Sleep apnea and snoring
Snoring is a sound, apnea is a pause in breathing. One does not imply the other, and you cannot tell them apart by how loud the noise is. The diagnosis is not made from a questionnaire, an app or a description: it is made with a sleep study. The role of the ENT examination is different and just as important: to show exactly where the airway narrows.
When is snoring more than just noise?
These are the signs that change the picture:
- Pauses in breathing that your partner has noticed
- Waking up with a choking feeling or a sudden deep gasp
- Morning headache, dry mouth, a feeling that sleep is not restful
- Sleepiness during the day, especially while driving or during desk work
- Getting up to pee 2 or more times a night, with no other explanation
- Blood pressure that is hard to control
The last 2 are the ones most often overlooked, because nobody connects them with sleep.
Why does snoring matter beyond sleep?
Obstructive sleep apnea is not just a bad night. The repeated drops in oxygen and the brief awakenings keep the body in a constant state of alert, and this is linked to blood pressure that is harder to control, heart rhythm problems and poorer metabolic control.
There is also a more immediate side. Sleepiness at the wheel is a measurable risk, and undiagnosed sleep apnea increases the complications of general anesthesia. If you are going to have surgery for anything, this information is worth knowing beforehand.
What happens at the appointment?
We start with your history and with what the other person notices: what can be heard at night, whether there are pauses, what your days are like, what medications you take, how much alcohol you drink in the evening and whether your weight has changed in recent years.
Where does the airway narrow?
This is the question the ENT examination answers, and no sleep study can answer it. We check the nose for the septum, turbinates and nasal valve, the soft palate and uvula, the size of the tonsils, the base of the tongue and the position of the lower jaw. Body mass index (BMI) and neck circumference are also recorded.
In most adults the narrowing is not in one place but in 2 or 3. This explains why a single operation rarely solves the problem on its own.
When is a sleep study needed?
Always, when sleep apnea is suspected. International guidelines are clear on one point: questionnaires and scores are not used as diagnostic tools, they only help estimate how likely sleep apnea is.
There are 2 ways to do a sleep study:
A home sleep study with an approved device is enough for patients without other serious health problems whose picture suggests moderate or severe sleep apnea.
A full sleep study in a sleep lab is needed when there is also significant heart or lung disease, a neuromuscular condition, hypoventilation (breathing too shallowly), long-term use of opioids, a history of stroke or severe insomnia.
There is one point that is often missed: when a home sleep study comes back negative, unclear or technically inadequate, it does not rule out sleep apnea, and a full sleep study may then follow.
Drug-induced sleep endoscopy
When surgery is being considered, examining the airway during sedated sleep shows what really happens: which point collapses first, and in what way. This is the difference between guessing where the blockage is and actually seeing it.
Treatment
CPAP
CPAP remains the first-line treatment for moderate and severe sleep apnea, because it keeps the airway open with air under pressure and works regardless of where the narrowing is. The real problem is not how well it works but whether people keep using it, since a large share of patients give it up within the first year.
The role of the nose
This needs some clarification, because it often creates the wrong expectations.
Nose surgery on its own has not been shown to reliably reduce the number of breathing pauses. What it has consistently shown is 2 other things: it lowers the pressure CPAP needs, and it greatly improves how well CPAP is tolerated, turning patients who could not stand it at all into regular users.
So the nose is treated not as a treatment for sleep apnea, but as a precondition for its treatment to work. When this is clear from the start, nobody is disappointed at the end.
Oral appliances
Mouth guards that move the lower jaw forward (mandibular advancement devices) are an evidence-based option in mild and moderate sleep apnea, as well as for people who cannot tolerate CPAP. They are custom-made, and their effect is confirmed with a repeat sleep study, because feeling better is not enough proof.
Surgical options
With suitable anatomy, surgery on the palate and tonsils improves the picture. For patients with specific characteristics, hypoglossal nerve stimulation (a tongue nerve stimulator) is now also available. The decision is made individually, after a full mapping of the airway, and never on the basis of snoring alone.
Weight, sleeping position and habits
Weight loss has one of the biggest effects on severity and works alongside every other treatment. In some patients sleep apnea is positional, meaning it happens mainly when lying on the back, so sleeping on your side helps. Alcohol and sedatives in the evening relax the throat muscles and consistently make things worse.
Frequently asked questions
If there are no pauses in breathing, no daytime sleepiness and no other findings, it is most likely simple snoring. Loudness, however, is not a criterion in either direction, which is why the assessment is based on the overall picture.
These devices give an indication and nothing more. They can be a reason to get checked, but they do not replace a sleep study, and a negative result from them does not rule out sleep apnea.
As long as the sleep apnea is there, yes, because CPAP manages the problem without removing it. Significant weight loss or successful surgery can change things, but this is confirmed with a new sleep study, not with the feeling that you are sleeping better.
Because the nose was one point of narrowing and not necessarily the decisive one. The sound is produced mainly at the soft palate, so better breathing through the nose does not stop it on its own.
Quite a lot, and in some patients it is decisive. Fat around the throat and the belly directly affects severity, which is why weight loss is part of the plan even when another treatment starts at the same time.
If the sleep study shows that the sleep apnea is positional, sleeping on your side plays a real role. Without a study we do not know, so changing position reduces the noise without telling us what is happening with your breathing.
When should you not wait?
Immediately
Sleepiness at the wheel
If you have felt drowsy or fallen asleep while driving, the assessment should not be postponed. Until it is done, driving should be limited.
Soon
Waking up choking together with chest pain or palpitations
Night-time episodes combined with heart symptoms need to be assessed from both sides, ENT and cardiology, without delay.
Soon
Planned surgery under general anesthesia
If sleep apnea is suspected and you are going to have surgery, tell the anesthesiologist beforehand, because it changes how the anesthesia and the monitoring after surgery are planned.
Medical review: Dr. Ioannis KotrotsosENT Surgeon and Specialist in Phoniatrics and Pediatric Audiology.
Πηγές: Kapur VK et al., Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea, AASM, 2017. Patil SP et al., Treatment of Adult Obstructive Sleep Apnea with Positive Airway Pressure, AASM, 2019.
The information on this page is for general information only and does not replace a medical examination. For diagnosis and treatment, please consult a doctor.
