Question 1

Almost everyone snores at one time or another. When does snoring become a problem?

Dr. Trisha Srivastava · Accepted Answer

When it becomes regular. With a common cold or a sore throat, snoring for a week or 15 days that then settles is understandable. The problem is snoring every day: sleeping with the mouth open, then feeling tired and without energy the next day because sleep was inadequate. When those symptoms become chronic, happening almost daily, they need attention, because this is not normal. Snoring is a widely ignored symptom: people say they snore a little and only their partner is disturbed, so they see no problem.

Question 2

Most people who snore are not aware of it until they have symptoms the next day. How can GPs and other doctors tell when the time has come for ENT referral or intervention?

Dr. Trisha Srivastava · Accepted Answer

I would start with the level of obstruction. Nasal symptoms are ones patients notice themselves, without a partner telling them: one nostril that is always blocked, or a nose that clogs up whenever they lie down. Then there is the patient who believes they slept well but has symptoms such as headache the next day. A young patient of 28 or 29 whose blood pressure is still within the normal range but rising can come for a routine ENT examination to rule out an underlying problem.

Question 3

People are often afraid of surgery. For a condition as common as snoring, which lifestyle changes reduce it or bring it under better control?

Dr. Trisha Srivastava · Accepted Answer

Not every patient who comes in with snoring is advised surgery; it is not a matter of fixing the nose or removing the tonsils for everyone. Sedentary lifestyles are very common now, with long hours in a chair working at a laptop, and they are causing obesity. The first lifestyle modification is a more active life: exercise daily, be careful about what you eat, cut down on fatty and unhealthy food, and try to reduce weight. Often nothing is structurally at fault: the palate is not bulky and the nose is fine, but the patient has a thick neck, and a thick neck is itself one of the reasons people develop obstructive sleep apnoea. Regular exercise helps with that. Lifestyle modification is the first stage. With a very obese patient, we advise lifestyle modification and weight loss first, then reassess, and give treatment options on that basis: the patient can become a CPAP user or undergo surgery as required. CPAP needs some thought. It comes with a mask worn over the face that delivers pressurised air through the night, and many people do not like that pressure on their face and stop using the machine. If the patient has a badly deviated septum, the pressure has to be set high to get past that obstruction, and in those cases surgery becomes important. Otherwise, if your life is sedentary, make the effort to change it.

Question 4

What is the definition of a thick neck? Neck size can also reflect muscularity. Does it mean fat around the neck, or does a muscular neck count too?

Dr. Trisha Srivastava · Accepted Answer

It means fat around the neck. During sleep, muscle tone falls, and fat around the neck makes the airway collapse and pushes the base of the tongue back over the epiglottis. By the OSA definition, a neck circumference of more than 43 cm in men and more than 40 cm in women is considered a thick neck. Usually, if a patient is obese, the neck will also be thick.

Question 5

Can you elaborate on circadian rhythm and hormones in relation to sleep?

Dr. Trisha Srivastava · Accepted Answer

In stage 3 of non-REM sleep, growth hormones are released in the body. They are responsible for repairing the muscle wear and tear that has happened through the day, and they help with growth: children gain their height and weight through the growth hormones produced. If you do not go into stage 3 sleep and stay in light sleep, the reparative, restorative action that is supposed to happen in your body does not happen, and you feel tired the next day.

Question 6

Can you elaborate on the stages of sleep?

Dr. Trisha Srivastava · Accepted Answer

Every individual goes through 4 to 5 sleep cycles a night, and each cycle lasts around 90 to 110 minutes. Sleep is divided into non-rapid eye movement (NREM) and rapid eye movement (REM) sleep, and NREM sleep is further divided into three stages: N1, N2 and N3. N1 is the lightest sleep: if someone wakes you from it, you wake immediately, without brain fog or fatigue, and it makes up only about 5% of the night's sleep. N2 and N3 make up the majority, around 75% of our entire sleep. They are followed by REM sleep, the stage of vivid dreams, in which memory is consolidated: whatever has happened through the day goes into long-term memory.

Question 7

How do most patients reach your clinic with this problem: by doctor referral or self-referral? And are you creating awareness in the general community?

Dr. Trisha Srivastava · Accepted Answer

It is a blend. From what I have tracked, most come through patients I have already treated: they had a good response after surgery, they refer others, and those patients tell me so. I also have an Instagram account where I create general awareness, and patients come from there as well. Artemis is a large hospital with many departments, so cross-referrals come into our outpatient clinic too. GPs usually fix common problems such as colds themselves, and they do a great job; when a problem is not getting fixed, they refer to us. GP referrals make up probably 20 to 30% of my outpatient practice.

Question 8

Can taking wine, or alcohol generally, at night help reduce this problem?

Dr. Trisha Srivastava · Accepted Answer

I have not read in any textbook or literature that wine helps. Chamomile tea is one of the things people say calms the nerves, and some people take melatonin at night. Alcohol does not make sleep better: it disrupts sleep and it causes dryness.

Question 9

Can you compare CPAP with BiPAP?

Dr. Trisha Srivastava · Accepted Answer

The concept of CPAP and BiPAP differs, and many patients who cannot manage a CPAP machine are moved to a BiPAP machine. A PAP machine is basically an airway splint: it delivers pressurised air that keeps the upper airway open where it would otherwise block, at the retropalatal level or at the base of the tongue. In BiPAP there is an inspiratory phase and an expiratory phase, and the pressure settings differ between them depending on where the problem lies. For instance, a patient may need a pressure of around 8 on inspiration but only around 4 on expiration, and the machine is set accordingly. CPAP gives continuous air pressure: it does not matter whether it is the inspiratory or the expiratory phase, the pressure remains the same, providing a pneumatic splint for the airway.

Question 10

Athletes have complained to me of poor sleep after vigorous exercise. What is the relationship between vigorous exercise and lack of sleep?

Dr. Trisha Srivastava · Accepted Answer

It could be related to the muscle wear and tear that a lot of exercise causes; that could be the reason. I am not sure about this.

Question 11

When people are very tired and sleep deeply, some who do not normally snore do snore that night. Is that common?

Dr. Trisha Srivastava · Accepted Answer

That is common, and it is physiological. When you are very tired after a hard day, snoring that night is fine. Not every snoring has to be branded a pathology or seen as a bad thing. When it becomes chronic and disrupts day-to-day life, that is when it has to be looked into, to find out what is going on.

Question 12

Can we conclude that snoring is more a structural problem than a physiological one?

Dr. Trisha Srivastava · Accepted Answer

It is both, depending on the patient. On the structural side, an ENT examination can find a definite anatomical obstruction in the nose, the nasopharynx or the oropharynx. There you can explain to the patient that the snoring and the poor sleep come from that structural block, and that fixing it will improve the snoring. This can happen in a lean individual with a badly deviated septum: you correct it, the problem is sorted, and after the procedure the patient says the snoring has stopped.

Question 13

What are the non-surgical treatment options?

Dr. Trisha Srivastava · Accepted Answer

The non-surgical options are the CPAP and BiPAP machines, and the choice depends on severity. Patients with mild obstructive sleep apnoea can start with lifestyle modification rather than going straight to a machine. A PAP machine is used for patients with severe disease, including those whose oxygen saturation falls into the 70s or even the 60s at night, and it is the option for patients who do not want surgery or are unfit for it.

Question 14

As a simple summary: snoring is common, but when it is regular it usually reflects an obstruction, either from a temporary condition such as a cold or from an underlying problem the ENT specialist assesses, treated with surgery or with devices such as CPAP and BiPAP. Is that correct?

Dr. Trisha Srivastava · Accepted Answer

As a basic understanding, yes. If snoring happens temporarily, or on days when you are tired, you do not need to worry about it much. But if it becomes chronic, or the snoring is so loud that it disturbs your family members' sleep and they complain, it is time to see an ENT specialist for a basic diagnostic examination: to check whether everything is fine and whether you need a sleep study. The therapy is decided on that basis.

Live Discussion with Dr. Trisha Srivastava