One day I boarded a night train to come back to Chennai. There was another gentleman, heavily built and middle-aged, on the adjacent lower berth. After a few minutes of conversation, I wished my co-passenger ‘Good Night’. He wished me in return: ‘Sound Sleep’.
In about 10 minutes, he was fast asleep. But I could not sleep because he was snoring loudly as were many others. Many were Heroic Snorers, though heroic in this case has nothing to do with heroism. At one point, my neighbour stopped breathing for a few seconds. Medically this is called apnea. Apnea is absence of breathing through nose and mouth for 10 seconds or more, while Heroic Snoring is defined as very loud snoring, which can be heard in the next room even when the doors are closed.
Snoring is common in obese men. But it is also less commonly found in thin people, women and children. A combination of heroic snoring, sleep apnea and daytime sleepiness is called Sleep Apnea Syndrome (SAS), which is very dangerous.
Sleep apnea is caused by the collapse of the upper part of the pharyngeal airway. Normally the airway is kept open by special C-shaped cartilages and the muscular contraction of the upper end. When a person goes to sleep, the muscle relaxes, especially after a heavy meal, alcohol or sleeping tablets. An obstruction in the airway produces a vibration of the pharyngeal tissues, palate and uvula, which produces the noise (snoring). If snoring continues, the patient may develop headache, general fatigue, memory loss, deceased libido, irritability and depression. This is also a cause for road accidents, since the driver may fall asleep at the wheel.
There are three varieties of SAS. Obstructive Sleep Apnea Syndrome (OSAS), which is assessed and treated by ENT surgeons and could be due to problems like large tonsils, adenoids, nasal polyps, nasal allergy and deviated nasal septum. In the central type, the sleep centre in the brain is affected and is treated by neurophysicians. In the mixed type, both these factors are found.
To diagnose the problem, the patient has to undergo a test called Polysomnography. He/she has to sleep in a sleep lab while being connected to a machine. The recordings will help the doctor figure out what sleep apnea the patient suffers from. Polysomnography records blood pressure, lowest blood oxygen saturation, apenic spells, ECG changes and other changes. Other tests include dynamic MRI studies, endoscopy and CT scans.
In general the treatment for OSAS includes avoiding of alcohol, sedatives and hypnotics; weight reduction (the ideal weight is height in cm minus 100); sleeping on the side rather than on the back; removal of lesion in nose, naso pharynx, oral cavity, hypo pharynx and larynx; volumetric reduction of tissues of soft palate and base of tongue by radio frequency; uvulopalatoplasty with a cold knife or radio frequency or laser.
One method of treatment, which is not easily accepted by patients, is the use of the Continuous Positive Airway Pressure (CPAP) machine. A mask is worn over the nose and mouth during sleep to aid breathing to allow air and pressure to overcome the obstruction of the airway. This helps the patient sleep well and helps overcome daytime sleepiness.
An extreme treatment option, in rare cases, is tracheostomy (making a hole into the treachea in the neck) which can be closed during the day and opened at night for obstruction-free breathing.
