There is a common notion in the Filipino culture that snoring is an indication of good sleep. However, many studies have already found that making such stertorous, snorting or grunting sounds while asleep could be a sign of more serious health problems.

MIMS spoke to Dr José Florencio Lapeña, the Professional Regulation Commission’s Most Outstanding Professional in Medicine for 2017 and Overall Outstanding Professional 2017 – 6th Eric Nubla Excellence Awardee, to discuss some of the most common causes of snoring in Filipinos.

“Snoring in adults may be occasional, and may not need further investigation due to social and lifestyle factors such as extreme fatigue, alcohol inebriation, and weight gain,” Dr Lapeña explained. “Having said that, there are instances where snoring signals sleep disordered breathing, and obstructive sleep apnea—these conditions warrant consultation with a physician.”

He adds that snoring in children is usually caused by enlarged tonsils and/or adenoids, and always warrants further investigation.

Snoring due to obstruction in the nose and throat

Dr Lapeña gives some pointers on how to relieve some of most common causes of nose and throat obstruction:
  1. Relaxed throat muscles – improve sleep hygiene by avoiding sleeping pills and ethanol
  2. Obesity – control dietary intake, and practice regular exercises; lose weight scientifically—avoid fad diets or quick weight loss remedies; continuous positive airway pressure (CPAP) may be recommended
  3. Long soft palate and/or uvula – at first consider positioning therapy (avoid sleeping supine), followed by office palate-stiffening procedures. Surgeries such as uvulopalatoplasty (trimming the uvula and palate) and uvulopalatopharyngoplasty (trimming the uvula, palate, and part of the pharyngeal wall with removal of the tonsils) have mixed results in treating obstructive sleep apnea
  4. Obstruction due to mucus – treat the underlying rhinosinusitis; if allergic or hyperreactive, individuals must avoid allergen and irritant exposure. Saline nasal douches and medications may also be prescribed
  5. Nose or nasal septum deformities – depending on the severity and degree of deformity, devices to widen the nasal airway or surgical correction (septoplasty, septorhinoplasty, turbinoplasty) may be recommended
  6. Enlarged tonsils and adenoids – adenotonsillectomy may be recommended, especially in children

Tests and treatments available in the Philippines

“The most important thing to do is for a qualified physician to obtain a comprehensive history and conduct a directed physical examination,” said Dr Lapeña on the initial steps a patient must take to curb snoring.

“This may include questions on snoring type, duration and patterns to establish sleep-disordered breathing or frank obstructive sleep apnea, and may use certain questionnaires, such as the Epworth Sleepiness Scale. In children, actual observed apneas, nocturnal eneuresis (bed-wetting), hyperactivity and/or somnolence are also elicited.”

Dr Lapeña enumerated possible examinations needed, including waist and neck circumference in adults, craniofacial dimensions and cricomental distance assessment, upper-lower jaw relationships, dentition and occlusion, nasal airflow and appearance (rhinoscopy), tongue-palate and tonsil size and position (Mallampati Classification and Friedman Staging).

“Awake flexible nasopharyngolaryngoscopy (inserting a thin, flexible endoscope through the nose) is an office procedure that usually allows evaluation of the nose, entire pharynx (throat, including collapsibility by Müller maneuver) and larynx (voicebox) that can be performed even in small children.

“In many cases, a good clinical history and physical examination suffice to diagnose the cause of snoring, and a preliminary recommendation to manage it can be made,” Dr Lapeña adds.

Ancillary evaluations are not always necessary, said Dr Lapeña, but when needed, these may include screening overnight home pulse oximetry to monitor oxygen saturation, and full- or split-night hospital polysomnography (a formal sleep study, the gold standard for diagnosing obstructive sleep apnea) performed at a reputable center and interpreted by a qualified sleep medicine specialist.

“Imaging studies may also be requested in certain instances, depending on the cause of snoring. All these are available in the Philippines,” confirms Dr Lapeña.

Working with sleep specialists

Sleep study is also one of the keys to treating snores. Dr Lapeña shared: “Polysomnography and formal evaluation by a sleep medicine specialist is invaluable in patients with multilevel obstruction, as they may need multilevel surgeries.

“I generally operate on patients that need surgery depending on the surgery needed. Over 90 percent of my children needing adenotonsillectomy, adenoidectomy, or tonsillectomy have benefited from surgery, with almost immediate resolution of snoring and sleep disordered breathing or obstructive sleep apnea.”

As for his patients who subsequently started CPAP, the doctor admits that while a large portion of his patients are happy with how CPAP works, there are a few who found the device difficult to sleep with. MIMS

PRC Awardees Dr Jose Florencio Lapena

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