more dangerous than drunk driving.

Awareness and Knowledge of OSA

With the increase in understanding of the potential serious effects of OSA, we should look out for this disease in our loved ones. Research, done a while ago, stated that the occurrence of OSA occurs mainly in adult males, with a prevalence of about 4% and about 2% amongst females. However, as each individual country starts to examine their own population, the numbers of new OSA cases diagnosed are quite alarming.

In our beloved Singapore, the latest study in 2016 revealed that one in three (33%) of our population has OSA, and 10% of the population has the severe form of the disease. This number is extremely high, and is probably due to increasing obesity, work stress and voluntary sleep deprivation.

Armed with the knowledge we have on OSA, we must start becoming aware of the disease in our loved ones.  We will need to know its symptoms and seek medical assistance for its diagnosis and treatment.

Symptoms of OSA

There are many symptoms of OSA, and not all patients will present with general symptoms. More often than not, some symptoms may even go unrecognized. General symptoms like snoring, un-refreshing sleep, frequent awakenings, morning headaches, mood swings, memory problems, frequent urination at night (Nocturia), and daytime sleepiness are symptoms that are difficult to identify, especially when they develop gradually. More revealing symptoms like choking or gasping at night, and witnessed apnoea with no perceivable breathing sounds usually alerts spouses and family to send patients to seek help.

Diagnosis of OSA

The diagnosis of this condition cannot simply be based on symptoms alone, as the true danger of OSA is in its frequency of airway obstruction and the quantity and frequency of oxygen reduction. Therefore, a sleep study has to be conducted to ascertain the presence and severity of the disease.

There are 4 different levels of sleep studies that are conducted. The ideal sleep study can accurately diagnose OSA and exclude other sleep disorders. This is classified as Level 1, or overnight attended sleep study. During the study, eleven different channels are monitored, and these include, but are not limited to, measurements of brain waves, heart rhythm, airflow, blood oxygen levels, body movement and position, breathing effort, breathing sounds and video imaging.

  • Level 1 study is the gold standard but has to be conducted in a sleep lab with a technician present during the study for monitoring purposes
  • Level 2 study monitors the same parameters but is carried out using comprehensive portable devices in the hospital ward or at home
  • Level 3 study is a limited study that does not monitor sleep staging or sleep disruption
  • Level 4 study is a single to dual channel study that acts as a screening tool

A specialist trained in management of sleep disorders can organize a sleep study after establishing that a patient has a significant risk of OSA. Based on the result, a course of action has to be taken to treat and prevent the consequences of OSA.

As mentioned earlier, the mildest form of airway disturbance during sleep is snoring. It might just require some simple management strategies while moderate to severe OSA will require more comprehensive solutions to achieve a significant improvement or surgical cure.

Snoring treatment

  • Conservative treatment includes weight loss, sleep hygiene and sleeping on the side
  • Non-invasive treatments include Positive Airway Pressure (PAP), using a machine that pumps air and a facial mask, or a mouthguard (oral appliance)

Moderate to severe OSA

  • Non-invasive treatment includes PAP.
  • Invasive treatment through oral maxillofacial surgery includes soft tissue surgeries (nasal surgery, soft palate implant/reduction, adenoid and tonsil removal and tongue reduction) and hard tissue surgeries (chin and jaw advancement surgeries).

Knowing that snoring can be serious and someone you love used to snore in their sleep, get medical advice immediately to help address OSA and avoid complications.


Dr Eric Lye

Dr. Eric Lye
BDS (Singapore), FRACDS (Australia), MDS (OMS) Singapore,
FAMS (Singapore) PhD (Raboud University of Nijmegen)