Do you snore?

A businessman admitted in a hospital mid-last year sparked complaints from other patients and nurses on night duty. He was snoring very loudly.

Dr Samuel Nyaga, an ear, nose and throat surgeon, and the founder of Nairobi Sleep Centre, was called in to see him.

The 40-year-old had severe sleep apnoea, a condition which he thought was normal, but had cost him four fiancés already.

“When airflow to the respiratory tract stops during sleep and causes severe snoring and temporarily breathlessness, then that person has sleep apnoea,” says Dr Nyaga.

Many people ignore the snoring but if left untreated, it can lead to brain disorders, dementia and even death.

Obstructive sleep apnoea in adults occurs when the muscles in the back of the throat relax, causing the airway to narrow or close.

In children, it is mostly caused by enlarged tonsils or adenoid tissues.

When a person cannot get enough air, it can lower the oxygen level in their blood. The brain senses the inability to breathe and briefly rouses them from sleep so that they can reopen the airway. The awakening is so short that people usually do not remember it.

“Pauses in between snoring means the blood is not getting enough oxygen. The brain senses this and makes one wake up. This person, therefore, has multiple sleep arousals- keep twisting and turning in bed because the brain is in distress,” says Dr David Musyoka, a consultant ENT specialist, differentiating obstructive sleep apnoea from central sleep apnoea, saying that the latter is caused by the lack of brain simulation.

Sleeplessness is becoming common. In the last five years, Dr Nyaga says he has seen an increase in the number of adults seeking treatment for sleep problems.

“More people are getting sensitised that snoring is not a normal thing, and they are getting knowledge of the dangers,” he said.

Dangers

However, Dr Nyaga says, many people do not perceive it as a threat yet it is linked to deadly consequences. Dangers and complications include risk of strokes, heart attacks, high blood pressure, and diabetes, sleep deprivation, loss of libido, daytime sleepiness and fatigue, liver problems, and impotence.

“The exhaustion of never having a full night’s sleep can cause memory loss, anxiety and depression. It also causes inattention that can lead to traffic accidents,” says Dr Nyaga, as he remembers one of his patients. James*, 35, was a bank manager who would sleep when chairing meetings. But his biggest red flag, and what prompted him to seek medical advice, was when he was involved in an accident along the Nairobi-Nakuru highway after he fell asleep on the wheel.

Does lifestyle contribute to sleep apnoea? “The causes of sleep apnoea are also closely related to a patient’s lifestyle, such as eating habits, exercise, smoking, and alcohol consumption,” Dr Nyaga said.

“A man is two to three times more likely to get it, and with progressed age. But the biggest predisposing factor, apart from sex and age, is being overweight.”

Other risk factors include obesity, a large neck or large tonsils and a small jaw. Sleep apnoea does not present itself until after an individual falls asleep. The only way to diagnose it is to monitor someone’s sleep through a polysomnogram (PSG).

“A PSG usually requires one to stay overnight in a hospital or a sleep study centre. The price ranges from Sh30,000 to Sh50,000. While sleeping, the polysomnogram measures the activity of different organs associated with sleep,” said Dr Nyaga.

These tests include measuring the brain waves, eye movement, changes in oxygen levels in the blood, muscle activity, heart rate and rhythm, among others.

“Sleep endoscopy, also known as a sleep nasoendoscopy (SNE), is also recommended to identify the actual obstruction in a person’s throat. It’s done by passing a flexible scope through the throat to see the hindrance,” added Dr Musyoka.

The mode of treatment is dependent on both the root cause and diagnosis. The goal is to make sure that the patient’s airway is not obstructed during sleep.

Treatment

When sleep apnoea is mild, Dr Nyaga advises patients on lifestyle modifications and improved sleep hygiene as part of their treatment methods.

“These usually include dieting and exercising, reducing intake of alcohol, wearing comfortable sleepwear, not carrying food or electronics to bed, making sleep time a routine, eating three hours before bedtime and investing in good beds and mattresses,” he says.

“I also recommend six to nine hours of sleep a night for an adult,” he says.

However, for severe sleep apnoea, he recommends a special mask treatment or surgery. “The mask is worn at night and gently delivers airflow to keep the airways open at night,” he says.

For this, a dental device may also be necessary to keep the lower jaw positioned forward.

But many patients are hesitant to wear the mask because they are uncomfortable and expensive.

“It costs close to Sh500,000. Not many people can afford that. And up to 30 percent of patients end up abandoning their machines because of the discomfort,” he says. Surgery, which is the last resort, involves more than one procedure. “In children, the options of surgery are tonsillectomy- the removal of tonsils, resecting pallets and the removal of adenoids,” says Dr Musyoka says. “A patient may need to continue using the facemask even when surgery successfully reduces the severity of sleep apnoea. In adults, surgery options include tissue removal and shrinkage, nerve stimulation, implants, jaw repositioning, and tracheostomy,” says Dr Nyaga.

Surgery is however less effective and it isn’t considered a reliable treatment for obstructive sleep apnoea.

Shrinking the tissue at the rear of the mouth and the back of the throat is done for mild to moderate sleep apnoea.

“With jaw repositioning, the jaw is moved forward. This enlarges the space behind the tongue and soft palate, making obstruction less likely. With implants, plastic rods are surgically implanted into the soft palate,” says Dr Nyaga.

Insertion of a stimulator for the nerve that controls tongue movement helps keep the tongue in a position that keeps the airway open.

The last resort is the tracheostomy, which is creating a new air passageway. It’s usually done if other treatments have failed and if the sleep apnoea is severe and life-threatening.

“Surgery costs between Sh250,000 and Sh300,000, depending on the type, and the hospital a patient goes to,” says Dr Musyoka.

But Dr Nyaga is hopeful that there will be easier and more affordable treatment options in the near future. Until then, he advises those who snore to see a doctor.

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