Help for those who snore

New test predicts how much snorers can expect to reduce their snoring following nose and mouth surgery

Civil servant Harry She, who used to suffer from abrupt wakenings during his sleep, had both nose and mouth surgery last year. -- PHOTO: MIKE LEE FOR THE STRAITS TIMES
Civil servant Harry She, who used to suffer from abrupt wakenings during his sleep, had both nose and mouth surgery last year. -- PHOTO: MIKE LEE FOR THE STRAITS TIMES

A good night's rest may come easy to most people, but there are many whose beauty sleep is disrupted due to their snoring problem.

In some cases, surgery is required to remove obstructions in their nose or mouth to help them breathe better.

For those who are unsure if it is worth going through all that trouble, there is now a way to gauge how much their snoring may improve even before they go under the knife.

  • Tips to prevent or reduce snoring

  • 1. Lose weight: Increased tissue bulk in the mouth and neck of obese people narrows the airway.

    In addition, a large abdomen pushes up the diaphragm and reduces the size of the lungs, making inhalation more strenuous.

    2. Quit smoking: Smoking increases the production of mucus in the nose and throat, and irritation and swelling in the mucous membranes of the upper airway, all of which constrict the airway.

    3. Sleep on your side: Lying on your back makes the tongue fall backwards into the throat. When you lie on your side, the tongue falls to the side of the mouth instead.

    4. Avoid using sedatives, sleeping pills or alcohol before sleep: These deepen a person’s sleep and cause his upper airway tissues to relax more than usual, which obstruct the entrance to the throat. They also reduce the muscle tone in the tissues of the throat.

    5. Avoid being sleep-deprived: Fatigue also results in the over-relaxation of airway muscles and tissues.

    6. Avoid going to bed on a full stomach: The need to move food through the gastrointestinal tract shunts blood towards the area. Hence, less blood goes to the airway muscles, resulting in more muscle relaxation.

    Lying flat can aggravate the symptoms of heartburn. When stomach acid goes up the oesophagus into the throat, it results in muscle spasms and, in turn, a narrowed airway.

    Source: Dr Kenny Pang, an ear, nose and throat surgeon at the Asia Sleep Centre at Paragon

All it takes is a simple test that has been co-devised by a local surgeon.

Civil servant Harry She, 32, underwent this test recently while seeking help for his loud snoring.

He was asked to part his lips slightly and keep his tongue in a neutral position, then breathe in through his mouth and vibrate his palate, in what is known as a palatal flutter. This is unlike a gargle which is produced when one exhales.

This test was devised in 2013 by Dr Kenny Pang, an ear, nose and throat surgeon at the Asia Sleep Centre at Paragon, and Dr Brian Rotenberg, an associate professor at the department of otolarynogology - head and neck surgery at Western University in Britain.

It aims to predict how much a patient's snoring would improve following surgery.

Patients like Mr She, who can create the palatal flutter noise with the mouth slightly open, but not when it is closed, are categorised as having a positive Pang-Rotenberg (PR) sign.

This means that nasal and palate surgery may help to reduce his snoring by up to 90 per cent, going by the findings of a study by the two doctors that was published last month in The Laryngoscope.

The study examined 153 patients with snoring issues from Singapore, Canada, India and Hong Kong, of which 137 underwent nasal and palate surgery at the same time.

Ninety-nine patients who were PR-positive had close to a 90 per cent reduction in their snoring level.

This is much higher than the 65 per cent reduction for the 38 patients who were PR-negative, defined by the ability to create the palatal flutter noise with the mouth slightly open and completely closed. This is because they have thicker muscles at the back of the nose.

The remaining 16 patients opted for only nasal surgery and therefore acted as the control group.

Knowing which group patients fall into is useful for doctors to manage the expectations of patients and their bed partners during pre-surgery counselling, said Dr Pang.


Close to half of the adult population snore occasionally, according to medical literature, said Dr Han Hong Juan, a consultant at the department of otolaryngology at Singapore General Hospital.

Of greater concern is that up to 30 per cent are habitual snorers. Among them, half have obstructive sleep apnoea (OSA), a condition in which the airway collapses and becomes completely blocked during sleep.

When the body senses the brain is being deprived of oxygen, the person wakes up very briefly to take a gasp of air and begin breathing again.

While snoring and OSA do not always develop hand in hand, at least 75 per cent of OSA sufferers have a snoring problem, said Dr David Lau, a specialist ear, nose and throat surgeon at Gleneagles Medical Centre.

It is thought that 15 per cent of Singapore's population have OSA.

Leaving it untreated, however, can raise a person's risk of hypertension, heart attack and stroke.

Doctors say the best way to manage OSA is to wear a continuous positive airway pressure machine during sleep. This is a pump which pushes air into the airway through a mask strapped to the head.

The other option is to wear a mandibular (lower jaw) advancement splint on the teeth to move the lower jaw forward to widen the airway.

Dr Lau estimated that three-quarters of OSA patients settle for either of these non-invasive treatments.

The remaining patients choose surgery, which targets the source of the airway obstruction.

Mr She was one such patient. The father of one said he had been snoring since he was a child, but recent abrupt wakenings took a toll on his sleep.

He had headaches and got very sleepy during the day, to the extent that it affected his work.

Last September, he did an overnight sleep study at home. Results showed he stopped breathing close to 13 times in an hour and his blood oxygen level was constantly at 91 per cent, when the normal level is above 95 per cent.

Dr Pang later diagnosed him with moderate OSA, and found several anatomical obstructions in his nose and mouth which needed to be corrected through surgery so he could breathe better during sleep.

In the same month, he had both nose and mouth surgery done in a day procedure: Dr Pang re-aligned the partition separating the two sides of his nose (nasal septum), reduced his sinus turbinates and trimmed his soft palate, uvula and tonsils.


Checks with other ear, nose and throat surgeons showed that it would take more than one study to convince them to routinely categorise their patients according to the newly devised PR sign.

Dr Dharambir Sethi, from Novena ENT - Head & Neck Surgery Specialist Centre at Mount Elizabeth Novena Hospital, said he would be willing to try the PR sign on his patients and document their outcomes to validate it.

"For the PR sign to be clinically useful, there has to be sufficient data in the literature of others who have used it and found it to be useful," he said.

Dr Pang has spoken to several hundred ENT surgeons at overseas conferences to promote the PR sign, but has not had the chance to speak to doctors here.

Meanwhile, Mr She has a renewed zest for life now that he enjoys restful nights. He has lost 13kg since last September through diet and regular exercise.

"The operation has really changed my life because I can now sleep through the night," he said.

"I'm amazed at how good-quality sleep repairs my body. I feel that I'm raring to go each morning now."

A version of this article appeared in the print edition of The Straits Times on June 18, 2015, with the headline 'Help for those who snore'. Subscribe