Why do people snore? Snoring is caused by the vibration of respiratory structures due to obstructed air movement during breathing while sleeping. Many people snore occasionally, especially when suffering from a cold or allergies, or after consuming alcohol. This type of snoring is usually not a major health concern.

However, snoring can be more than just a nuisance; it can indicate underlying health issues such as obstructive sleep apnea (OSA), a serious condition where breathing repeatedly stops and starts during sleep. If snoring is loud, chronic, accompanied by choking or gasping, or causes daytime sleepiness, it’s important to seek medical advice to rule out OSA.

The word “apnea” comes from Greek and means “not breathing.” Obstructive sleep apnea (OSA) is a sleep-related breathing disorder that involves cessation or decrease in airflow in the presence of breathing effort. OSA occurs when the muscles relax during sleep, causing soft tissue in the throat to collapse and block the upper airway. Think of this as trying to drink via a narrow, poor-quality paper straw; the sucking negative pressure you put on the straw collapses it, making it hard to pull liquid through to drink. Similarly, when air cannot pass through your windpipe, you are not breathing enough to maintain oxygen levels in your blood. This can lead to a reduction in blood oxygen saturation. As the body detects the lack of oxygen, episodes of brief arousal from sleep will occur to restore normal breathing, resulting in poor quality of sleep and excessive daytime sleepiness.

Many OSA patients remain undiagnosed as the symptoms begin insidiously and are often present for years before the patients are referred for evaluation. The symptoms include a spouse’s report of disruptive snoring, witnessed apnea, gasping and choking sensations that arouse the patient from sleep, excessive daytime sleepiness, nonrestorative sleep, poor memory, and concentration. In adults, obesity is the most common risk factor for OSA. Other risk factors include large neck size, middle-aged and older men, post-menopausal women, enlarged tonsils/adenoids, Down Syndrome, and head and neck bony or soft tissue structural abnormalities.

OSA can be dangerous if left untreated. It is associated with an increased risk of cardiovascular mortality and stroke. It can cause daytime drowsiness, which can be dangerous if you are driving or doing something that needs your full attention. Falling asleep while using power tools, operating machinery, or driving can lead to deadly consequences for you or others. The effects of OSA can also contribute to or worsen high blood pressure or Type 2 diabetes.

Obstructive sleep apnea is diagnosed with overnight polysomnography (PSG). A PSG detects the frequency of apnea and hypopnea during sleep. Evaluation of the upper airway is needed for all patients with OSA. The treatment of OSA partly depends on the severity of the pathology. Positive airway pressure (PAP) therapy is the standard treatment option. While surgery has a certain role in treating OSA, there is a wide range of possible surgical procedures for OSA. The procedure of choice depends on the level of obstruction during sleep apnea. When there is an anatomical deformity that can be corrected to alleviate mechanical obstruction, surgery can be very effective. Oral appliances (OA) are another treatment option but are only useful in certain conditions. Other than these treatment options, lifestyle modifications such as weight loss, avoidance of alcohol prior to bedtime, and sleeping in a lateral position are also very important, especially in obese patients.

It’s important for individuals who suspect they have OSA to seek medical evaluation and treatment. Proper management of OSA can significantly reduce the risks and improve quality of life.

Dr. Sow Yih Liang is a Consultant Ear, Nose and Throat (Otorhinolaryngology) Head and Neck Surgeon in Loh Guan Lye Specialists Centre. He enjoys sharing his medical knowledge with his fellow medical practitioners through organising or contributing as a speaker at workshops, symposiums or conference. Apart from engaging himself in numerous research and publication works, Dr. Sow is also actively involved in delivering oral and poster presentations. He was an adjunct lecturer for University Malaysia Sarawak (UNIMAS) from year 2016 to 2018. He also helped to train open system postgraduate students in Otorhinolaryngology, postgraduate students in Family Medicine Programme and medical student for elective attachment.

Introduction:

Diabetic retinopathy, a complication arising from diabetes, affects the eyes by causing damage to the blood vessels in the retina, the light-sensitive nerve at the back of the eye. Despite often exhibiting no symptoms in its early stages, diabetic retinopathy can lead to severe vision issues and, if left untreated, even blindness. Both type 1 and type 2 diabetes can predispose individuals to diabetic retinopathy, with the risk increasing based on the duration of diabetes and inadequate blood sugar control.

This article aims to provide an overview of diabetic retinopathy, its causes, symptoms, stages, risk factors, complications, and the importance of timely eye examinations for effective management.

Causes:

The primary cause of diabetic retinopathy is elevated blood sugar levels, leading to the gradual blockage of capillaries that supply blood to the retina. This process triggers the growth of abnormal blood vessels prone to leakage.

Symptoms:

Diabetic retinopathy may initially be asymptomatic, but as the condition progresses, the following symptoms may emerge:

– Floaters or dark lines in your vision.

– Blurred vision.

– Vision fluctuations.

– Dark or blank areas in your field of vision.

– Vision loss.

Stages:

Diabetic retinopathy has two stages:

1. Early diabetic retinopathy, also known as nonproliferative diabetic retinopathy (NPDR), where abnormal new blood vessels have not yet formed.

2. Advanced diabetic retinopathy, or proliferative diabetic retinopathy, characterised by the growth of abnormal blood vessels in the retina.

Risk Factors:

Several factors can increase the risk of diabetic retinopathy, including the duration of diabetes, poorly controlled blood sugar levels, hypertension, high cholesterol, pregnancy, and tobacco use.

Complications:

Diabetic retinopathy can lead to serious eye problems, such as:

   •   Bleeding inside the eye’s gel-like substance (vitreous), known as vitreous hemorrhage which can cause floating spots.

   •   Retinal detachment leads to visual field loss.

   •   Glaucoma, a condition when eye pressure is increased.

   •   Blindness, especially if the condition is not well-managed or is accompanied by macular edema or glaucoma.

Images by Dr. Lim Chang Zhen

When to See an Eye Doctor:

For Type 1 Diabetes, initial eye screening should occur within 3-5 years of diabetes onset. Type 2 Diabetes individuals should undergo eye screening at the time of diabetes diagnosis.  Pregnant women with pre-existing diabetes should have an eye examination before pregnancy, in the first trimester, and then close follow-up throughout pregnancy and the postpartum period.

Follow-up Eye Examination:

After the initial screening, individuals with diabetes should have annual eye examinations, even if there are no signs of diabetic retinopathy. More severe cases of diabetic retinopathy may require more frequent eye examinations. Regular and thorough eye exams are essential for preventing vision loss in individuals with diabetes. If you experience sudden changes in your vision, such as blurriness, spots in your visual field, floaters, or haziness, it’s crucial to promptly visit your eye doctor.

Treatment of Diabetic Retinopathy:

Treatment options include:

– Injections: Anti-VEGF drugs injected into the eye can slow down or reverse swelling in the retina.

– Laser Therapy: Used to shrink abnormal blood vessels, stop leakage, and reduce swelling in the retina.

– Eye surgery: In cases of excessive bleeding, scars, or retina detachment, vitreo-retina surgery may be required.

Image by Shroff Eye Centre

Prevention:

While diabetic retinopathy cannot be entirely prevented, several steps can reduce its risk, including:

– Controlling diabetes through a healthy lifestyle, including diet, exercise, and compliance with prescribed medications.

– Regularly monitoring blood sugar levels as advised by healthcare providers.

– Managing blood pressure and cholesterol through lifestyle changes or medications.

– Quitting smoking or using tobacco products, as smoking elevates the risk of diabetic complications.

– Remaining vigilant for any vision changes and promptly consulting an eye doctor.

Conclusion:

Optimal control of diabetes is crucial to avoid its complications, especially diabetic retinopathy. By closely monitoring blood sugar levels, following prescribed treatment regimes, living a healthy lifestyle, and undergoing regular eye check-ups, individuals can significantly lower their risk. Early detection and timely intervention are essential for effective treatment and preserving vision.

Dr. Lim Chang Zhen has developed expertise in various procedures and surgeries. His areas of specialisation encompass cataract surgery with premium lenses, diabetic retinopathy, eye infections, glaucoma, laser treatment, and pterygium surgery. Dr. Lim ensures that his patients receive the highest standard of care, incorporating the latest advancements in the field of ophthalmology.

by Dr. Koay Han Siang
Consultant Paediatrician & Paediatric Cardiologist

Chest pain in children and adolescents is a common reason for visits to both general practitioners and paediatric specialists. This experience can be particularly distressing for both the child and their parents, fueled by concerns about its association with heart attacks in adults.

The causes of chest pain in this age group can be categorised as either non-cardiac or cardiac in origin. The reassuring news is that non-cardiac causes are the primary culprits, accounting for the majority of cases. Only a small percentage, ranging from 1% to 4%, is attributed to cardiac issues.

What Will the Doctor Do?

Parents typically seek help by bringing their child to a clinic or casualty. The doctor’s initial approach involves obtaining a detailed medical history. Questions will cover the nature, location, timing, and factors influencing the pain, along with a review of the child’s previous medical and family history. This is followed by a thorough physical examination, which includes assessing the child’s general condition, blood pressure, saturation levels, breathing, heart rate, chest wall palpation, and listening to the lungs and heart. Often, the cause of chest pain can be identified through these evaluations alone.

Common Non-Cardiac Causes

The most frequently identified non-cardiac cause is of musculoskeletal origin, involving muscles, bones, and related structures of the chest wall. A history of injury, excessive or new physical activity, vigorous coughing, aggravation by certain maneuvers, and/or localised tenderness during examination may point to this category.

Reflux esophagitis (inflammation of the food passage) is another common non-cardiac cause. This is suggested by the timing of pain in relation to meals, intake of spicy foods, and/or a burning sensation resembling heartburn.

Asthma, chest infections, or inflammation of the lung covering layers are also common culprits, often accompanied by difficulty in breathing, audible wheezing, fever, and/or cough. Additionally, psychogenic chest pain in adolescents should not be overlooked, and certain stressors may require professional counselling or psychological intervention. A significant proportion of cases fall into the idiopathic group, where no identifiable cause for chest pain is found.

Cardiac Chest Pain

When the origin of chest pain remains uncertain or there is suspicion of cardiac involvement, your GP or Paediatric Specialist may refer your child to a Paediatric Cardiologist. Certain findings during history-taking or physical examination, such as episodes of near fainting or fainting, racing heartbeats, sweatiness, pain on exertion, known cardiac disease or connective tissue disorders, and positive family history, may warrant this referral.

Different heart-related issues can manifest as chest pain. These may encompass a range of conditions such as myocarditis (inflammation of the heart muscle), arrhythmias (disruptions in heart rhythm), abnormal coronary artery origin, pulmonary hypertension, cardiomyopathy (a dysfunction in the heart muscle’s performance), aortic or pulmonary valve stenosis, pericarditis (inflammation affecting the layers enveloping the heart), and Marfan syndrome, among others.

Fortunately, Paediatric Cardiologists can often diagnose these conditions through non-invasive evaluations such as electrocardiogram (ECG) and echocardiogram (heart ultrasound scan). In rare cases, additional tests like blood tests, exercise stress tests, 24-hour electrocardiogram recordings, cardiac MRI, or diagnostic cardiac catheterisation may be needed.

Treatment Approaches

The treatment of chest pain depends on its underlying cause. Simple analgesia and rest are often sufficient for musculoskeletal pain, while diet and lifestyle modifications may be recommended for reflux esophagitis. Cases with psychogenic origins may require referral to a counsellor or psychologist. Reassurance through detailed explanations to both parents and the child is crucial in alleviating anxiety, enabling the child to resume normal activities, including school and sports. For cardiac chest pain, specific management by a Paediatric Cardiologist will depend on the identified causes.

In Conclusion

Chest pain is a common occurrence in children and adolescents, with the majority of cases being non-cardiac, self-limited, and benign. Seeking early medical evaluation from a doctor is recommended to rule out serious medical conditions and provide peace of mind to both the child and their parents.